Gout in North America

Gout is the most prevalent inflammatory arthritis in North America, affecting approximately 3.8% of the population in Canada and 5.1% in the United States (US). Epidemiological modeling through 2050 projects that high-income North America will sustain the highest age-standardized prevalence of gout globally. This rising burden is accompanied by heavy socioeconomic costs and striking demographic shifts. Driven by obesity, early-onset gout among American youth escalated by 63% over the last three decades, while nearly one-third of US adolescents now exhibit hyperuricemia, in contrast to ~20% of adults. Furthermore, profound racial inequities persist; Black patients experience a five-fold higher rate of emergency department (ED) visits for gout flares compared to White patients, and older Asian Americans face the highest overall prevalence. Primary care providers manage 70% to 80% of gout cases in both nations. Suboptimal longitudinal care has led to severe reliance on acute services. Post-ED care continuity remains poor, frequently resulting in low rates of follow-up serum urate testing, high readmission rates, and inappropriate opioid prescribing. Diagnostically, polarizing light microscopy of synovial fluid remains the gold standard, supplemented by advanced ultrasound and dual-energy computed tomography imaging, although this technology is limited by provider availability. Treatment paradigms prioritize a treat-to-target strategy to maintain serum urate levels below 6 mg/dL. Allopurinol is the preferred first-line therapy, with recent clinical data validating its safety and efficacy when progressively titrated in patients with chronic kidney disease. Second-line febuxostat requires shared decision making in the context of cardiovascular disease, while advanced, refractory tophaceous gout is managed in the US with intravenous pegloticase which can be co-administered with methotrexate to mitigate immunogenicity. Ultimately, optimizing North American gout outcomes requires improvement in health services delivery with multidisciplinary models of care serving as an emerging solution.