Gout Linked to Higher Risk of Lower Extremity Amputation in Veterans

Ted Mikuls, MD, MSPH, Veterans Affairs Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, shares recent findings indicating veterans with gout are more likely to undergo lower extremity amputations compared to those without gout.

What inspired you to research the association between gout and lower extremity amputation?

I became interested in the association between gout and lower extremity amputation (LEA) because, over the years, I have seen several of my patients, both veteran and nonveteran, with gout having to undergo amputations. This led me to ask, “are veteran patients with gout more prone to amputations?” This was not an obvious association, so I was curious to learn more.

Can you describe your study’s design, participants, and outcome measures?

We used national administrative data to examine the association between gout and LEAs. More specifically, we looked at patients who used US Department of Veterans Affairs services between January 2000 and July 2015, most of whom were men over the age of 60 years.

Patients with gout were identified using diagnostic codes and filtered by age, sex, and year of benefits enrollment. Attributes of serum urate control and treatment with urate-lowering therapy were assessed as factors associated with LEA.

Can you walk us through your findings? What would you say are the key takeaways from the study?

The study looked at the connection between patients with gout and the associated rates of LEAs compared to patients without gout. The key takeaway is that US veterans with gout were 20% more likely to undergo LEA. This increase was independent of comorbidities, such as diabetes, chronic kidney disease, peripheral vascular disease, and others that serve as established risk factors for LEA and are more common in gout.

The study also showed serum urate control among patients with gout was independently associated with the LEA rate, suggesting the possibility that LEA may be preventable in some patients. 

How might these data impact clinical practice?

Gout is a systemic, debilitating disease that can have serious consequences beyond painful flares. However, too often, only the acute symptoms of gout, like pain and flares, are addressed.

These data suggest a real urgency to treat gout and its underlying cause—elevated uric acid levels—to prevent permanent damage that in rare instances might culminate in LEA. It is imperative for clinicians to understand and educate on gout’s systemic nature, including how it can impact veteran patients and how gout can become uncontrolled, even with treatment.

Do you plan to conduct further research into gout or lower extremity amputation in veterans?

While this study suggests that gout is independently associated with an increased rate of LEA in veterans, additional research is needed to better understand the degree to which amputations can be prevented. For instance, it is possible that systematic screening efforts that include gout history or marked hyperuricemia could be used as indicators for additional studies that could ultimately prevent LEA in some patients.

Furthermore, the participants of this study were predominantly male patients, so it would be interesting to see the specific breakdown of men vs women in future studies. Overall, we know additional research can lead to a better understanding of the correlation between gout and permanent damage on the body, including the need for LEA.

Is there anything else you would like to add?

Gout is a chronic, systemic, and progressive disease that needs to be treated with urgency and attention. The disease is often poorly managed and undertreated, which can lead to permanent damage to the bones and joints, LEAs, and systemic urate deposition throughout the body.

This study contributes to a growing body of research that underscores the systemic burden of the disease, but more research and education is needed to help physicians and patients understand the urgency of lowering uric acid levels to manage gout and prevent poor outcomes.

About Dr Mikuls

Ted Mikuls, MD, MSPH, has been in practice as a rheumatologist for more than 20 years. He currently resides in Omaha, Nebraska, where he is affiliated with multiple hospitals in the area, including Veterans Affairs Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center. Dr Mikuls is also the Stokes-Shackleford Professor of Rheumatology and vice chair for research in the department of internal medicine at University of Nebraska.

Reference:
Mikuls TR, Soto Q, Petro A. Comparison of rates of lower extremity amputation in patients with and without gout in the US Department of Veterans Affairs health system. JAMA Netw Open. 2022;5(1):e2142347. doi:10.1001/jamanetworkopen.2021.42347