Gout: a practical approach to diagnosis and management in low- and middle-income countries and resource-limited...

The prevalence of gout is increasing worldwide, with rapid rises reported in low- and middle-income countries (LMICs), particularly in parts of Asia, Latin America, and Africa. Several international organizations have published guidelines for optimal gout management, most of which are from developed countries with high-income settings. Therefore, implementing these recommendations in LMICs and other resource-limited settings (RLS) is often difficult due to several barriers. These include a shortage of rheumatologists and other relevant specialists, workforce constraints, limited access to advanced diagnostic modalities (e.g., compensated polarized light microscopy, ultrasound, and dual-energy computed tomography), restricted availability and affordability of newer effective therapies, as well as limited access to HLA-B*58:01 testing before initiating allopurinol in at-risk populations. As a result, gout care in these settings may be suboptimal. This review summarizes these barriers and proposes pragmatic, context-appropriate strategies to address them. It emphasizes targeted education and the development of multidisciplinary gout care teams, including primary care physicians, nurses, and pharmacists, who deliver most gout care in LMICs/RLS. It also outlines structured collaboration with higher-level facilities (e.g., through teleconsultation and case conferences) to support difficult cases and strengthen referral pathways. National rheumatology societies and health authorities should adapt international guidelines to local constraints and establish reimbursement or authorization pathways for high-cost urate lowering therapy not included in essential drug lists. In addition, trained community health workers can support gout care by identifying people with gout, providing basic education, promoting regular follow-up, facilitating access to appropriate care, and correcting misconceptions about gout. Key Points • LMIC/RLS gout care is limited by diagnostic capacity and management constraints, especially workforce shortages. • Collaboration among higher-level facilities, rheumatology societies, and health authorities is key to improving gout management. • International guidelines should be adapted to local constraints in LMICs/RLS.