Explaining the natural course of gout to people living in the tropics.

Abstract

Dear Editor, We read with great interest the article by Shimizu and Rooks entitled “Slowly melting the urate snow in joints: Explaining gout attacks to patients”, in which they described a method of explaining the natural course of gout to patients in order to improve their adherence to long-term urate-lowering therapy (ULT).1 We commend the authors for their simple and accurate description of gout. In this description, snow falling on a roof represents the continuous accumulation of monosodium urate (MSU) crystals in the joints. The sunlight slowly melting the snow cover clearly represents the dissolution of MSU crystals by ULT. However, the use of this method could have limited success in explaining gout to people living in tropical areas who have never encountered snowfall. For people with gout in the tropics, different analogies may be more relatable. We would like to share other methods of explaining the natural course and treatment of gout that we have used in our practice. The first method is a modification of the “dirty dish” hypothesis, described by Perez-Ruiz et al2 In this analogy, the dish represents the joints in which the MSU crystals (the food residue) are continually building up. The longer the dirty dish is left unattended, the more effort and time are needed to clean it properly, similar to people with advanced gout requiring more intensive and longer duration of ULT before tophus disappearance. Large chunks of food residue may slough off if the dish is scrubbed too vigorously, similar to MSU crystal shedding and subsequent gout flares that are common during the early phase of ULT.3 The second method is a more literal explanation of the MSU crystal deposition in gout. We ask gout patients to imagine a glass of salty fluid with coarse grains of salt within. The grains keep growing as long as the liquid is saturated with salt. The salty fluid must be exchanged with fresh water to make the grains of salt disappear. This is similar to what happens in people with gout; MSU crystals keep growing inside the joints as long as the body is saturated with urate (hyperuricemia). ULT reduces the urate concentration in the blood, and drives the dissolution of MSU crystals. Gout flares occurring soon after initiation of ULT can be explained using the same analogy; an abrupt refilling of the glass with water (ULT) causes turbulence that stirs up the grains of salt from the bottom of the glass (crystal shedding and gout flare). For people with gout, accurate understanding of the underlying pathology of gout is essential to ensure successful control of serum urate levels. Interventions that put emphasis on patient education lead to improved adherence to ULT, more patients achieving target serum urate levels, and better clinical outcomes.4 Explaining gout to patients is more art than science. It depends on each patient's level of health understanding, as well as geographical and cultural factors. Explaining gout using the snowfall method may be suitable for people living in countries with colder climates. The dirty dish or grain of salt analogies may be more relatable to people with a wider range of geographical and cultural backgrounds. Regardless of the methods used to explain gout, the key message that must be effectively delivered is that gout is a chronic condition that needs regular long-term treatment to keep serum urate at a target level. None. KJ and ND planned and drafted the manuscript. Both authors have reviewed and given approval to the submitted version of the manuscript.