Determinants of the clinical outcomes of gout during the first year of urate-lowering therapy

Association between the initial dose urate-lowering drugs and gout flares in adult males with gout

OBJECTIVES

Frequent gout attacks in the initial introduction of urate-lowering therapy (ULT) are significant causes of poor drug adherence and ULT discontinuation. Initial low-dose urate-lowering drugs may be effective in reducing gout flares, however robust evidence is sparse. The aim of this study was therefore to assess the association of initial dose urate-lowering drugs with gout flares in adult males with gout during the initial introduction of ULT.

METHODS

This cohort study obtained data on consecutive gout patients from a single-centre gout cohort study from August 2017 to October 2020. A standard questionnaire was applied to collect demographic and clinical information, and biochemical parameters were tested on the same day. The primary endpoint was to estimate the association of initial dose febuxostat with gout flares, using Cox hazard models with inverse probability of treatment weighting (IPTW).

RESULTS

A total of 582 gout patients were included in this study. During the 6-week follow-up, 71 (12.2%) patients suffered gout flares. In the main analysis using Cox hazard models with IPTW, compared with colchicine prophylaxis, initial low-dose febuxostat alone had no statistical significance with the increased risk of gout flares [hazard ratio (HR) 1.26; 95% CI 0.58, 2.72], while initial high-dose febuxostat was associated with an increased risk of gout flares (HR 3.08; 95% CI 1.34, 7.07).

CONCLUSIONS

This observational study demonstrated that initial low-dose febuxostat was equally effective in preventing gout flares as colchicine prophylaxis, while initial high-dose febuxostat alone was associated with an increased risk of gout flares.

Predictors of Inadequate Serum Urate Response to Low-Dose Febuxostat in Male Patients with Gout

Objective

This study aimed to understand predictors of inadequate response (IR) to low-dose febuxostat treatment based on clinical variables.

Methods

We pooled data from 340 patients of an observational cohort and two clinical trials who received febuxostat 20 mg/day for at least 3 months. IR was defined as failure to reach the target serum urate level (sUA<6 mg/dL) at any time point during 3 months treatment. The potential predictors associated with short- or mid-term febuxostat IR after pooling the three cohorts were explored using mixed-effect logistic analysis. Machine learning models were performed to evaluate the predictors for IR using the pooled data as the discovery set and validated in an external test set.

Results

Of the 340 patients, 68.9% and 51.8% were non-responders to low-dose febuxostat during short- and mid-term follow-up, respectively. Serum urate and triglyceride (TG) levels were significantly associated with febuxostat IR, but were also selected as significant features by LASSO analysis combined with age, BMI, and C-reactive protein (CRP). These five features in combination, using the best-performing stochastic gradient descent classifier, achieved an area under the receiver operating characteristic curve of 0.873 (95% CI [0.763, 0.942]) and 0.706 (95% CI [0.636, 0.727]) in the internal and external test sets, respectively, to predict febuxostat IR.

Conclusion

Response to low-dose febuxostat is associated with early sUA improvement in individual patients, as well as patient age, BMI, and levels of TG and CRP.

An updated systematic review and meta-analysis of randomised controlled trials on the effects of urate-lowering therapy initiation during a gout flare

BACKGROUND

There is uncertainty about the optimal time to start urate-lowering therapy (ULT) in the setting of a gout flare. The aim was to perform a systematic review and meta-analysis of randomised controlled trials (RCTs) assessing the effects of ULT initiation during a gout flare.

METHODS

This systematic review was conducted in accordance with PRISMA methodology. MEDLINE, EMBASE and The Cochrane Library were searched for studies published between database inception to 1 March 2023. RCTs published in English that examined ULT initiation during a gout flare in adults ≥18 years were included. The quality of included studies was assessed using the revised Cochrane Risk of Bias tool 2.0. Data were extracted for the following outcomes: patient-rated pain score, duration of gout flare, recurrent gout flares, time to achieve target serum urate, adherence to ULT, patient satisfaction with treatment and adverse events. Meta-analyses were performed using Review Manager v5.4. This study is registered on PROSPERO, number CRD42023404680.

RESULTS

A total of 972 studies were identified and of these, six RCTs met the criteria for inclusion in the analysis. Three studies were assessed as having high risk of bias, one study as having some concerns, and two studies as having low risk of bias. In total, there were 445 pooled participants; 226 participants randomised to early initiation of ULT and 219 to placebo or delayed initiation of ULT. Allopurinol was used in three studies, febuxostat in two studies and probenecid in one study. Few participants (n = 62, 13.9 %) had tophaceous gout. Participants with renal impairment were excluded from most studies. There were no differences in patient-rated pain scores at baseline, days 3-4, days 7-8, day 10 or days 14-15 (p ≥ 0.42). Additionally, there was no significant difference in time to resolution of gout flare (standardised mean difference 0.77 days; 95 % CI -0.26 to 1.79; p = 0.14) or the risk of recurrent gout flare in the subsequent 28 to 30 days (RR 1.06; 95 % CI 0.59 to 1.92; p = 0.84). Adverse events were similar between groups. The included studies did not report time to achieve target serum urate, long-term adherence to ULT, or patient satisfaction with treatment.

CONCLUSION

There appears to be no evidence for harm or for benefit to initiating ULT during a gout flare. These findings have limited applicability to patients with tophaceous gout, or those with renal impairment.

Is colchicine prophylaxis required with start-low go-slow allopurinol dose escalation in gout? A non-inferiority randomised double-blind placebo-controlled trial

OBJECTIVES

To determine whether placebo is non-inferior to low-dose colchicine for reducing gout flares during the first 6 months of allopurinol using the 'start-low go-slow' dose approach.

METHODS

A 12-month double-blind, placebo-controlled non-inferiority trial was undertaken. Adults with at least one gout flare in the preceding 6 months, fulfilling the American College of Rheumatology (ACR) recommendations for starting urate-lowering therapy and serum urate ≥0.36 mmol/L were recruited. Participants were randomised 1:1 to colchicine 0.5 mg daily or placebo for the first 6 months. All participants commenced allopurinol, increasing monthly to achieve target urate <0.36 mmol/L. The primary efficacy outcome was the mean number of gout flares/month between 0 and 6 months, with a prespecified non-inferiority margin of 0.12 gout flares/month. The primary safety outcome was adverse events over the first 6 months.

RESULTS

Two hundred participants were randomised. The mean (95% CI) number of gout flares/month between baseline and month 6 was 0.61 (0.47 to 0.74) in the placebo group compared with 0.35 (0.22 to 0.49) in the colchicine group, mean difference 0.25 (0.07 to 0.44), non-inferiority p=0.92. There was no difference in the mean number of gout flares/month between randomised groups over the 12-month period (p=0.68). There were 11 serious adverse events in 7 participants receiving colchicine and 3 in 2 receiving placebo.

CONCLUSIONS

Placebo is not non-inferior to colchicine in prevention of gout flares in the first 6 months of starting allopurinol using the 'start-low go-slow' strategy. After stopping colchicine, gout flares rise with no difference in the mean number of gout flares/month between groups over a 12-month period.

TRIAL REGISTRATION NUMBER

ACTRN 12618001179224.

The Effect of Decrease in Serum Urate for the Risk of Gout Flares During Urate-Lowering Therapy Initiation Among Chinese Male Gout Patients: A Prospective Cohort Study

Purpose

Higher baseline serum urate or higher initial urate-lowering medication dose increased risk of gout flares during urate-lowering therapy (ULT) initiation. The decrease in serum urate may play a crucial role in this process. Therefore, we aim to explore the relationship between decrease in serum urate and the risk of gout flares during ULT initiation.

Patients and Methods

A 12-week prospective cohort study of Chinese male gout patients was conducted at Shandong Provincial Clinical Research Center for Immune Diseases and Gout in China. Patients were grouped by baseline serum urate (7-7.9 mg/dL, 8-8.9 mg/dL and ≥9 mg/dL). All patients received febuxostat 20 mg daily during weeks 0-4, then escalated to 40mg during weeks 4-12 if serum urate >6mg/dL. The main outcomes were the number of gout flares and the decrease in serum urate. Poisson regression was performed.

Results

A total of 282 participants were enrolled, of whom 260 completed (84, 87 and 89 in each group) from March 2021 to December 2021. A 44.2% of all participants experienced at least one gout flare. In the multivariate Poisson regression 1, Δ serum urate 0-12 weeks (IRR 1.184, 95% CI, 1.062-1.320; P=0.002), the number of gout flares before treatment 1 year (1.017, 1.010-1.024; P<0.001) and tophus (1.580, 1.023-2.440; P=0.039) were independently associated with the number of gout flares. While in the multivariate Poisson regression 2, baseline serum urate (1.256, 1.050-1.503; P=0.013) and the number of gout flares before treatment 1 year (1.014, 1.007-1.022; P<0.001) were independently associated with the number of gout flares, Δ serum urate 0-12 weeks (1.055, 0.923-1.207; P=0.433) was no longer a risk factor.

Conclusion

ULT-induced gout flares depend on the degree of decrease in serum urate, which is affected by baseline serum urate. Higher baseline serum urate and greater decrease in serum urate lead to higher risk of gout flares.

Elevated serum CA72-4 predicts gout flares during urate lowering therapy initiation: a prospective cohort study

OBJECTIVE

Gout flares during urate-lowering therapy (ULT) initiation are common, but predictors of these flares are poorly understood. The aim of this study was to determine whether serum CA72-4 is an independent predictor for gout flares during ULT initiation.

METHODS

A prospective cohort study was conducted between March 2021 and January 2022. Men with gout, at least one gout flare in the past year, and at least three serum CA72-4 measurements in the previous six months were enrolled. Participants were grouped according to their highest recorded serum CA72-4 levels (above or within the normal range). All participants took oral febuxostat 20 mg daily without flare prophylaxis therapy, and attended face-to-face visits every four weeks until 24 weeks. The incidence of gout flare was compared between the two groups. Backward stepwise logistic regression analyses were used to identify risk factors associated with flares. Receiver operating characteristic curve analysis was used to evaluate prediction efficacy.

RESULTS

A total of 193 completed the study (79 with high CA72-4; 114 with normal CA72-4). The cumulative incidence of at least one gout flare was 48.1% (62.1% in the high CA72-4 group, 38.4% in the normal CA72-4 group, P = 0.001), and recurrent (≥2) flares was 33.0% (47.1% in the high CA72-4 group, 23.2% in the normal CA72-4, P < 0.001). High CA72-4, disease duration, intra-articular tophus size, glucose, high-density lipoprotein-cholesterol and ESR were independent risk factors for gout flares. Serum CA72-4 alone predicted recurrent flares with an area under the curve of 0.63 (95% CI = 0.54, 0.71), and 0.78 (95% CI = 0.71, 0.85) when combined with other independent variables.

CONCLUSION

High serum CA72-4 predicts the risk of gout flares during ULT initiation.

TRIAL REGISTRATION

ChiCTR; https://www.chictr.org.cn/; ChiCTR2100043573.

When underlying biology threatens the randomization principle - initial gout flares of urate-lowering therapy

Flare is the dominant feature of gout and occurs because of inflammatory response to monosodium urate crystals; prevention of gout flares should be the major goal of gout care. However, a paradoxical increase in the risk of flare following initiation of urate-lowering therapy presents considerable challenges for proving the expected long-term benefits of flare prevention in clinical trials. Nevertheless, excluding from enumeration flares that occur in the initial post-randomization period (which can last several months to 1 year) can threaten the core benefits of randomization: the characteristics of the remaining participants can differ from those who were randomized, introducing potential bias from confounding (both measured and unmeasured); participants who drop out or die are excluded from the analysis, introducing potential selection bias; and, finally, ignoring initial flares underestimates participants’ experience during the trial. This Perspective discusses these issues and recommends measures that will allow for high-level evidence that preserves the randomization principle, to satisfy methodological scrutiny and generate robust evidence-based guidelines for gout care.

The paradoxical increase in gout flare risk upon initiation of urate-lowering therapy presents challenges for the measurement and analysis of gout flares in clinical trials of urate-lowering therapy. In this Perspective, the authors highlight these issues and discuss potential solutions.

Association of Sodium-Glucose Transport Protein 2 Inhibitor Use for Type 2 Diabetes and Incidence of Gout in Taiwan

IMPORTANCE

The use of sodium-glucose transport protein 2 (SGLT2) inhibitors is currently a standard intervention in patients with type 2 diabetes (T2DM) and exerts favorable pleiotropic effects to consistently lower blood urate levels. However, to date, no association between SGLT2 inhibitor use and the incidence of gout have been established.

OBJECTIVE

To investigate whether prescribed SGLT2 inhibitors are associated with lower gout incidence in patients with T2DM.

DESIGN, SETTING, AND PARTICIPANTS

In a cohort study, all patients with incident T2DM in Taiwan National Health Institution databases between May 1, 2016, and December 31, 2018, were retrospectively analyzed. As a comparator, patients using dipeptidyl peptidase 4 (DPP4) inhibitors were included. A total of 47 905 individuals receiving an SGLT2 inhibitor and 183 303 receiving a DPP4 inhibitor were evaluated, along with 47 405 pairs of patients using an SGLT2 inhibitor or DPP4 inhibitor in 1:1 propensity score-matched analyses. Data analysis was conducted from April 1 to June 30, 2021.

MAIN OUTCOMES AND MEASURES

A gout diagnosis was based on the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and the International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). Multiple Cox proportional hazards regression models were used to calculate hazard ratios (HRs) and 95% CIs.

RESULTS

In total, 231 208 patients with T2DM were included in the population; 113 812 individuals (49.22%) were women, and the mean (SD) age was 61.53 (12.86) years. The overall gout incidence was 20.26 per 1000 patient-years for SGLT2 inhibitor users and 24.30 per 1000 patient-years for DPP4 inhibitor users. When potential risk factors were adjusted in the propensity score-matched population, use of SGLT2 inhibitors was associated with a lower risk of gout (HR, 0.89; 95% CI, 0.82-0.96) compared with DPP4 inhibitors, particularly for patients receiving dapagliflozin (HR, 0.86; 95% CI, 0.78-0.95). A sensitivity analysis, performed when a gout diagnosis was ascertained using the ICD-9-CM or ICD-10-CM code with gout-related medication, also showed a significantly lower risk for gout incidence of 15% with SGLT2 inhibitors (HR, 0.85; 95% CI, 0.74-0.97). Subgroup analysis indicated that SGLT2 inhibitor benefits in patients with T2DM to achieve a lower gout risk were not different across subgroups.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that patients with T2DM who are receiving SGLT2 inhibitors may have a lower risk for gout compared with those receiving DPP4 inhibitors.

Treatment advances in gout

The purpose of gout treatment is to alleviate symptoms of flares, prevent flares from recurring by lowering serum urate, and minimize structural joint damage and functional impairment. In recent years, several new medications to treat gout have been developed, and novel agents continue to be investigated, in addition to several long-established treatments. Although a number of effective therapies are available, optimal management and outcomes are frequently not achieved due to physician under prescribing of urate-lowering therapy (ULT) and poor adherence with therapy when it is prescribed. This article reviews recent developments in the management of gout with reference to recently published clinical guidelines, outlines some important questions regarding the safety and efficacy of particular agents, and remaining gaps in our knowledge about the most effective strategies for using currently available treatments.

Assessing the sensitivity to change of the OMERACT ultrasound structural gout lesions during urate-lowering therapy

Objectives

To evaluate the sensitivity to change of ultrasound structural gout lesions, as defined by the Outcome Measures in Rheumatology (OMERACT) ultrasound group, in patients with gout during urate-lowering therapy (ULT).

Methods

Ultrasound (28 joints, 26 tendons) was performed in patients with microscopically verified gout initiating or increasing ULT and repeated after 3 and 6 months. Joints and tendons were evaluated by ultrasound for presence of the OMERACT structural gout lesions—double contour sign (DC), tophus, aggregates and erosion—scored binarily. A sum score was calculated at patient and lesion level. Changes at 3 and 6 months in patient sum scores and lesion scores at different locations were evaluated.

Results

50 patients (48 men), mean age 68.9 (range, 30–88) years, were included. Ultrasound showed a statistically significant decrease in DC and tophus sum scores from 0 months (3.16 and 2.68, respectively) to 3 months (2.33 and 2.43) and 6 months (1.34 and 1.83) (all p<0.002). The aggregate sum score only decreased significantly from 3 to 6 months (6.02 to 5.02, p=0.002), whereas erosion sum score remained almost unchanged. All four structural lesions were most commonly found in metatarsophalangeal (MTP) 1 joints (>1 lesions bilaterally), and furthermore MTP2–4 and knee joints were common sites especially for DC. Likewise, these regions were the locations with most pronounced changes in scores.

Conclusion

Ultrasound assessment of the OMERACT structural gout lesions scored binarily seems to be a useful tool for monitoring urate depositions during ULT. Particularly DC and tophus showed sensitivity to change after only 3 months of treatment.

Allopurinol adherence and its predictors in gout: a national cohort study in US veterans

Background

Allopurinol is a frequently used, effective, and affordable medication for gout. However, poor adherence to allopurinol is a key reason for patients not reaching treatment goals. The aim of this study was to comprehensively assess factors associated with high allopurinol adherence in gout.

Methods

In this national cohort study, we used the health-care databases of the US Department of Veterans Affairs (VA) from 2002 to 2016 and a new-user design to assess potential predicting factors of allopurinol adherence. Veterans were included in this study if they had International Classification of Diseases (ninth revision) code 274.x for gout in two or more outpatient encounters or one or more inpatient encounters during 2002-16; incident allopurinol use; and at least 12 months of observation. Potential predictors of allopurinol adherence (defined as medication possession ratio [days used divided by days prescribed] of >80%) were examined using Andersen's health-care utilisation model and multivariable-adjusted logistic regression analyses.

Findings

Between Oct 1, 2002, and Sept 30, 2016, 565 812 potentially eligible patients were included in the VA database, of whom 264 614 (46·8%) met the eligibility criteria and were included in the study cohort. The mean age was 67·8 years (SD 11·7) and mean body-mass index was 33·0 kg/m² (6·4). Factors significantly associated with higher odds of allopurinol adherence in multivariable-adjusted analyses were older age (odds ratio 1·01, 95% CI 1·01-1·01); Deyo-Charlson comorbidity index score of 1 (1·05, 1·02-1·07) or 2 or more (1·05, 1·03-1·07) versus a score of 0; higher body-mass index (all categories from 25 to <30 [1·12, 1·08-1·17] to ≥45 [1·47, 1·39-1·55] vs 18·5 to <25); a military service connection of 50% or higher (1·37, 1·29-1·46) versus 0%; care in a community-based outpatient clinic (1·11, 1·08-1·14) versus in a VA Medical Center; and rural residence (1·02, 1·00-1·05). Factors significantly associated with lower odds of allopurinol adherence were black (0·74, 0·72-0·76), Hispanic (0·68, 0·65-0·72), or other race or ethnicity (0·86, 0·82-0·89) versus white race; non-rheumatologist care provider (0·83, 0·79-0·88); allopurinol start dose of 101-200 mg per day (0·93, 0·91-0·95) or more than 300 mg per day (0·75, 0·72-0·79) versus 100 mg per day or less; or allopurinol use in the previous year (0·80, 0·79-0·82). Compared with residence in the Midwest, patients in other US regions had lower odds of adherence (mid-Atlantic 0·89, 0·87-0·92; northeast 0·84, 0·81-0·87; south 0·85, 0·83-0·88; west 0·86, 0·83-0·89). Compared with a baseline serum urate of 360 to less than 480 μmol/L, serum urate of less than 360 μmol/L was associated with higher odds of adherence (1·28, 1·25-1·32), whereas baseline serum urate of 480 to less than 600 μmol/L (0·86, 0·84-0·88) or 600 to less than 720 μmol/L (0·92, 0·89-0·94) was associated with lower odds of adherence.

Interpretation

We identified several important factors associated with high allopurinol adherence. Clinicians and policy makers can now target modifiable factors at the patient, provider, or systems level, with the aim of improving allopurinol adherence, and thereby overall gout care.

Utilization of acute gout prophylaxis in the real world: a retrospective database cohort analysis

OBJECTIVE

Determine the real-world incidence of acute gout prophylaxis (AGP) prescribing when a xanthine oxidase inhibitor (XOI) is initiated and describe characteristics of AGP prescribing.

METHODS

Retrospective cohort analysis from 2007 to 2017 using medical and prescription claims from an administrative database (IQVIA™ Health Plan Claims Database) among adult patients with a diagnosis of gout. Primary endpoint was the proportion of patients receiving AGP among all patients newly initiated on XOI therapy. Secondary endpoints included incidence proportions of acute flare and of XOI discontinuation among patients who received AGP compared to those who did not. Chi-square and Fisher's exact tests were used in univariate analysis of proportions between treatment groups.

RESULTS

A total of 7414 patients were included for analysis. There were 697 patients (9.4%) who received AGP with XOI initiation and colchicine alone was the most common medication used among patients who received prophylaxis (n = 303, 43.4%). The incidence proportion of patients with an acute gout flare within 3 months of index was 21.5% in the AGP cohort and 12.7% in the no prophylaxis cohort (p < 0.001). The proportion of patients who discontinued XOI within 12 months of initiation was 38.7% in the AGP cohort and 46.2% in the no prophylaxis cohort (p < 0.001).

CONCLUSION

In the real world, the proportion of patients who receive AGP with initiation of XOI therapy is low and discontinuation of XOI within 12 months of initiation is significant. In this analysis, use of AGP was not associated with a lower risk of acute gout flare after initiation of XOI therapy. Key Points • Real-world acute gout prophylaxis (AGP) prescribing with xanthine oxidase inhibitor (XOI) initiation is very low despite current guideline recommendations • More than one third of patients discontinue XOIs within 12 months of initiation regardless of AGP prescribing.

[Evaluation of a 12-week allopurinol-lowering therapy in combination with the non-steroidal anti-inflammatory drug meloxicam in patients with gout]

AIM

To evaluate a 12-week course of combined alloturinol-lowering therapy with a prophylactic anti-inflammatory dose of movalis for the frequency of exacerbations and the quality of life of patients with gout.

MATERIALS AND METHODS

Allopurinol was administered orally, 1 time per day. Every 3 weeks, the dosage of the drug was increased by 50 mg to 300 mg per day under the control of the level of serum uric acid (sUA). The total daily dose of the drug movalis, used in the form of different dosage forms, was 7.515 mg. The clinical effectiveness of the treatment was evaluated after 3, 6, 9 and 12 weeks according to physical examination, the dynamics of joint pain at rest, during movement and palpation, according to the visual analogue scale (VAS) in millimeters, Likert scale, EuroQol-5D-5L questionnaire, care for oneself, habitual daily activities, the presence of anxiety and depression, assessment of satisfaction with treatment (on a scale of 1 to 5, where 1 is the complete absence of improvement or worsening, and 5 is a very good result); took into account the period of remission, as well as the time before the onset of relapse of gouty arthritis. An adverse event (AE) was recorded.

RESULTS AND DISCUSSION

On the background of treatment with movalis 7.5 mg per day more than two-thirds of patients showed no worsening of the articular syndrome with an increase in the dose of allopurinol to 300 mg per day. By the 12th week of observation, a significant difference was found between the severity of gouty arthritis characteristics in the direction of improving mobility, self-care, normal daily activities, reducing soreness, reducing anxiety and depression (p0.05). In addition, the ESR and sUA levels were significantly different initially and at the final observation point (p0.05), which indicates a positive effect on the inflammatory process. A 3-month course of combination therapy was not accompanied by significant increases in blood pressure, changes in creatinine clearance in blood serum. There were no adverse events from the gastrointestinal tract. 90.9% of patients rated the treatment result as very good. AE in the form of a skin allergic rash was observed in one patient; it did not require interruption of treatment and completely stopped without consequences after completion of the course.

CONCLUSION

12 a week-long combined therapy of the allopurinol-reducing drug with the anti-inflammatory dose movalis prevents the exacerbation of the articular syndrome and improves the quality of life of patients with gout.

Evaluation of febuxostat initiation during an acute gout attack: A prospective, randomized clinical trial

OBJECTIVE

Urate-lowering treatment (ULT) is recommended in gout management. However, initiation of ULT during an acute gout flare is still inconclusive. This study aimed to evaluate the efficacy and safety of the ULT febuxostat administered at initiation of an acute gout attack.

METHODS

A prospective randomized controlled clinical trial was conducted for 12 weeks in primary gout patients who were admitted with acute gout attacks. Subjects were randomly assigned to the febuxostat group in which febuxostat, 40mg daily, was administered in the primary care setting for attacks, or to the control group in which febuxostat, 40mg daily, was administered after the attacks. All patients received adequate anti-inflammatory and analgesic therapies. Serum urate (SU) levels were monitored throughout the study. Pain, measured using a visual analogue scale (VAS), and gout recurrence rate were used as primary outcomes. Flare-related inflammation biomarkers were selected as secondary outcomes.

RESULTS

Fifty-two patients completed the study (febuxostat group: n=28; control group: n=24). No significant differences were detected in VAS scores between the two groups over the first 14-day observation period (P>0.05). Administration of febuxostat decreased SU levels significantly during the first 2-week period. However, the gout recurrent rate or gout flare-related inflammation indicators did not change in the febuxostat or control groups. Treatment-related adverse events were mild and similar between groups.

CONCLUSION

Initiation of the urate-lowering drug febuxostat during an acute gout attack caused no significant difference in daily pain, recurrent flares, or adverse effects. The treatment significantly decreased SU levels in the early stage and might have potential long-term benefits in these patients.

The effects of antihypertensive class on gout in older adults: secondary analysis of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial

OBJECTIVES

Gout is a common complication of blood pressure management and a frequently cited cause of medication nonadherence. Little trial evidence exists to inform antihypertensive selection with regard to gout risk.

METHODS

The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) was a randomized clinical trial on the effects of first-step hypertension therapy with amlodipine, chlorthalidone, or lisinopril on fatal coronary heart disease or nonfatal myocardial infarction (1994-2002). Trial participants were linked to CMS and VA gout claims (ICD9 274.XX). We determined the effect of drug assignment on gout with Cox regression models. We also determined the adjusted association of self-reported atenolol use (ascertained at the 1-month visit for indications other than hypertension) with gout.

RESULTS

Claims were linked to 23 964 participants (mean age 69.8 ± 6.8 years, 45% women, 31% black). Atenolol use was reported by 928 participants at the 1-month visit. Over a mean follow-up of 4.9 years, we documented 597 gout claims. Amlodipine reduced the risk of gout by 37% (hazard ratio 0.63; 95% CI 0.51--0.78) compared with chlorthalidone and by 26% (hazard ratio 0.74; 95% CI 0.58--0.94) compared with lisinopril. Lisinopril nonsignificantly lowered gout risk compared with chlorthalidone (hazard ratio 0.85; 95% CI 0.70--1.03). Atenolol use was not associated with gout risk (adjusted hazard ratio 1.18; 95% CI 0.78--1.80). Gout risk reduction was primarily observed after 1 year of follow-up.

CONCLUSION

Amlodipine lowered long-term gout risk compared with lisinopril or chlorthalidone. This finding may be useful in cases where gout risk is a principal concern among patients being treated for hypertension.This trial is registered at clinicaltrials.gov, number: NCT00000542.

A Traditional Clinic Chinese Medicine Prescription Qu-Zhuo-Tong-Bi (QZTB) Alleviates Gouty Arthritis in Model Rats

Qu-Zhuo-Tong-Bi (QZTB) is an empirical traditional Chinese medicine prescription for treating acute gouty arthritis clinically without serious adverse effects in mainland China. However, the biochemical mechanism underlying the therapeutic action produced by QZTB treatment against acute gouty arthritis and the effect on recurrent attack remain unknown. In this study, we investigated the anti-inflammatory and analgesic effects of QZTB on acute gouty arthritis and the recurrent attack in rats, as well as the underlying mechanisms. The gouty arthritis model was established by intra-articular injection of monosodium urate (MSU) crystal suspension (2 mg/50 μL) into the right ankle joint of Sprague Dawley (SD) male rats. QZTB (500 mg/kg) and the positive control drug meloxicam were administrated by gavages twice a day for 7 days before, or 3 days after, first MSU injection in different experiments, respectively. The analgesic effects were evaluated by pain-like behaviors and hind paw mechanical withdrawal threshold testing. The anti-inflammatory activities were evaluated by ankle swelling measurement, histologic examination, NLRP3 inflammasome, and inflammatory cytokine expression. Western blot and quantitative real-time PCR were used to detect the protein and mRNA expressions of NLRP3. IL-1β and TNF-α level in the blood serum were detected by enzyme-linked immunosorbent assay (ELISA). QZTB can suppress ankle swelling and synovial inflammation in the MSU-induced gouty arthritis rat model. QZTB alleviated the acute attack and prevented the recurrent attack of gouty arthritis. In addition, QZTB treatment significantly decreased both mRNA and protein levels of NLRP3, as well as the production of IL-1 and TNF-α in the ankle joint of model rats. Taken together, these results suggest that QZTB may be a promising herbal formula for the prevention and treatment of gouty arthritis in humans.

Factors Influencing the Effectiveness of Allopurinol in Achieving and Sustaining Target Serum Urate in a US Veterans Affairs Gout Cohort

OBJECTIVE

To assess factors associated with the ability to achieve and maintain target serum urate (SU) with allopurinol in patients with gout.

METHODS

We used US Veterans Affairs (VA) databases from 2002-2012. Eligible patients had ≥ 1 inpatient or ≥ 2 outpatient visits with a diagnostic code for gout, filled a new index allopurinol prescription, had at least 1 posttreatment SU level measured, and met the 12-month observability rule. Treatment successes were defined as the achievement of postindex SU < 6 mg/dl (success 1) and postindex SU < 6 mg/dl that was sustained (success 2).

RESULTS

Of the 198,839 unique patients with allopurinol use, 41,153 unique patients (with 47,072 episodes) and 17,402 unique patients (with 18,323 episodes) were eligible for analyses for success 1 and success 2; 42% each achieved (success 1) or achieved and maintained postindex SU < 6 mg/dl (success 2). In multivariable-adjusted models, factors associated with significantly higher odds of both outcomes were older age, normal body mass index, Deyo-Charlson index score of 0, rheumatologist as the main provider rather than non-rheumatologist, midwestern US location for the healthcare facility, a lower hospital bed size, military service connection for medical conditions of 50% or more (a measure of healthcare access priority), longer distance to the nearest VA facility, and lower preindex SU.

CONCLUSION

We identified novel factors associated with maintaining SU < 6 mg/dl based on a theoretical model. Several potentially modifiable factors can be targeted by individual/provider/systems interventions for improving successful achievement and maintenance of target SU in patients with gout.

[Light and Shadow of Hyperuricemia - Neuroprotection, Comorbidities and Therapeutic Strategies]

Light and Shadow of Hyperuricemia - Neuroprotection, Comorbidities and Therapeutic Strategies Abstract. Hyperuricemia can lead to gout but also favor the appearance of comorbidities like hypertension, kidney insufficiency, type 2 diabetes, myocardial infarction and strokes. Uric acid does not only have, however, negative impact on the body, but seems to influence positively certain inflammatory and degenerative neurological diseases. The inflammatory reaction at the center of a gout attack is mediated by interleukin 1. Therefore, antagonists against interleukin 1 or IL-1 receptors can be used for treatment if colchicine, steroids or nonsteroidal anti-inflammatory drugs are ineffective or contraindicated. First-line drug for urate-lowering therapy is allopurinol that positively influences comorbidities as well.

Prescribing patterns and healthcare costs of gout

OBJECTIVE/METHODS

The Longitudinal Health Insurance Database (LHID) 2010 was used to identify gout cases and their number of gout flares.

RESULTS

Out of 21,376 gout patients, a total of 3561 (16.7%) had frequent gout flares (≥3 gout flares/year). Average all-cause healthcare utilization (35.9 visits vs. 30.7 visits; p < .001) and gout-related utilization (22.7 visits vs. 15.6 visits; p < .001) were higher in frequent gout flare patients than in those with infrequent gout flares. The median gout-related cost (USD $369 vs. $285; p < .001), but not all-cause costs (p = .25), were higher in frequent gout flare patients compared to the infrequent group. Over 55.8% of the flares were treated with colchicine + NSAIDs.

CONCLUSIONS

In conclusion, patients with frequent gout flares had higher healthcare utilization and gout-related healthcare costs. Colchicine + NSAIDs are commonly used therapy for gout flare.

Prognostic factors associated with early gout flare recurrence in patients initiating urate-lowering therapy during an acute gout flare

Lowering serum urate levels below the threshold for crystal formation with urate-lowering therapy (ULT) has been associated with a lower risk for gout flare reoccurrences. However, gout patients on ULT still commonly suffer from recurring gout flares. The purpose of this study was to explore prognostic factors associated with gout flare recurrence within the first 3 months, in gout patients starting ULT during an acute gout flare. Post-hoc analysis of trial data on acute gout patients randomized to either gout flare standard of care or anakinra treatment were used, including baseline demographic, laboratory, clinical, and patient-reported variables, as well as 3-month follow-up data on gout flare recurrences. Only patients starting ULT at baseline were included. Using variable selection based on clinical relevance, univariate, and multivariate binary logistic regression analyses were done to examine predictors of gout flare reoccurrence. A total of 75 patients were included in this study, of which 36 (48%) experienced a gout flare ≤ 3 months post baseline. The multivariate regression analysis revealed that CRP levels > 30 mg/L (OR 9.47) and lack of prophylaxis when starting ULT (OR 11.56) were independently associated with gout flare recurrence. Similar results were found for the univariate regression analyses. Our results show that CRP levels > 30 mg/L and lack of prophylaxis when starting ULT were prognostic factors for early gout flare reoccurrence in patients starting ULT during an acute gout flare. KEY POINTS: • Gout flare recurrences were common within the first 3 months after starting urate-lowering therapy in gout patients. • Intake of prophylaxis when starting ULT had a strong protective effect on gout flare recurrences. • C-reactive protein level > 30 mg/L was an additional prognostic factor for early (≤ 3 months) gout flare reoccurrence in patients starting ULT during an acute gout flare.

How Would You Manage This Patient With Gout?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center

Gout is the most common form of inflammatory arthritis. In 2012, the American College of Rheumatology (ACR) issued a guideline, which was followed in 2017 by one from the American College of Physicians (ACP). The guidelines agree on treating acute gout with a corticosteroid, nonsteroidal anti-inflammatory drug, or colchicine and on not initiating long-term urate-lowering therapy (ULT) for most patients after a first gout attack and in those whose attacks are infrequent (<2 per year). However, they differ on treatment of both recurrent gout and problematic gout. The ACR advocates a "treat-to-target" approach, and the ACP did not find enough evidence to support this approach and offered an alternative strategy that bases intensity of ULT on the goal of avoiding recurrent gout attacks ("treat-to-avoid-symptoms") with no monitoring of urate levels. They also disagree on the role of a gout-specific diet. Here, a general internist and a rheumatologist discuss these guidelines; they debate how they would manage an acute attack of gout, if and when to initiate ULT, and the goals for ULT. Lastly, they offer specific advice for a patient who is uncertain about whether to begin this therapy.

Impact of Non-Adherence and Flare Resolution on the Cost-Effectiveness of Treatments for Gout: Application of a Linked Pharmacometric/Pharmacoeconomic Model

BACKGROUND

Dual urate-lowering therapy (ULT) with lesinurad in combination with either allopurinol or febuxostat is an option for patients with gout unsuccessfully treated on either monotherapy. Treatment failure is often a result of poor medication adherence. Imperfect adherence in clinical trials may lead to biased estimates of treatment effect and confound the results of cost-effectiveness analyses.

OBJECTIVES

To estimate the impact of varying medication adherence on the cost effectiveness of lesinurad dual therapy and estimate the value-based price of lesinurad at which the incremental cost-effectiveness ratio is equal to £20,000 per quality-adjusted life-year (QALY).

METHODS

Treatment effect was simulated using published pharmacokinetic-pharmacodynamic models and scenarios representing adherence in clinical trials, routine practice, and perfect use. The subsequent cost and health impacts, over the lifetime of a patient cohort, were estimated using a bespoke pharmacoeconomic model.

RESULTS

The base-case incremental cost-effectiveness ratios comparing lesinurad dual ULT with monotherapy ranged from £39,184 to £78,350/QALY gained using allopurinol and £31,901 to £124,212/QALY gained using febuxostat, depending on the assumed medication adherence. Results assuming perfect medication adherence imply a per-quarter value-based price of lesinurad of £45.14 when used in dual ULT compared with allopurinol alone and £57.75 compared with febuxostat alone, falling to £25.41 and £3.49, respectively, in simulations of worsening medication adherence.

CONCLUSIONS

The estimated value-based prices of lesinurad only exceeded that which has been proposed in the United Kingdom when assuming both perfect drug adherence and the eradication of gout flares in sustained treatment responders.

Monosodium urate burden assessed with dual-energy computed tomography predicts the risk of flares in gout: a 12-month observational study : MSU burden and risk of gout flare

Background

Predicting the risk of flares in patients with gout is a challenge and the link between urate burden and the risk of gout flare is unclear. The objective of this study was to determine if the extent of monosodium urate (MSU) burden measured with dual-energy computed tomography (DECT) and ultrasonography (US) is predictive of the risk of gout flares.

Methods

This prospective observational study recruited patients with gout to undergo MSU burden assessment with DECT (volume of deposits) and US (double contour sign) scans of the knees and feet. Patients attended follow-up visits at 3, 6 and 12 months. Patients having presented with at least one flare at 6 months were compared to those who did not flare. Odds ratios (ORs) (95% confidence interval) for the risk of flare were calculated.

Results

Overall, 64/78 patients included attended at least one follow-up visit. In bivariate analysis, the number of joints with the double contour sign was not associated with the risk of flare (p = 0.67). Multivariate analysis retained a unique variable: DECT MSU volume of the feet. For each 1 cm³ increase in DECT MSU volume in foot deposits, the risk of flare increased 2.03-fold during the first 6 months after initial assessment (OR 2.03 (1.15–4.38)). The threshold volume best discriminating patients with and without flare was 0.81 cm³ (specificity 61%, sensitivity 77%).

Conclusions

This is the first study showing that the extent of MSU burden measured with DECT but not US is predictive of the risk of flares.

Electronic supplementary material

The online version of this article (10.1186/s13075-018-1714-9) contains supplementary material, which is available to authorized users.

Non-pharmacologic measures for gout management in the prospective GOSPEL cohort: Physicians' practice and patients' compliance profiles

OBJECTIVES

Gout management includes non-pharmacological measures (NPM). The main objective of this study was to describe the NPM proposed by physicians and their implementation by patients after 3-6 months. The secondary objective was to identify NPM compliance profiles among these patients.

METHODS

Ancillary observational study using the GOSPEL French cohort of 1003 patients with gout, based on questionnaires for physicians and patients at inclusion and then after 3-6 months. Patients were included by a representative sample of 398 general practitioners (GP) and 109 private-practice rheumatologists. Modifiable risk factors of hyperuricemia and proposed NPM were compared. Patient compliance profiles were identified by multiple correspondence and hierarchical clustering analysis.

RESULTS

The study included 630 patients: 80.7% were obese or overweight, 51% reported excessive alcohol consumption. Physicians identified fewer modifiable risk factors than their real prevalence in the cohort. Physicians proposed NPM to 57% of patients, particularly diet modifications (46.4%). Increasing physical activity (P < 0.0001) was the best followed NPM. The physician's influence in the decision of starting NPM was more frequent among GPs' patients (P = 0.01). Three patients' compliance profiles were identified. "Very good responders" (55.8%) implemented all the proposed NPM. "Good responders" (12.7%) had a more severe disease and followed the proposed NPM, but for alcohol consumption. "Bad responders" (31.5%) did not modify their life style: these were older patients with a very recent gout diagnosis.

CONCLUSION

More personalized care about NPM requires adapting the practitioner's approach to patients' compliance profiles, especially elderly patients with recent gout.

Allopurinol Medication Adherence as a Mediator of Optimal Outcomes in Gout Management

BACKGROUND

Patient and provider factors, including allopurinol medication adherence, affect gout treatment outcomes.

OBJECTIVES

The aim of this study was to examine associations of patient and provider factors with optimal gout management.

METHODS

Linking longitudinal health and pharmacy dispensing records to questionnaire data, we assessed patient and provider factors among 612 patients with gout receiving allopurinol during a recent 1-year period. Associations of patient (medication adherence and patient activation) and provider factors (dose escalation, low-dose initiation, and anti-inflammatory prophylaxis) with serum urate (SU) goal achievement of less than 6.0 mg/dL were examined using multivariable logistic regression. Medication adherence was assessed as a mediator of these factors with goal achievement.

RESULTS

A majority of patients (63%) were adherent, whereas a minority received dose escalation (31%). Medication adherence was associated with initiation of daily allopurinol doses of 100 mg/d or less (odds ratio [OR], 1.82; 95% confidence interval [CI], 1.20-2.76). In adjusted models, adherence (OR, 2.35; 95% CI, 1.50-3.68) and dose escalation (OR, 2.48; 95% CI, 2.48-4.25) were strongly associated with SU goal attainment. Low starting allopurinol dose was positively associated with SU goal attainment (OR, 1.11; 95% CI, 1.02-1.20) indirectly through early adherence, but also had a negative direct association with SU goal attainment (OR, 0.21; 95% CI, 0.12-0.37).

CONCLUSIONS

Medication adherence and low starting dose combined with dose escalation represent promising targets for future gout quality improvement efforts. Low starting dose is associated with better SU goal attainment through increased medication adherence, but may be beneficial only in settings where appropriate dose escalation is implemented.

What Is the Evidence for Treat-to-Target Serum Urate in Gout?

PURPOSE OF REVIEW

Most current clinical guidelines for gout management advocate a treat-to-target serum urate approach, although notable differences exist. Serum urate is a rational target for gout treatment given the central role of urate in disease causality, its association with key outcomes and its practicality of use in clinical practice. This review analyses the evidence for this strategy in gout.

RECENT FINDINGS

Recent studies have confirmed the efficacy of urate-lowering therapy in achieving serum urate targets, both in trials using fixed doses and those applying a treat-to-target strategy. In a limited number of long-term studies (> 12-month duration), interventions that incorporate a treat-to-target serum urate approach have been shown to promote regression of tophi, reduce the frequency of gout flares and improve MRI-detected synovitis. A strong case can be made for a treat-to-target serum urate strategy in gout, supported by existing knowledge of disease pathophysiology, outcomes from urate-lowering therapy studies and emerging results of randomised strategy trials of sufficient duration.

Effects of Febuxostat in Early Gout: A Randomized, Double-Blind, Placebo-Controlled Study

Objective

To assess the effect of treatment with febuxostat versus placebo on joint damage in hyperuricemic subjects with early gout (1 or 2 gout flares).

Methods

In this double‐blind, placebo‐controlled study, 314 subjects with hyperuricemia (serum uric acid [UA] level of ≥7.0 mg/dl) and early gout were randomized 1:1 to receive once‐daily febuxostat 40 mg (increased to 80 mg if the serum UA level was ≥6.0 mg/dl on day 14) or placebo. The primary efficacy end point was the mean change from baseline to month 24 in the modified Sharp/van der Heijde erosion score for the single affected joint. Additional efficacy end points included change from baseline to month 24 in the Rheumatoid Arthritis Magnetic Resonance Imaging Scoring (RAMRIS) scores for synovitis, erosion, and edema in the single affected joint, the incidence of gout flares, and serum UA levels. Safety was assessed throughout the study.

Results

Treatment with febuxostat did not lead to any notable changes in joint erosion over 2 years. In both treatment groups, the mean change from baseline to month 24 in the modified Sharp/van der Heijde erosion score for the single affected joint was minimal, with no between‐group differences. However, treatment with febuxostat significantly improved the RAMRIS synovitis score at month 24 compared with placebo treatment (change from baseline −0.43 versus −0.07; P <0.001), decreased the overall incidence of gout flares (29.3% versus 41.4%; P < 0.05), and improved serum UA control (62.8% versus 5.7%; P < 0.001). No major safety concerns were reported.

Conclusion

Urate‐lowering therapy with febuxostat improved magnetic resonance imaging–determined synovitis and reduced the incidence of gout flares in subjects with early gout.

Stepwise dose increase of febuxostat is comparable with colchicine prophylaxis for the prevention of gout flares during the initial phase of urate-lowering therapy: results from FORTUNE-1, a prospective, multicentre randomised study

Objectives

To determine whether febuxostat with stepwise dose increase is as useful as colchicine prophylaxis in reducing gout flares during the initial introduction of urate-lowering therapy in patients with gout in comparison with febuxostat with no dose titration.

Methods

In this prospective, multicentre, randomised open-label comparative study, patients were randomised to group A (stepwise dose increase of febuxostat from 10 to 40 mg/day), group B (fixed-dose febuxostat 40 mg/day plus colchicine 0.5 mg/day) or group C (fixed-dose febuxostat 40 mg/day) and observed for 12 weeks. Gout flare was defined as non-steroidal anti-inflammatory drug use for gout symptoms.

Results

A total of 255 patients were randomised, and 241 patients were treated. Among the treated patients, gout flares were experienced by 20/96 (20.8%) in group A, 18/95 (18.9%) in group B and 18/50 (36.0%) in group C. The incidence of flare was significantly lower in groups A and B than that in group C (P=0.047 and P=0.024, respectively), although the differences were not significant after correction for multiple comparisons. No significant difference was noted between the incidence of gout flare in groups A and B.

Conclusions

Our data suggested that stepwise dose increase of febuxostat and low-dose colchicine prophylaxis effectively reduced gout flares in comparison with fixed-dose febuxostat alone. Stepwise dose increase of febuxostat may be an effective alternative to low-dose colchicine prophylaxis during the introduction of urate-lowering therapy.

Trial registration number

UMIN 000008414.

Gout Self-Management in African American Veterans: A Qualitative Exploration of Challenges and Solutions From Patients' Perspectives

OBJECTIVE

To explore gout self-management and associated challenges and solutions in African Americans.

METHODS

We conducted semistructured interviews with 35 African American veterans with gout, who received health care at Birmingham or Philadelphia Veterans Affairs (VA) medical centers, had filled urate-lowering therapy (ULT; most commonly allopurinol) for at least 6 months, and had a ULT medication possession ratio ≥80%. The interview protocol was constructed to explore key concepts related to gout self-management, including initial diagnosis of gout, beginning medical care for gout, the course of the gout, ULT medication adherence, dietary strategies, comorbidity and side effects, and social support.

RESULTS

Thirty-five African American male veterans with gout who had ≥80% ULT adherence (most commonly, allopurinol) were interviewed at Birmingham (n = 18) or Philadelphia (n = 17) VA medical centers. Mean age was 65 years, mean body mass index was 31.9 kg/m² , 97% had hypertension, 23% had coronary artery disease, and 31% had renal failure. The main themes motivating African American veterans to better gout self-management were fear of pain, adherence to medications, self-discipline, lifestyle changes, information gathering, and developing a positive outlook. Birmingham participants more frequently revealed skipping gout medications. More Philadelphia participants discussed lifestyle/diet changes to prevent gout flares, indicated limiting social activities that involved drinking, and sought more information about gout self-management from health care providers and internet sources.

CONCLUSION

Identified themes, including cultural differences by site, led to the development of a patient-centered intervention to improve gout self-management in African American men with gout.

2016 updated EULAR evidence-based recommendations for the management of gout

Background

New drugs and new evidence concerning the use of established treatments have become available since the publication of the first European League Against Rheumatism (EULAR) recommendations for the management of gout, in 2006. This situation has prompted a systematic review and update of the 2006 recommendations.

Methods

The EULAR task force consisted of 15 rheumatologists, 1 radiologist, 2 general practitioners, 1 research fellow, 2 patients and 3 experts in epidemiology/methodology from 12 European countries. A systematic review of the literature concerning all aspects of gout treatments was performed. Subsequently, recommendations were formulated by use of a Delphi consensus approach.

Results

Three overarching principles and 11 key recommendations were generated. For the treatment of flare, colchicine, non-steroidal anti-inflammatory drugs (NSAIDs), oral or intra-articular steroids or a combination are recommended. In patients with frequent flare and contraindications to colchicine, NSAIDs and corticosteroids, an interleukin-1 blocker should be considered. In addition to education and a non-pharmacological management approach, urate-lowering therapy (ULT) should be considered from the first presentation of the disease, and serum uric acid (SUA) levels should be maintained at<6 mg/dL (360 µmol/L) and <5 mg/dL (300 µmol/L) in those with severe gout. Allopurinol is recommended as first-line ULT and its dosage should be adjusted according to renal function. If the SUA target cannot be achieved with allopurinol, then febuxostat, a uricosuric or combining a xanthine oxidase inhibitor with a uricosuric should be considered. For patients with refractory gout, pegloticase is recommended.

Conclusions

These recommendations aim to inform physicians and patients about the non-pharmacological and pharmacological treatments for gout and to provide the best strategies to achieve the predefined urate target to cure the disease.

The Budget Impact of Increased Use of Febuxostat in the Management of Gout: A US Health Plan Managed Care Pharmacy and Medical Costs Perspective

PURPOSE

Gout is a chronic disease characterized by the deposition of urate crystals in the joints and throughout the body, caused by an excess burden of serum uric acid (sUA). The study estimates pharmacy and medical cost budgetary impacts of wider adoption by US payers of febuxostat, a urate-lowering therapy (ULT) for the treatment of gout.

METHODS

A US payer-perspective budget impact model followed ULT patients from a 1,000,000-member plan over 3 years. The current market share scenario, febuxostat (6%) and ULT allopurinol (94%), was compared with an 18% febuxostat market share. Data were implemented from randomized controlled trials, census and epidemiologic studies, and real-world database analyses. An innovation was the inclusion of gout-related chronic kidney disease costs. Cost results were estimated as annual and cumulative incremental costs, expressed as total costs, cost per member per month, and cost per treated member per month. Clinical results were also estimated.

FINDINGS

Increasing the febuxostat market share resulted in a 6.3% increase in patients achieving the sUA target level of <6.0 mg/dL and a 1.4% reduction in gout flares during the 3-year period. Total cost increased 1.4%, with a 49.9% increase in ULT costs, a 1.4% reduction in flare costs, a 1.2% reduction in chronic kidney disease costs, and a 2.8% reduction in gout care costs. The cumulative incremental costs were $1,307,425 in the first year, $1,939,016 through the second year, and $2,092,744 through the third year. By the third year, savings in medical costs offset most of the increase in treatment costs. Impacts on cumulative cost per member per month and cumulative cost per treated member per month followed the same pattern, with the highest impact in the first year and cumulative impacts declining during the 3-year period. The cumulative cost per member per month impact was estimated as $0.109, $0.081, and $0.058 and the cumulative cost per treated member per month impact was estimated as $12.416, $9.207, and $6.625 in the first year, through the second year, and through the third year, respectively.

IMPLICATIONS

Expanding the febuxostat market share would result in improved clinical outcomes, but with an overall increase in costs over 3 years due to higher costs of treatment. By the third year, savings in medical costs, primarily in chronic kidney disease costs, would offset most of the increase in treatment costs. Expanded use of febuxostat in the treatment of all gout patients, independent of renal impairment status, should be considered based on improved clinical outcomes and longer-term medical cost savings associated with these improved outcomes.

Gout Prophylaxis Evaluated According to the 2012 American College of Rheumatology Guidelines: Analysis from the CORRONA Gout Registry

OBJECTIVE

To analyze prophylaxis using the CORRONA (COnsortium of Rheumatology Researchers Of North America) Gout Registry according to the American College of Rheumatology (ACR) guidelines, and to evaluate whether differences in disease characteristics influenced prophylaxis.

METHODS

All patients with gout in the CORRONA Gout Registry between November 1, 2012, and November 26, 2013, were included. They were divided into 2 groups: "receiving prophylaxis" versus "not receiving prophylaxis" at the time of enrollment. Patients having a flare at time of visit were excluded. Descriptive statistics and multivariable logistic regression models were performed to evaluate the factors associated with prophylaxis.

RESULTS

There were 1049 patients with gout available for analysis. There were 441 patients (42%) receiving prophylaxis and 608 (58%) not receiving prophylaxis. The most common drugs used for prophylaxis were colchicine (78%) and nonsteroidal antiinflammatory drugs (32%). Prophylaxis drug combination was used by 45 patients (10.2%). Patients in the "receiving prophylaxis" group were more likely to have a gout duration of ≤ 1 year (n = 68, p < 0.001), ≥ 1 flare in the year previous to enrollment (p < 0.001), ≥ 1 healthcare uses in the last year [Emergency Department (p = 0.029); outpatient visit to primary care, rheumatologist, or urgent care clinic (p < 0.001)], have tophi (p < 0.001), report pain > 3 (p = 0.001), and have disease activity > 10 (p < 0.001) compared with patients in the "not receiving prophylaxis" group.

CONCLUSION

Forty-two percent of patients with gout in the CORRONA Gout Registry were receiving prophylaxis. Prophylaxis was significantly more common in patients with a higher disease burden and activity, which is in agreement with the ACR guidelines. Our study highlights disease characteristics influencing prophylaxis and furthers our knowledge on current use of flare prophylaxis.

Febuxostat in the management of gout: a cost-effectiveness analysis

OBJECTIVE

To determine the cost-effectiveness of febuxostat vs allopurinol for the management of gout.

METHODS

A stochastic microsimulation cost-effectiveness model with a US private-payer perspective and 5-year time horizon was developed. Model flow based on guideline and real-world treatment paradigms incorporated gout flare, serum uric acid (sUA) testing, treatment titration, discontinuation, and adverse events, chronic kidney disease (CKD) incidence and progression, and type 2 diabetes mellitus (T2DM) incidence. Outcomes were estimated for the general gout population and for gout patients with CKD stages 3/4. Modeled treatment interventions were daily oral febuxostat 40-80 mg and allopurinol 100-300 mg. Baseline patient characteristics were taken from epidemiologic studies, efficacy data from randomized controlled trials, adverse event rates from package inserts, and costs from the literature, government sources, and expert opinion. Eight clinically-relevant incremental cost-effectiveness ratios were estimated: per patient reaching target sUA, per flare avoided, per CKD incidence, progression, stages 3/4 progression, and stage 5 progression avoided, per incident T2DM avoided, and per death avoided.

RESULTS

Five-year incremental cost-effectiveness ratios for the general gout population were $5377 per patient reaching target sUA, $1773 per flare avoided, $221,795 per incident CKD avoided, $29,063 per CKD progression avoided, $36,018 per progression to CKD 3/4 avoided, $71,426 per progression to CKD 5 avoided, $214,277 per incident T2DM avoided, and $217,971 per death avoided. In patients with CKD 3/4, febuxostat dominated allopurinol for all cost-effectiveness outcome measures.

CONCLUSIONS

Febuxostat may be a cost-effective alternative to allopurinol, especially for patients with CKD stages 3 or 4.

Significance of the initiation time of urate-lowering therapy in gout patients: A retrospective research

OBJECTIVE

To evaluate the efficacy and safety of the initiation time of urate-lowering treatments (ULT) in gout patients.

METHOD

We retrospectively reviewed patients who were diagnosed with gout and were treated with ULT for at least 3 years. They were divided into two groups: group 1: 123 patients initiating ULT during an acute attack of gout; group 2: 457 patients prescribed ULT after an acute attack. Both demographic and clinical characteristics associated with gout were analyzed.

RESULTS

Comparing patients in group 1 versus group 2: the former exhibited a shorter duration of gout (6.3±2.1 vs. 8.9±3.3 years). At the baseline, there was no significant difference in mean serum urate (SU; 7.8±1.4mg/dL vs. 7.9±1.9mg/dL, respectively). SU target levels (<6.0mg/dL) were achieved by 66.7 and 65.6% of the patients, respectively. The duration from initiation of ULT until the SU target was attained was lower in group 1 than in group 2. During the first 12 weeks, patients on ULT in group 1 had higher attack rates than those in group 2. The incidence of chronic kidney disease increased in percentage in group 1 was lower than in group 2.

CONCLUSIONS

Our survey revealed that in patients experiencing acute gout, initiation of ULT decreased the time required to reach the target SU and the incidence of CKD, but the attack rate was greater in the first 12 weeks.

Modifiable factors associated with allopurinol adherence and outcomes among patients with gout in an integrated healthcare system

OBJECTIVE

To identify modifiable patient and provider factors associated with allopurinol adherence and the achievement of a serum urate acid (SUA) goal in gout.

METHODS

We identified a retrospective cohort of patients with gout, newly treated with allopurinol. All patient data came from administrative datasets at a large integrated health delivery system. Patients were ≥ 18 years old at time of initial allopurinol dispensing, and had 12 months or more of membership and drug eligibility prior to the index date. Allopurinol adherence was defined as a proportion of days covered ≥ 0.80, evaluated during the first 12 months of observation after the initial dispensing. Multivariable logistic regression was used to examine factors associated with allopurinol nonadherence and attaining an SUA concentration < 6.0 mg/dl.

RESULTS

We identified 13,341 patients with gout with incident allopurinol use (mean age 60 yrs, 78% men). Of these, 9581 patients (72%) had SUA measured both at baseline and during followup. Only 3078 patients (32%) attained an SUA target of < 6.0 mg/dl during followup. Potentially modifiable factors associated with treatment adherence and obtaining the SUA goal in the multivariable analysis included concomitant diuretic use, prescriber specialty, and allopurinol dosing practices. Adherent patients were 2.5-fold more likely than nonadherent patients to achieve an SUA < 6.0 mg/dl during observation.

CONCLUSION

Among patients with gout initiating allopurinol in our study, 68% did not reach the SUA goal and 57% of patients were nonadherent. Modifiable factors, including allopurinol dose escalation, treatment adherence, rheumatology referral, and concomitant medication use, could be important factors to consider in efforts aimed at optimizing gout treatment outcomes.

Uricosuric medications for chronic gout

BACKGROUND

Uricosuric agents have long been used in the treatment of gout but there is little evidence regarding their benefit and safety in this condition.

OBJECTIVES

To assess the benefits and harms of uricosuric medications in the treatment of chronic gout.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 4, 2013), Ovid MEDLINE and Ovid EMBASE for studies to the 13 May 2013. We also searched the World Health Organization Clinical Trials Registry, ClinicalTrials.gov and the 2011 to 2012 American College of Rheumatology and European League against Rheumatism abstracts. WE considered black box warnings and searched drug safety databases to identify and describe rare adverse events.

SELECTION CRITERIA

We considered all randomised controlled trials (RCTs) or quasi-randomised controlled trials (controlled clinical trials (CCTs)) that compared uricosuric medications (benzbromarone, probenecid or sulphinpyrazone) alone or in combination with another therapy (placebo or other active uric acid-lowering medication, or non-pharmacological treatment) in adults with chronic gout for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the studies for inclusion, extracted data and performed a risk of bias assessment. Main outcomes were frequency of acute gout attacks, serum urate normalisation, study participant withdrawal due to adverse events, total adverse events, pain reduction, function and tophus regression.

MAIN RESULTS

The search identified four RCTs and one CCT that evaluated the benefit and safety of uricosurics for gout. One study (65 participants) compared benzbromarone with allopurinol for a duration of four months; one compared benzbromarone with allopurinol (36 participants) for a duration of nine to 24 months; one study (62 participants) compared benzbromarone with probenecid for two months and one study (74 participants) compared benzbromarone with probenecid. One study (37 participants) compared allopurinol with probenecid. No study was completely free from bias.Low-quality evidence from one study (55 participants) comparing benzbromarone with allopurinol indicated uncertain effects in terms of frequency of acute gout attacks (4% with benzbromarone versus 0% with allopurinol; risk ratio (RR) 3.58, 95% confidence interval (CI) 0.15 to 84.13), while moderate-quality evidence from two studies (101 participants; treated for four to nine months) indicated similar proportions of participants achieving serum urate normalisation (73.9% with benzbromarone versus 60% with allopurinol; pooled RR 1.27, 95% CI 0.90 to 1.79). Low-quality evidence indicated uncertain differences in withdrawals due to adverse events (7.1% with benzbromarone versus 6.1% with allopurinol; pooled RR 1.25, 95% CI 0.28 to 5.62), and total adverse events (20% with benzbromarone versus 6.7% with allopurinol; RR 3.00, 95% CI 0.64 to 14.16). The study did not measure pain reduction, function and tophus regression.When comparing benzbromarone with probenecid, there was moderate-quality evidence based on one study (62 participants) that participants taking benzbromarone were more likely to achieve serum urate normalisation after two months (81.5% with benzbromarone versus 57.1% with probenecid; RR 1.43, 95% CI 1.02 to 2.00). This indicated that when compared with probenecid, five participants needed to be treated with benzbromarone in order to have one additional person achieve serum urate normalisation (number needed to treat for an additional beneficial outcome (NNTB) 5). However, the second study reported no difference in the absolute decrease in serum urate between these groups after 12 weeks. Low-quality evidence from two studies (129 participants) indicated uncertain differences between treatments in the frequency of acute gout attacks (6.3% with benzbromarone versus 10.6% with probenecid; pooled RR 0.73, 95% CI 0.09 to 5.83); fewer withdrawals due to adverse events with benzbromarone (2% with benzbromarone versus 17% with probenecid; pooled RR 0.15, 95% CI 0.03 to 0.79, NNTB 7) and fewer total adverse events (21% with benzbromarone versus 47% with probenecid; pooled RR 0.43, 95% CI 0.25 to 0.74; NNTB 4). The studies did not measure pain reduction, function and tophus regression.Low-quality evidence based on one small CCT (37 participants) indicated uncertainty around the difference in the incidence of acute gout attacks between probenecid and allopurinol after 18 to 20 months' treatment (53% with probenecid versus 55% with allopurinol; RR 0.96, 95% CI 0.53 to 1.75). The study did not measure or report the proportion achieving serum urate normalisation, pain reduction, function, tophus regression, withdrawal due to adverse events and total adverse events.

AUTHORS' CONCLUSIONS

There was moderate-quality evidence that there is probably no important difference between benzbromarone and allopurinol at achieving serum urate normalisation, but that benzbromarone is probably more successful than probenecid at achieving serum urate normalisation in people with gout. There is some uncertainty around the effect estimates, based on low-quality evidence from only one or two trials, on the number of acute gout attacks, the number of withdrawals due to adverse events or the total number of participants experiencing adverse events when comparing benzbromarone with allopurinol. However, when compared with probenecid, benzbromarone resulted in fewer withdrawals due to adverse events and fewer participants experiencing adverse events. Low-quality evidence from one small study indicated uncertain effects in the incidence of acute gout attacks when comparing probenecid with allopurinol therapy. We downgraded the evidence because of a possible risk of performance and other biases and imprecision.

Prophylaxis for acute gout flares after initiation of urate-lowering therapy

This review summarizes evidence relating to prophylaxis for gout flares after the initiation of urate-lowering therapy (ULT). We searched MEDLINE via PubMed for articles published in English from 1963 to 2013 using MEsH terms covering all aspects of prophylaxis for flares. Dispersion of monosodium urate crystals during the initial phase of deposit dissolution with ULT exposes the patient to an increased rate of acute flares that could contribute to poor treatment adherence. Slow titration of ULT might decrease the risk of flares. According to the most recent international recommendation, the two first-line options for prophylaxis are low-dose colchicine (0.5 mg once or twice a day) or low-dose NSAIDs such as naproxen 250 mg orally twice a day. They can be given for up to 6 months. If these drugs are contraindicated, not tolerated or ineffective, low-dose corticosteroids (prednisone or prednisolone) might be used. Recently, reports for four trials described the efficacy of canakinumab and rilonacept, two IL-1 inhibitors, for preventing flares during the initiation of allopurinol therapy. Prophylaxis for flares induced by ULT is an important consideration in gout management. Low-dose colchicine and low-dose NSAIDs are the recommended first-line therapies. Although no IL-1 blockers are approved as prophylactic treatment, this class of drug could become an interesting option for patients with gout with intolerance or contraindication to colchicine, NSAIDs or corticosteroids.

Facilitators and barriers to adherence to urate-lowering therapy in African-Americans with gout: a qualitative study

Introduction

Limited literature exists for qualitative studies of medication adherence in gout, especially in African-Americans. The aim of this study was to examine the facilitators and barriers to adherence to urate-lowering therapy (ULT) in African-Americans with gout.

Methods

In this study, nine nominal groups lasting 1 to 1.5 hours each were conducted in African-Americans with gout, six with low ULT and three with high ULT adherence (medication possession ratios of <0.80 or ≥0.80, respectively). Patients presented, discussed, combined and rank ordered their concerns. A qualitative analysis was performed.

Results

This study included 43 patients with mean age 63.9 years (standard deviation, 9.9), 67% men, who participated in nine nominal groups (seven in men, two in women): African-American men (n = 30); African-American women (n = 13). The main facilitators to ULT adherence (three groups) were the recognition of the need to take ULT regularly to prevent gout flares, prevent pain from becoming chronic/severe and to have less dietary restriction; the lack of side effects from ULT; trust in physicians; and avoiding the need to seek emergent/urgent care for flares. Patients achieved high ULT adherence by organizing their pills using the pillbox and the incorporation of ULT intake into their routine to prevent forgetting. The main barriers to optimal ULT adherence were (six groups): doubts about effectiveness of ULT, concerns about cost and side effects, concomitant medications, forgetfulness, refilling the prescriptions on time, pill size and difficulty in swallowing, competing priorities, patient preference for alternative medicines (that is, cherry juice) and frequent travel.

Conclusions

Identification of facilitators and barriers to high ULT adherence in African-Americans with gout in this study lays the foundation for designing interventions to improve ULT adherence in racial minorities.

Current concepts in the treatment of gouty arthritis

Gouty arthritis is an extremely painful condition that causes functional impairment. Gouty arthritis has become increasingly complex because of multiple comorbidities, iatrogenic factors and hyperuricemia that is refractory to treatment. In this review, we present a general overview of gouty arthritis including its pathophysiology, clinical presentations, diagnosis, predisposing factors and prophylactic therapy for preventing gouty arthritis flares.

Febuxostat for treating chronic gout

BACKGROUND

Gout is the most common inflammatory arthritis in men over 40 years and has an increasing prevalence among postmenopausal women. Lowering serum uric acid levels remains one of the primary goals in the treatment of chronic gout. In clinical trials, febuxostat has been shown to be effective in lowering serum uric acid levels to < 6.0 mg/dL.

OBJECTIVES

To evaluate the benefits and harms of febuxostat for chronic gout.

SEARCH METHODS

We searched The Cochrane Library, MEDLINE, EMBASE, and International Pharmaceutical Abstracts from inception to July 2011. The ClinicalTrials.gov website was searched for references to trials of febuxostat. Our search did not include any restrictions.

SELECTION CRITERIA

Two authors independently reviewed the search results and disagreements were resolved by discussion. We included any controlled clinical trial or open label trial (OLT) using febuxostat at any dose.

DATA COLLECTION AND ANALYSIS

Data and risk of bias were independently extracted by two authors and summarised in a meta-analysis. Continuous data were expressed as mean difference and dichotomous data as risk ratio (RR).

MAIN RESULTS

Four randomised trials and two OLTs with 3978 patients were included. Risk of bias differed by outcome, ranging from low to high risk of bias. Included studies failed to report on five to six of the nine outcome measures recommended by OMERACT. Patients taking febuxostat 120 mg and 240 mg reported more frequent gout flares than in the placebo group at 4 to 28 weeks (RR 1.7; 95% CI 1.3 to 2.3, and RR 2.6; 95% CI 1.8 to 3.7 respectively). No statistically significant differences were observed at 40 mg and 80 mg. Compared to placebo, patients on febuxostat 40 mg were 40.1 times more likely to achieve serum uric acid levels < 6.0 mg/dL at 4 weeks (95% CI 2.5 to 639), with an absolute treatment benefit of 56% (95% CI 37% to 71%). For febuxostat 80 mg and 120 mg, patients were 68.9 and 80.7 times more likely to achieve serum uric acid levels < 6.0 mg/dL at their final visit compared to placebo (95% CI 13.8 to 343.9, 95% CI 16.0 to 405.5), respectively; with an absolute treatment benefit of 75% and 87% (95% CI 68 to 80% and 81 to 91%), respectively. Total discontinuation rates were significantly higher in the febuxostat 80 mg group compared to placebo (RR 1.4; 95% CI 1.0 to 2.0, absolute risk increase 11%; 95% CI 3 to 19%). No other differences were observed.When comparing allopurinol to febuxostat at 24 to 52 weeks, the number of gout flares was not significantly different between the two groups, except for febuxostat 240 mg (RR 2.3; 95% CI 1.7 to 3.0). Patients on febuxostat 40 mg showed no statistically significant differences in benefits or harms. Patients on febuxostat 80 mg and 120 mg were 1.8 and 2.2 times more likely to achieve serum uric acid levels < 6.0 mg/dL at their final visit (95% CI 1.6 to 2.2, 95% CI 1.9 to 2.5) with an absolute treatment benefit of 29% and 44% (95% CI 25% to 33%, 95% CI 38% to 50%), respectively, at 24 to 52 weeks. Total discontinuation rates were higher for febuxostat 80 mg and 120 mg compared to allopurinol (RR 1.5; 95% CI 1.2 to 1.8, absolute risk increase 11%; 95% CI 6% to 16%; and RR 2.6; 95% CI 2.0 to 3.3, absolute risk increase 20%; 95% CI 3% to 14%, respectively). Discontinuations due to adverse events were similar across groups. Total adverse events were lower for febuxostat 80 mg and 120 mg compared with allopurinol (RR 0.93; 95% CI 0.87 to 0.99, absolute risk increase 6%; 95% CI 0.7% to 11%; and RR 0.90; 95% CI 0.84 to 0.96, absolute risk increase 8%; 95% CI 3% to 13%, respectively). No other relevant differences were noted.After 3 years of follow-up there were no statistically significant differences regarding effectiveness and harms between febuxostat 80 mg or 120 mg and allopurinol groups (adverse event rate per 100 patient-years 227, 216, and 246, respectively).

AUTHORS' CONCLUSIONS

Although the incidence of gout flares requiring treatment may be increased in patients taking febuxostat compared to placebo or allopurinol during early treatment, no such increase in gout flares was observed in the long-term follow-up study when compared to allopurinol. Febuxostat at any dose was shown to be beneficial in achieving serum uric acid levels < 6.0 mg/dL and reducing serum uric acid levels in the period from baseline to final visit when compared to placebo and to allopurinol. However, the grade of evidence ranged from low to high, which indicates that further research is needed.

The rheumatology of gout

Gout is a metabolic disorder of purine metabolism with primary manifestations of acute and chronic arthritis and tophus formation. The prevalence of gout appears to be increasing and may affect up to 8 million people in the United States. The development of novel therapies for gout after a 40-year hiatus has opened new understanding of this disease. In addition to causing severe musculoskeletal pain, gout is associated with impaired quality of life, reduced functional status, and injury to joints. The quality of care for many patients with gout is unfortunately not in keeping with current guidelines. The approval of new therapies to treat hyperuricemia, such as febuxostat and pegloticase, has increased our knowledge of the challenges of adequately controlling the disease. Rather than providing a comprehensive overview of gout, this review focuses on new developments in the clinical aspects of gout and highlights advances in the drug therapy of gout.