If a disease is highly treatable, even curable, you'd think sufferers would be doing all they can to rid themselves of it. But people who have gout, the world's most common form of inflammatory arthritis that often manifests in the big toe joint, don't seem to be getting cured.
Rates of gout are soaring in Britain, with about one in 40 affected - the highest incidence in Europe. But treatment remains as poor as it was in the late 1990s, according to a study published in January in the Annals of the Rheumatic Diseases.
The study, which analysed long-term primary care medical records of about 4.5 million of the British population, found that between 1997 and 2012, the prevalence of gout rose by 64 per cent, increasing by about 4 per cent every year.
Yet only a third of people with gout were being treated with urate-lowering drugs, a percentage that remained constant over the entire period.
In Hong Kong, statistics on the prevalence of gout locally are scarce. The most recent data available was the Health Department 2000-2001 annual report, which stated a gout prevalence of 5 per cent to 6 per cent.
Dr Eric Chak Hing-chung, a specialist in orthopaedics and traumatology at Central Consultative Clinic, says Hongkongers have a low level of awareness and insufficient knowledge on the complications or the deformity that can result from gouty arthritis. Patients only consult specialists in their acute stage.
Historically, gout has been portrayed as a benign and even comical condition that is self-inflicted through overeating and alcohol excess, say a team of European researchers whose study in the Annals of the Rheumatic Diseases in 2012 reviewed existing papers on gout. This, they say, has led to a majority of gout patients receiving inadequate advice and treatment.
"Suboptimal care and outcomes reflect inappropriately negative perceptions of the disease, both in patients and providers. Doctors often focus on managing acute attacks rather than viewing gout as a chronic progressive crystal deposition disease. Urate-lowering treatment is underprescribed and often underdosed," say the researchers in their report.
One of the oldest diseases described in medical literature, it was earlier referred to as "the king of diseases and the disease of kings" due to association with an overindulgent lifestyle and food habits.
"There's a misconception that gout can be managed with diet alone," says Dr Chan Tak-hin, a specialist in rheumatology and chairman of the Hong Kong Arthritis and Rheumatism Foundation.
"While dietary modification is important, many gout patients require proper medication to keep the disease under control. Without it, patients will continue suffering from frequent gout arthritis," Chan says.
Gout occurs when too much uric acid builds up in the body, causing crystals to form in joints, making them inflamed and painful, and leading to disability due to pain and loss of joint function. Uric acid is produced during the breakdown of purine, a substance found in many foods including meat, offal, seafood, beans, peas, lentils, oatmeal, spinach, asparagus, mushrooms, yeast and alcohol.
The condition mainly affects men between the age of 30 and 60, or earlier if there is a history of renal or purine insufficiency. Women are also susceptible to it, especially after menopause when oestrogen loses its uricosuric effect (promoting the excretion of uric acid in urine).
Most gout patients also have other pre-existing conditions like hypertension, high cholesterol, renal failure, obesity, coronary heart disease and diabetes.
Apart from affecting the joints, there has been increasing evidence that links it with major cardiovascular diseases. It can also be insidious, with uric acid crystals depositing in the kidneys as stones, and causing renal damage.
"The picture hasn't changed; the common presentation is an overweight man occasionally with a family history of gout and often with recurrent attacks," says Dr Hans Schrader, the executive medical director at Matilda International Hospital.
"As we see an increase in obesity, it is to be expected that gout problems will increase," he says.
There is consensus among local doctors that the prevalence of gout in Hong Kong may be increasing.
Co-morbidities promoting abnormally high levels of uric acid in the blood such as untreated hypertension, obesity, diabetes, atherosclerosis (hardening and narrowing of the arteries), and chronic kidney disease, are on the rise.
An urbanised lifestyle, unhealthy diet, excessive alcohol consumption, and medications such as thiazide diuretics (for hypertension), low dose aspirin and anti-rejection drugs are also contributing to its rise.
Gout also runs in families, say University of Nottingham scientists in a study published in December in the Annals of the Rheumatic Diseases.
The scientists studied the entire 23 million population of Taiwan, where gout is most prevalent in the world, and found the risk of an individual with any first-degree relative suffering from gout is about twice that of the normal population.
"Genetic factors contribute one-third in men and one-fifth in women," says the study's lead researcher Dr Kuo Chang-fu.
The treatment of gout is relatively straightforward and involves a multidisciplinary approach. Non-steroidal anti-inflammatory and prophylactic medications like Allopurinol are commonly prescribed in Hong Kong. Along with medication, the Department of Health advises gout patients to avoid foods high in purine, stop smoking and consuming alcohol, and to drink at least two litres of water a day to flush out uric acid from the body.
Since gout most often is acute and painful, patients usually seek treatment immediately. However, convincing patients to take preventive measures to avoid recurrences is difficult.
"I know quite a number of patients who probably could manage their disease without taking preventive Allopurinol, but whose lifestyle just does not allow a reduced dose," says Schrader. "They're reluctant to change their habits in diet, alcohol and weight management.
"The more often an attack, the higher the chance of permanent joint damage, and not many patients are aware of this," he says.
Education about the condition and triggers associated with acute gout attacks is imperative. When patients can recognise the start of an attack and how to manage it, adherence to medication and lifestyle changes will greatly improve the management of their disease.
"Patients with complications, such as severe cases not responding to conventional treatment or tophaceous [chronic] gout are better managed by specialists," says Chan. "Specialists have the responsibility to provide adequate continuing medical education training on gout management for our general practice colleagues."