The impact of gout on work absence and productivity

Course and predictors of work productivity in gout - results from the NOR-Gout longitudinal 2-year treat-to-target study

OBJECTIVES

In patients with gout there is a lack of longitudinal studies on the course of work productivity. We explored longitudinal changes in and predictors of work productivity over 2 years.

METHODS

Patients in the NOR-Gout observational study with a recent gout flare and serum urate (sUA) >360 µmol/l attended tight-control visits during escalating urate lowering therapy according to a treat-to-target strategy. From the Work Productivity and Activity Impairment (WPAI) questionnaire, scores for work productivity and activity impairment were assessed over 2 years together with the Beliefs about Medicines Questionnaire and a variety of demographic and clinical variables.

RESULTS

At baseline patients had a mean age of 56.4 years and 95% were males. WPAI scores at baseline were 5.0% work missed (absenteeism), 19.1% work impairment (presenteeism), 21.4% overall work impairment and 32.1% activity impairment. Work productivity and activity impairment improved during the first months, and remained stable at 1 and 2 years. Comorbidities were not cross-sectionally associated with WPAI scores at baseline, but predicted worse work impairment and activity impairment at year 1. The Beliefs about Medicines Questionnaire subscale with concerns about medicines at baseline independently predicted worse overall work impairment and worse activity impairment at year 1.

CONCLUSIONS

In patients with gout who were intensively treated to the sUA target, work productivity and activity impairment were largely unchanged and at 1 year predicted by comorbidities and patient concerns about medication.

Measuring, Analyzing, and Presenting Work Productivity Loss in Randomized Controlled Trials: A Scoping Review

OBJECTIVES

This study aimed to conduct a scoping review of randomized controlled trials (RCTs) and investigate which work productivity loss outcomes were measured in these RCTs, how each outcome was measured and analyzed, and how the results for each outcome were presented.

METHODS

A systematic search was conducted from January 2010 to April 2020 from 2 databases: PubMed and Cochrane Central Register of Controlled Trials. Data on country, study population, disease focus, sample size, work productivity loss outcomes measured (absenteeism, presenteeism, employment status changes), and methods used to measure, report, and analyze each work productivity loss outcome were extracted and analyzed.

RESULTS

We found 435 studies measuring absenteeism or presenteeism, of which 155 studies (35.6%) measured both absenteeism and presenteeism and were included in our final review. Only 9 studies also measured employment status changes. The most used questionnaire was the Work Productivity and Activity Impairment Questionnaire. The analysis of absenteeism and presenteeism data was mostly done using regression models (n = 98, n = 98, respectively) for which a normal distribution was assumed (n = 77, n = 89, respectively). Absenteeism results were most often presented in time whereas presenteeism was commonly presented using a percent scale or score.

CONCLUSIONS

There is a lack of consensus on how to measure, analyze, and present work productivity loss outcomes in RCTs published in the past 10 years. The diversity of measurement, analysis, and presentation methods used in RCTs may make comparability challenging. There is a need for guidelines providing recommendations to standardize the comprehensiveness and the appropriateness of methods used to measure, analyze, and report work productivity loss in RCTs.

Working From Home During the COVID-19 Pandemic: The Association With Work Productivity Loss Among Patients and Caregivers

OBJECTIVE

The aim of this study was to measure the association of working from home (WFH) with work productivity loss due to caregiving responsibilities or health problems during the COVID-19 pandemic.

METHODS

We conducted an online survey of family/friend caregivers (n = 150 WFH/75 non-WFH) and patients (n = 95/91) who worked during the past 7 days in May and July 2020, respectively. Absenteeism and presenteeism were measured using the Valuation of Lost Productivity questionnaire.

RESULTS

Working from home was associated with higher odds of absenteeism (odds ratio, 2.53; 95% confidence interval, 1.11 to 5.77) and presenteeism (2.79; 1.26 to 6.18) among caregivers and higher odds of presenteeism among patients (2.78; 1.13 to 6.84). However, among caregivers with absenteeism more than 0 days, WFH was significantly associated with fewer absent workdays.

CONCLUSIONS

Working from home was not associated with overall absenteeism and presenteeism in caregivers or patients. Working from home allows a more flexible and inclusive workplace without impacting productivity, although further research is needed.

Comparison of Benzbromarone and Allopurinol on Primary Prevention of the First Gout Flare in Asymptomatic Hyperuricemia

Objectives. Whether uric acid-lowering agent use in asymptomatic hyperuricemia can reduce the development of the first gout flare remains unsettled. The goal of the present research was to test the efficacy of benzbromarone and allopurinol on primary prevention of the first gout flare in persons with asymptomatic hyperuricemia in Taiwan. Methods. One observational cohort study was constructed to examine the 2001−2015 dataset adapted from the National Health Insurance Program of Taiwan containing the claims data of 2 million beneficiaries. Asymptomatic hyperuricemia was considered as individuals on uric acid-lowering therapy who did not have gout flares. Individuals aged 20−84 without gout flares who had the use of benzbromarone alone were assigned into a benzbromarone group. Individuals ages 20−84 without gout flares who had the use of allopurinol alone were assigned into an allopurinol group. The final study included 6111 pairs of 1:1 propensity score-matched individuals from both benzbromarone and allopurinol groups. The end point was assigned as individuals who were newly diagnosed with their first gout flare. The incidence rate of the first gout flare was estimated between the benzbromarone and allopurinol groups. A Cox proportional hazards regression model was applied to explore the hazard ratio and 95% confidence interval of the first gout flare related to benzbromarone use and allopurinol use. Results. The incidence rate of the first gout flare was lower in the benzbromarone group compared with an allopurinol group (3.29 versus 5.46 per 1000 person-months, incidence rate ratio = 0.60 and 95% confidence interval = 0.56−0.64). After adjustment for co-variables, the adjusted hazard ratio of the first gout flare was 0.63 (95% confidence interval = 0.59−0.68, p < 0.001) for the benzbromarone group when compared with the allopurinol group. Conclusion. People with asymptomatic hyperuricemia taking benzbromarone have a lower hazard of developing their first gout flare when compared with those taking allopurinol. Based on the medication safety, the therapeutic effects and the low price, with oral administration once daily, we suggest that benzbromarone should be the first drug of choice if clinicians are treating asymptomatic hyperuricemia.

Relationship between hyperuricemia with deposition and sexual dysfunction in males and females

PURPOSE

The association between gout, the most common crystal arthropathy, and sexual dysfunctions has often been investigated by studies in the last decades. Despite the presence of shared risk factors and comorbidities and the possible effects on sexual health of long-term gout complications, awareness of this association is severely lacking and the pathogenetic mechanisms have only partially been identified. In the present review, we aimed to investigate the current evidence regarding the potential mechanisms linking sexual dysfunctions and gout.

METHODS

A comprehensive literature search within PubMed was performed to provide a summary of currently available evidence regarding the association between gout and sexual dysfunctions.

RESULTS

Gout and sexual dysfunctions share several risk factors, including diabesity, chronic kidney disease, hypertension, metabolic syndrome, and peripheral vascular disease. Gout flares triggered by intense inflammatory responses feature severe pain and disability, resulting in worse sexual function, and some, but not all, treatments can also impair sexual health. Long-term gout complications can result in persistent pain and disability due to joint deformity, fractures, or nerve compression, with negative bearing on sexual function. The presence of low-grade inflammation impairs both sex steroids synthesis and endothelial function, further advancing sexual dysfunctions. The psychological burden of gout is another issue negatively affecting sexual health.

CONCLUSIONS

According to currently available evidence, several biological and psychological mechanisms link sexual dysfunctions and gout. Addressing risk factors and providing adequate treatment could potentially have beneficial effects on both conditions. Appropriate clinical evaluation and multidisciplinary approach are recommended to improve patient care.

Quality of care in people requiring hospital admission for gout in Aotearoa New Zealand: a nationwide analysis

AIMS

To understand national trends in hospital admission for a primary diagnosis of gout in Aotearoa New Zealand over the past 10 years and the quality of care for gout received by these patients before and after the admission.

METHODS

Data from the Aotearoa New Zealand National Collections from 1 January 2007 to 31 December 2019 were analysed to determine rates of hospital admission for a primary diagnosis of gout. Admission data including cost-weight analysis, as well as quality of care data including gout-specific medication dispensing in the year prior and year after admission.

RESULTS

There were 13,721 admissions with a primary diagnosis of gout over the analysis period, with an average cost per admission in 2019 of NZD 4,301. The rate of admission per 100,000 population was highest in Pacific peoples followed by MĀori. Although dispensing of any allopurinol increased in the year after admission, rates of regular allopurinol dispensing remained low; 38.1% for admissions in 2018. Patients who were younger (especially 20-44 years), not enrolled in a primary health organisation before admission, and female had lower rate of regular allopurinol after admission.

CONCLUSION

In this nationwide study, rates of admission for gout were highest in Pacific peoples and in MĀori. Rates of regular allopurinol dispensing was low even after admission for a primary diagnosis of gout. These findings highlight the need for improvements in gout management in Aotearoa New Zealand, including in post-discharge planning from secondary care inpatient services. This article is protected by copyright. All rights reserved.

How to analyze work productivity loss due to health problems in randomized controlled trials? A simulation study

Background

An increasing number of randomized controlled trials (RCTs) have measured the impact of interventions on work productivity loss. Productivity loss outcome is inflated at zero and max loss values. Our study was to compare the performance of five commonly used methods in analysis of productivity loss outcomes in RCTs.

Methods

We conducted a simulation study to compare Ordinary Least Squares (OLS), Negative Binominal (NB), two-part models (the non-zero part following truncated NB distribution or gamma distribution) and three-part model (the middle part between zero and max values following Beta distribution). The main number of observations each arm, N_obs, that we considered were 50, 100 and 200. Baseline productivity loss was included as a covariate.

Results

All models performed similarly well when baseline productivity loss was set at the mean value. When baseline productivity loss was set at other values and N_obs = 50 with ≤5 subjects having max loss, two-part models performed best if the proportion of zero loss> 50% in at least one arm and otherwise, OLS performed best. When N_obs = 100 or 200, the three-part model performed best if the two arms had equal scale parameters for their productivity loss outcome distributions between zero and max values.

Conclusions

Our findings suggest that when treatment effect at any given values of one single covariate is of interest, the model selection depends on the sample size, the proportions of zero loss and max loss, and the scale parameter for the productivity loss outcome distribution between zero and max loss in each arm of RCTs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-021-01330-w.

Managing hyperuricemia and gout in chronic kidney disease: a clinical conundrum

PURPOSE OF REVIEW

There is controversy regarding the impact of hyperuricemia on the progression of chronic kidney disease (CKD), and gout remains sub optimally managed in this population. We discuss the prescribing of drugs for the treatment of gout in patients with CKD.

RECENT FINDINGS

There is a lack of consensus from expert guidelines, and prescribers have concerns regarding the risk of adverse reactions from medicines used to treat gout. These situations appear to contribute to suboptimal management of gout in this cohort. Recent data have challenged the role of urate lowering therapy (ULT) in the management of asymptomatic hyperuricemia in CKD.

SUMMARY

ULT should be commenced in all patients with severe, recurrent disease, tophaceous gout and evidence of joint damage. Most international guidelines recommend a treat-to-target approach for the management of gout. In CKD, ULT should be started at low dose with up titration adjusted to serum urate levels, rather than being based on the creatinine clearance. If patients fail first-line therapy, alternative agents are utilized, the specific agent depending on ease of access, burden of disease and other comorbidities. This approach should be incorporated into routine practice to ensure optimal treatment of gout in CKD. More research is required to investigate whether treatment of asymptomatic hyperuricemia has clinical benefits.

Effect of canakinumab on clinical and biochemical parameters in acute gouty arthritis: a meta-analysis

BACKGROUND

Targeted anti-IL-1β therapy may be a valuable option for the management of gouty arthritis. The present meta-analysis has evaluated the effect of canakinumab, an anti-IL-1β monoclonal antibody in gouty arthritis.

METHODS

A standard meta-analysis protocol was developed and after performing a comprehensive literature search in MEDLINE, Cochrane, and International Clinical Trial Registry Platform (ICTRP), reviewers assessed eligibility and extracted data from three relevant articles. A random-effects model was used to estimate the pooled effect size as the mean difference in Visual Analouge Scale (VAS) score, serum hsCRP, serum Amyloid A, and risk ratio for global assessment between the groups. Quality assessment was done using the risk of bias assessment tool and summary of findings was prepared using standard Cochrane methodology with GradePro GDT.

RESULTS

Treatment with canakinumab showed a mean reduction of VAS score by 14.59 mm [95% CI - 19.42 to - 9.77], serum hsCRP by 15.36 mg/L [95% CI 1.62-29.11], serum Amyloid A by 67.18 mg/L [95% CI 17.06-117.31], and improvement in patient global assessment (RR = 1.478; 95% CI 1.29-1.67) and physician global assessment (RR = 1.44; 95% CI 1.28-1.61). The probability that future studies may have a mean difference in VAS score less than zero has been calculated to be 27.3% using a cumulative distribution function (CDF) calculator.

CONCLUSION

This meta-analysis shows the beneficial effect of canakinumab over triamcinolone by reducing VAS score, serum hsCRP, serum amyloid A, and improvement in global assessments in acute gouty arthritis.

Gender and Ethnic Inequities in Gout Burden and Management

Although effective and low-cost urate-lowering therapy has been available for decades, inequities in gout management exist. Despite high impact of disease, rates of urate-lowering therapy prescription are low in women, in African-Americans in the United States, in Māori (Indigenous New Zealanders), and in Pacific peoples living in Aotearoa/New Zealand. Social determinants of health, barriers to accessing the health care system, health literacy demands, stigmatization, and bias contribute to inequities in gout burden and management. Approaches that focus on building health literacy and delivering culturally safe care lead to improved outcomes in gout, and offer important solutions to achieve health equity.

The impact of gout as described by patients, using the lens of The International Classification of Functioning, Disability and Health (ICF): a qualitative study

Background

The International Classification of Functioning, Disability and Health (ICF) aims to comprehensively describe the ways in which a person’s health condition affects their life. This study aimed to contribute to the development of an ICF core set for gout through patient opinion derived from focus groups and interviews.

Methods

We conducted a secondary qualitative analysis of data from three studies investigating the patient experience of gout. In total there were 30 individual interviews and 2 focus groups (N = 17) comprising 47 participants. We conducted thematic analysis of the textual data to extract meaning units, which were then linked to the ICF.

Results

A large number of ICF categories were relevant to patients with gout. Participants mentioned 93 third level categories, 17 of which were mentioned by more than 50% of patients. The most references for a single category was for b280, Sensation of pain, followed by personal factors (not yet categorised by the ICF). The most participants mentioned the environmental factor e355, Health professional support, followed by b280, Sensation of pain.

Conclusion

The categories identified in this study as relevant to patients with gout highlight the severe pain associated with this disease, the impact on mobility and corresponding life areas. The roles of health professional support, medication, and personal attitudes to disease management are also reflected in the data. These results will contribute to the development of the ICF core set for gout.

Gout

Gout is a chronic disease caused by monosodium urate (MSU) crystal deposition. Gout typically presents as an acute, self-limiting inflammatory monoarthritis that affects the joints of the lower limb. Elevated serum urate level (hyperuricaemia) is the major risk factor for MSU crystal deposition and development of gout. Although traditionally considered a disorder of purine metabolism, altered urate transport, both in the gut and the kidneys, has a key role in the pathogenesis of hyperuricaemia. Anti-inflammatory agents, such corticosteroids, NSAIDs and colchicine, are widely used for the treatment of gout flare; recognition of the importance of NLRP3 inflammasome activation and bioactive IL-1β release in initiation of the gout flare has led to the development of anti-IL-1β biological therapy for gout flares. Sustained reduction in serum urate levels using urate-lowering therapy is vital in the long-term management of gout, which aims to dissolve MSU crystals, suppress gout flares and resolve tophi. Allopurinol is the first-line urate-lowering therapy and should be started at a low dose, with gradual dose escalation. Low-dose anti-inflammatory therapies can reduce gout flares during initiation of urate-lowering therapy. Models of care, such as nurse-led strategies that focus on patient engagement and education, substantially improve clinical outcomes and now represent best practice for gout management.

Gout Severity, Socioeconomic Status, and Work Absence: A Cross-Sectional Study in Primary Care

OBJECTIVE

To examine the association between gout severity and socioeconomic status (SES) and gout severity and work absence.

METHODS

Postal questionnaires were sent to adult patients who were registered with 20 general practices and who had consultations regarding gout or had been prescribed allopurinol or colchicine in the preceding 2 years. Gout severity was defined using the following proxy measures: number of attacks, history of oligoarticular/polyarticular attacks, disease duration, and allopurinol use. SES was defined using the English index of multiple deprivation (area level) and using self-reported educational attainment (individual level). Work absence was defined as taking time off from work in the past 6 months because of gout. Adjusted odds ratios (OR_adj ; 95% confidence intervals [95% CIs]) were calculated using logistic regression models (adjusted for age, sex, body mass index, gout severity, and comorbidities).

RESULTS

A total of 1,184 completed questionnaires were returned. The mean age of patients was 65.6 years, and 84% were male. Not having attended further education ("further education" is defined as attendance after the statutory minimum school-leaving age of 16 years) was associated with having had ≥2 gout attacks in the last year (OR_adj 0.54 [95% CI 0.36-0.81]) and oligoarticular/polyarticular attacks (OR_adj 0.72 [95% CI 0.50-1.05]). Lower area-level deprivation was associated with fewer attacks (≥2) (OR_adj 0.71 [95% CI 0.51-0.98]). Work absence was associated with having had ≥2 gout attacks in the last year (OR_adj 2.91 [95% CI 1.22- 6.92]), oligoarticular/polyarticular attacks (OR_adj 3.10 [95% CI 1.46-6.61]), and shorter disease duration (>18 years) (OR_adj 0.13 [95% CI 0.03-0.50]).

CONCLUSION

Gout severity was associated with individual-level deprivation, countering the historic and negative perception of gout as a "rich man's disease." The association of gout severity with work absence reinforces the argument for earlier urate-lowering therapy to prevent attacks from becoming frequent and debilitating.

Adherence and Outcomes with Urate-Lowering Therapy: A Site-Randomized Trial

PURPOSE

The purpose of this study was to test a pharmacist-led intervention to improve gout treatment adherence and outcomes.

METHODS

We conducted a site-randomized trial (n=1463 patients) comparing a 1-year, pharmacist-led intervention to usual care in patients with gout initiating allopurinol. The intervention was delivered primarily through automated telephone technology. Co-primary outcomes were the proportion of patients adherent (proportion of days covered ≥0.8) and achieving a serum urate <6.0 mg/dl at 1 year. Outcomes were reassessed at year 2.

RESULTS

Patients who underwent intervention were more likely than patients of usual care to be adherent (50% vs 37%; odds ratio [OR] 1.68; 95% confidence interval [CI] 1.30, 2.17) and reach serum urate goal (30% vs 15%; OR 2.37; 95% CI 1.83, 3.05). In the second year (1 year after the intervention ended), differences were attenuated, remaining significant for urate goal but not for adherence. The intervention was associated with a 6%-16% lower gout flare rate during year 2, but the differences did not reach statistical significance.

CONCLUSIONS

A pharmacist-led intervention incorporating automated telephone technology improved adherence and serum urate goal in patients with gout initiating allopurinol. Although this light-touch, low-tech intervention was efficacious, additional efforts are needed to enhance patient engagement in gout management and ultimately to improve outcomes.

Urate-Lowering Therapy in Moderate to Severe Chronic Kidney Disease

CONTEXT

Hyperuricemia is an independent risk factor for progression of kidney disease.

OBJECTIVE

To determine whether lowering serum uric acid level (sUA) to below 6 mg/dL (target) improves mild to moderate chronic kidney disease (CKD) and whether CKD stage influences the benefit of lowering sUA to target.

DESIGN

Retrospective epidemiologic cohort study conducted over 8 years. Estimated glomerular filtration rate (eGFR) was required in the 6 months preceding the index date (defined as first occurrence of sUA < 7 mg/dL), and at least 1 sUA and eGFR were required during follow-up. Patients were urate-lowering therapy (ULT) naïve, aged 18 years or older, and had CKD Stages 2 to 4 at baseline. Health Plan enrollment with drug benefit was required. Exclusions included active cancer, dialysis, or other kidney disease.

MAIN OUTCOME MEASURES

A 30% decrease or 30% improvement in eGFR from baseline.

RESULTS

A total of 12,751 patients met inclusion criteria; 2690 patients received ULT during follow-up and 10,061 did not. Target sUA was achieved in 1118 patients (42%) receiving ULT. A 30% improvement in eGFR was likelier in patients who achieved the target (odds ratio [OR] = 1.78, p < 0.001). Pairwise comparison of CKD stages showed a 30% improvement in eGFR in CKD Stage 2 (OR = 2.26, p = 0.017) and Stage 3 (OR = 2.23, p < 0.001) but not Stage 4 (OR = 1.50, p = 0.081).

CONCLUSION

Patients who achieve an American College of Rheumatology target sUA below 6 mg/dL during ULT have higher rates of eGFR improvement, especially in CKD Stages 2 and 3.

Design and Rationale for the Veterans Affairs "Cooperative Study Program 594 Comparative Effectiveness in Gout: Allopurinol vs. Febuxostat" Trial

BACKGROUND

Gout patients do not routinely achieve optimal outcomes related in part to suboptimal administration of urate lowering therapy (ULT) including first-line xanthine oxidase inhibitors allopurinol or febuxostat. Studies leading to the approval of febuxostat compared this agent to allopurinol in inappropriately low, fixed doses. We will compare allopurinol with febuxostat in gout using appropriately titrated doses of both agents and a "treat-to-target" strategy congruent with specialty guidelines.

METHODS

We have planned and initiated the Veterans Affairs (VA) Cooperative Study Program (CSP) 594, Comparative Effectiveness in Gout: Allopurinol vs Febuxostat study. This large double-blind, non-inferiority trial will enroll 950 gout patients randomized to receive allopurinol or febuxostat. Patients will be followed for a total of 72 weeks encompassing 3 distinct 24-week study phases. During Phase I (0-24 weeks), participants will undergo gradual dose titration of ULT until achievement of serum uric acid (sUA) <6.0 mg/dL or <5.0 mg/dL if tophi are present. Dose escalation will not be allowed during final three study visits of Phase 2 (24-48 weeks) and during Phase 3 (48-72 weeks). The primary study outcome is the proportion of participants experiencing at least one gout flare during Phase 3. Subsequent to the 72-week study, participants will be followed passively for up to 10 years after the study to assess long-term health outcomes.

CONCLUSION

With its completion, the VA Comparative Effectiveness in Gout: Allopurinol vs Febuxostat study will demonstrate the central role of gradual ULT dose escalation and a treat-to-target strategy in gout management.

Work disability in gout: a population-based case-control study

OBJECTIVES

To examine the extent and cost of work disability among patients with gout compared with matched population controls and to analyse predictors of work disability.

METHODS

A regional cohort study using data from Swedish national and regional registries from January 2000 through December 2012, including 4571 patients with gout of working age, with a first recorded diagnosis of gout in the years 2003-2009 and 22 482 population controls, matched by age, sex and place of residence. Differences in baseline characteristics (educational level, income, previous employment and comorbidities) and the number of work-loss days (absenteeism) due to sick leave and disability pension for 3 years after identification were calculated. Predictors for new-onset work absenteeism (>90 days/year) in a subset were determined by conditional logistic regression.

RESULTS

Patients with gout (median age 53 years) had significantly more comorbidities, lower income and lower level of education than matched controls. The average work absentee rate during the 3-year follow-up period was higher among patients with gout than controls, 22% and 14%, respectively (P<0.0001). New-onset absenteeism was in multivariate analyses significantly predicted by gout (OR 1.47; 95% CI 1.23 to 1.75). Other variables independently related to new-onset absenteeism were education ≤12 years, previous unemployment and history of sick leave, in addition to several comorbidities (renal disease, cardiovascular disease, alcohol abuse and obesity).

CONCLUSIONS

Gout is associated with substantially higher work absenteeism and costs for society due to productivity loss, after adjusting for associated comorbidities and socioeconomic differences. Whether more intensive treatment of gout is cost-effective needs to be addressed in future studies.

What Outcomes are Important for Gout Patients? In-Depth Qualitative Research into the Gout Patient Experience to Determine Optimal Endpoints for Evaluating Therapeutic Interventions

Background and Objectives

Characterized by sudden onset of severe joint pain, swelling, redness, and tenderness to touch, gout ‘flare ups’ have a substantial impact on quality of life (QoL). This research employed a patient-centered approach to explore the symptoms and impacts of gout, and assess the content validity of existing patient-reported outcomes (PROs).

Methods

Qualitative interviews were conducted with 30 US gout patients (non-tophaceous: n = 20, tophaceous: n = 10) and five expert rheumatologists. Each interview included both concept elicitation (CE) questioning to learn about the patient experience and cognitive debriefing to assess the content validity of three PRO instruments (HAQ-DI, GAQ, and TIQ-20). Nine of the patients provided further real-time qualitative data through a smart phone application. All qualitative data were subject to thematic analysis using Atlas.ti. Two patient advisors and three expert clinicians were engaged as advisors at key stages throughout the research.

Results

Interview and real-time data identified the same core symptoms and proximal impact concepts. Severe pain (typically in joints of extremities) was described as the cardinal symptom, often accompanied by swelling, redness, heat, sensitivity to touch, and stiffness. Domains of QoL impacted included physical functioning, sleep, daily activities, and work. The PRO instruments were generally well-understood by patients, but each included items with questionable relevance to at least some of the sample, dependent on the specific joints affected.

Conclusions

Gout patients experience severe pain in affected joints, resulting in substantial limitations in physical functioning. Both the HAQ-DI and the TIQ-20 are useful for specific research purposes in the gout population, although modifications are recommended.

Electronic supplementary material

The online version of this article (doi:10.1007/s40271-016-0184-x) contains supplementary material, which is available to authorized users.

Effectiveness of an electronic patient-centred self-management tool for gout sufferers: a cluster randomised controlled trial protocol

INTRODUCTION

Gout is increasing despite effective therapies to lower serum urate concentrations to 0.36 mmol/L or less, which, if sustained, significantly reduces acute attacks of gout. Adherence to urate-lowering therapy (ULT) is poor, with rates of less than 50% 1 year after initiation of ULT. Attempts to increase adherence in gout patients have been disappointing. We aim to evaluate the effectiveness of use of a personal, self-management, 'smartphone' application (app) to achieve target serum urate concentrations in people with gout. We hypothesise that personalised feedback of serum urate concentrations will improve adherence to ULT.

METHODS AND ANALYSIS

Setting and designPrimary care. A prospective, cluster randomised (by general practitioner (GP) practices), controlled trial.

PARTICIPANTS

GP practices will be randomised to either intervention or control clusters with their patients allocated to the same cluster.

INTERVENTION

The intervention group will have access to the Healthy.me app tailored for the self-management of gout. The control group patients will have access to the same app modified to remove all functions except the Gout Attack Diary.

PRIMARY AND SECONDARY OUTCOMES

The proportion of patients whose serum urate concentrations are less than or equal to 0.36 mmol/L after 6 months. Secondary outcomes will be proportions of patients achieving target urate concentrations at 12 months, ULT adherence rates, serum urate concentrations at 6 and 12 months, rates of attacks of gout, quality of life estimations and process and economic evaluations. The study is designed to detect a ≥30% improvement in the intervention group above the expected 50% achievement of target serum urate at 6 months in the control group: power 0.80, significance level 0.05, assumed 'dropout' rate 20%.

ETHICS AND DISSEMINATION

This study has been approved by the University of New South Wales Human Research Ethics Committee. Study findings will be disseminated in international conferences and peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ACTRN12616000455460.

Treatment approaches and adherence to urate-lowering therapy for patients with gout

Gout is the most common inflammatory arthritis characterized by painful disabling acute attacks. It is caused by hyperuricemia and deposition of urate crystals in and around the joints. Long-standing untreated hyperuricemia can lead to chronic arthritis with joint damage, tophi formation and urate nephropathy. Gout is associated with significant morbidity and health care associated cost. The goal of long-term therapy is to lower the serum urate level to promote dissolution of urate crystals, reduce recurrent acute gout flares, resolve tophi and prevent joint damage. Despite the presence of established gout treatment guidelines and effective medications to manage gout, patient outcomes are often poor. Etiology for these shortcomings is multifactorial including both physician and patient characteristics. Poor adherence to urate-lowering therapy (ULT) is prevalent and is a significant contributor to poor patient outcomes. This article reviews the treatment strategies for the management of hyperuricemia in chronic gout, gaps in quality of care in gout management, factors contributing to poor adherence to ULT and discusses potential interventions to achieve improved gout-related outcomes. These interventions include initiation of prophylactic anti-inflammatory medication when starting ULT, frequent follow-ups, regular serum urate monitoring and improved patient education, which can be achieved through pharmacist- or nurse-assisted programs. Interventions such as these could improve adherence to ULT and, ultimately, result in optimal gout-related outcomes.

The Direct Economic Burden of Gout in an Elderly Canadian Population

Objective.

To estimate the direct healthcare cost and resource use from the public payer perspective between patients with incident gout and matched gout-free patients in Ontario.

Methods.

Patients with incident gout aged ≥ 66 with uninterrupted Ontario Health Insurance Plan (OHIP) coverage in the 1-year baseline period were included in the study. Patients with gout were indexed at first gout diagnosis or prescription over the study period April 1, 2008, to March 31, 2014. Gout-free patients with no gout diagnosis within history were matched (up to 5:1) to each patient with gout. Linked medical records were analyzed until end of study, death, or OHIP ineligibility. Bang and Tsiatis adjusted healthcare costs and resource use were compared using bootstrap p-values and 95% CI.

Results.

A total of 29,894 patients with gout and 148,231 gout-free patients were included in the study. Patients were 56% male, had a median Adjusted Clinical Group healthcare resource use band of moderate morbidity, and had a median age of 75–79 years. Baseline comorbidities were similar between groups except for renal disease. Analyzing 5-year total healthcare costs, patients with gout ($44,297) incurred a significantly higher average healthcare cost compared to gout-free patients ($33,965), for an incremental cost of $10,332 (95% CI $9617–$11,039; p < 0.01). Similar trends were observed in all individual healthcare component cost and use metrics.

Conclusion.

Following onset of gout, patients in Ontario incur significantly greater healthcare costs and resource use compared to matched gout-free patients. Alternative gout management strategies should be investigated to reduce the incremental burden of gout borne by the Ontario healthcare system.

The Human and Economic Burden of Difficult-to-Treat Gouty Arthritis

Gouty arthritis, one of the most painful and common forms of adult arthritis, is caused by monosodium urate crystal deposits in joints, most often in the lower extremities. Crystals trigger an inflammatory response leading to acute flares characterized by a rapid onset of pain, warmth, swelling, and redness in involved joints. Over time, continued monosodium urate crystal deposits and inflammation can lead to chronic tophaceous gout that result in bone erosion, progressing to joint destruction and significant disability. The goal of therapy in an acute gout flare is prompt and safe termination of pain and inflammation. Acute gouty arthritis is usually treated with nonsteroidal anti-inflammatory drugs, colchicine, or corticosteroids. However, for a growing number of patients, current standard treatments are ineffective or are contraindicated, largely due to the presence of comorbidities. Gouty arthritis can have a major negative impact of health-related quality of life, especially in patients with difficult-to-treat disease, as revealed by recent studies comparing health-related quality of life with that of the general population. Additionally, gouty arthritis also constitutes an important economic burden through absence from work and medical costs. This burden is even greater in patients with difficult-to-treat disease.

Gouty arthropathy: Review of clinico-pathologic and imaging features

Gout is a common inflammatory arthropathy in adults, with the prevalence increasing in males of older age. It occurs when monosodium urate (MSU) crystals are deposited in joints and connective tissue causing inflammation. The gold standard for the diagnosis of gout is the demonstration of negatively birefringent, needle-shaped MSU crystals through synovial fluid aspiration. However, this is an invasive technique and may not always be conclusive or feasible. Imaging techniques have been developed to aid in diagnosis of gout non-invasively. Radiography has a low utility in the early diagnosis of gout and demonstrates erosions in late stages. Ultrasound (US) has a high overall sensitivity in diagnosing gout with the 'double contour' sign having a high specificity. Magnetic resonance imaging is good at detecting tophi, bone marrow oedema and erosions, but has a limited role in diagnosis because of its high cost and limited availability. Conventional computed tomography (CT) has no role in the routine diagnosis of gout before development of erosions and tophi. A newer technology, dual-energy CT (DECT) has been shown to be able to detect MSU crystals burden with high accuracy. It has a higher specificity and lower sensitivity that US in gout diagnosis. However, because of radiation exposure and cost, it has a better utility in diagnosing clinically suspected gout complicated by other concurrent rheumatologic conditions or if radiography, US and synovial aspiration are inconclusive or not feasible. This paper will review the clinico-pathologic and imaging features of gouty arthropathy.

Overcoming adherence issues and other barriers to optimal care in gout

PURPOSE OF REVIEW

This review presents research published over the last year examining use of urate-lowering therapy (ULT) as well as trends over time in adherence to this class of agents. Additionally, it explores factors associated with nonadherence to ULTs for chronic gout and interventions to improve chronic gout management.

RECENT FINDINGS

New literature suggests prescriptions of ULTs for prevalent and incident gout patients remains lower than expected based on the burden of the disease in the population. Overall ULT adherence remains suboptimal, in part related to inadequate patient education and copayment costs; although one study demonstrated improvement in adherence over a 15-year study period. Finally, interventions that include patient education and medication titration based on laboratory results successfully lowered serum urate levels to less than 6 mg/dl in the majority of patients.

SUMMARY

Gout remains a prevalent disease that is poorly managed despite effective treatments. Recent research suggests that ULTs are underutilized and even when prescribed are not well adhered to. Patient-centered interventions that focus on education about pharmacologic therapy and lifestyle modifications with medication titration have resulted in a greater proportion of patients achieving recommended serum urate levels.

"You want to get on with the rest of your life": a qualitative study of health-related quality of life in gout

The objective of the study is to examine the impact of gout and its treatments on health-related quality of life (HRQOL) using focus group interviews. From the baseline phase of a cohort study of HRQOL in gout, 17 participants (15 males, mean age 71 years) with varying attack frequency and treatment with and without allopurinol participated in one of four focus group interviews. All interviews were audio-recorded and transcribed verbatim. Data was analysed thematically. Physical and psychosocial HRQOL in gout was affected by characteristics of acute gout (particularly the unpredictable nature of attacks, location of joint involved in an attack, pain and modifications in lifestyle), lack of understanding of gout by others (association with unhealthy lifestyle, symptoms ridiculed as non-severe and non-serious) as well as participants (not considered a disease) and the lack of information provided by physicians (about causes and pharmacological as well as non-pharmacological treatments of gout). Participants emphasised the impact of acute attacks of gout and prioritised dietary modifications and treatment of acute attacks over long-term urate-lowering therapy. Characteristics of acute gout, lack of understanding and information about gout and its treatments perpetuate poor HRQOL. HRQOL (maintenance of usual diet and reduced frequency of attacks) was associated with urate-lowering treatment. Better patient, public and practitioner education about gout being a chronic condition associated with co-morbidities and poor HRQOL may improve understanding and long-term treatment of gout.

Case study: a case of debilitating gout in the 1st metatarsophalangeal joint

Gout is a painful arthritic condition that affects many people worldwide. The disease has been associated with hyperuricaemia and life style risk factors such as obesity, alcohol intake, meat and seafood consumption. We present a case of a 67-year-old male with a history of gout, who attended the clinic with a painful 1st metatarsophalangeal joint, which had progressively worsened in pain, mobility and deformity in the last 20 years. Although lifestyle changes had been advised by the GP some years earlier such as a low purine based diet, management had only consisted of NSAID's, which had not significantly improved symptoms. Surgical excision of chalky white material from around the 1st metatarsophalangeal joint rendered the patient symptom free with increased mobility after 6 weeks. Histopathology confirmed the excised tissue as gouty tophus. Following this, the patient was placed on allopurinol, a xanthine oxidase inhibitor to prevent recurrent attacks. This case study highlights the importance of early recognition and prophylactic management in gout sufferers. In joints where the disease process is well-established surgical excision of the gouty tophus may help mitigate further disease progression, and restore quality of life to individuals.

Cost-effectiveness analysis of allopurinol versus febuxostat in chronic gout patients: a U.S. payer perspective

BACKGROUND

Gout is a chronic inflammatory condition associated with poor urate metabolism. Xanthine oxidase inhibitors such as allopurinol and febuxostat are recommended to reduce uric acid levels and to prevent gout attacks in adult patients. Under budget-driven constraints, health care payers are faced with the broader challenge of assessing the economic value of these agents for formulary placement. However, the economic value of allopurinol versus febuxostat has not be assessed in patients with gout over a 5-year time period in the United States.

OBJECTIVE

To evaluate the cost-effectiveness of allopurinol versus febuxostat in adult patients with gout over a 5-year time period from a U.S. health care payer's perspective.

METHODS

A Markov model was developed to compare the total direct costs and success of serum uric acid (sUA) level reduction associated with allopurinol and febuxostat. Treatment success was defined as patient achievement of a sUA level less than  6 mg/dL (0.36 mmol/L) at 6 months. Event probabilities were based on published phase III randomized clinical trials and included long-term sequelae from open-label extension studies. A hypothetical cohort of 1,000 adult gout patients with sUA levels of ≥ 8 mg/dL (0.48 mmol/L) who had received either allopurinol 300 mg or febuxostat 80 mg at model entry transitioned among the 4 health states defined by treatment success, treatment failure and switch, treatment dropout, and death. The length of each Markov cycle was 6 months. Costs were gathered from the RED BOOK, Medicare fee schedules, Healthcare Cost and Utilization Project's Nationwide Inpatient Sample, and for a limited number of inputs, expert consultation. Direct costs included treatment drug costs, costs for prophylaxis drugs, diagnostic laboratory tests, and the treatment and management of acute gout flare. Resource utilization was based on clinical evidence and expert consultation. All costs were inflated to 2014 U.S. dollars and were discounted at 3% in the base case. One-way sensitivity analysis and probabilistic sensitivity analyses (PSAs) were performed to assess the robustness of the results.

RESULTS

The total per patient cost incurred over 5 years was $50,295 for febuxostat and $48,413 for allopurinol, with an incremental total cost of $1,882. The expected percentage of treatment success during the 5-year period was 72 for febuxostat and 42 for allopurinol, resulting in an incremental percentage of treatment success of 30. The estimated incremental cost-effectiveness ratio for febuxostat compared with allopurinol was $6,322 per treatment success over a 5-year time period. The one-way sensitivity analysis indicated that the results were sensitive to probability of treatment success for allopurinol, probability of treatment dropouts for both allopurinol and febuxostat, and the probability of failure and switch to allopurinol. PSAs demonstrated that at a willingness-to-pay threshold of $50,000 per treatment success, febuxostat was cost-effective compared with allopurinol.

CONCLUSIONS

Febuxostat was found to be a cost-effective option compared with allopurinol based on a U.S. payer perspective.

Cost of illness and determinants of costs among patients with gout

OBJECTIVE

To estimate costs of illness in a cross-sectional cohort of patients with gout attending an outpatient rheumatology clinic, and to evaluate which factors contribute to higher costs.

METHODS

Altogether, 126 patients with gout were clinically assessed. They completed a series of questionnaires. Health resource use was collected using a self-report questionnaire that was cross-checked with the electronic patient file. Productivity loss was assessed by the Work Productivity and Activity Impairment Questionnaire, addressing absenteeism and presenteeism. Resource use and productivity loss were valued by real costs, and annual costs per patient were calculated. Factors contributing to incurring costs above the median were explored using logistic univariable and multivariable regression analysis.

RESULTS

Mean (median) annual direct costs of gout were €5647 (€1148) per patient. Total costs increased to €6914 (€1279) or €10,894 (€1840) per patient per year when adding cost for absenteeism or both absenteeism and presenteeism, respectively. Factors independently associated with high direct and high indirect costs were a positive history of cardiovascular disease, functional limitations, and female sex. In addition, pain, gout concerns, and unmet gout treatment needs were associated with high direct costs.

CONCLUSION

The direct and indirect costs-of-illness of gout are primarily associated with cardiovascular disease, functional limitations, and female sex.

Veterans Affairs databases are accurate for gout-related health care utilization: a validation study

Introduction

The aim of this study was to assess the accuracy of Veterans Affairs (VA) databases for gout-related health care utilization.

Methods

This retrospective study utilized VA administrative and clinical databases. A random sample of gout patients with visits (outpatient, inpatient or emergent/urgent care) with or without the diagnosis of gout (International Classification of Diseases, ninth revision, common modification ICD-9-CM code of 274.x or 274.xx) at the Birmingham VA hospital was selected. A blinded abstractor performed a review of VA electronic health records for the documentation of gout or gout-related terms (gouty arthritis, tophaceous gout, tophus/tophi, acute gout, chronic gout, podagra, urate stones, urate or uric acid crystals and so on) in the chief complaint, history of present illness or assessment and plan for the visit; this constituted the gold standard for gout-related utilization. The accuracy of database-derived gout-related claims was assessed by calculating sensitivity, specificity, and positive and negative predictive values (PPV and NPV).

Results

Of 108 potential visits, 85 outpatient, inpatient or urgent care/emergency room visits to a health care provider (85 patients: 84 men and 1 woman with a mean age of 63 years) and retrievable data from medical records constituted the analyzed dataset. Administrative claims for gout-related utilization with ICD-9 code for gout were accurate with a PPV of 86%, specificity of 95%, sensitivity of 86% and NPV of 95%.

Conclusions

VA databases are accurate for gout-related visits. These findings support their use for studies of health services and outcome studies. It remains to be seen if these findings are generalizable to other settings and databases.

Rilonacept for Gout Flare Prevention in Patients Receiving Uric Acid-lowering Therapy: Results of RESURGE, a Phase III, International Safety Study

Objective.

To evaluate the safety and efficacy of once-weekly subcutaneous rilonacept 160 mg for prevention of gout flares in patients initiating or continuing urate-lowering therapy (ULT).

Methods.

This phase III study was conducted in the United States, South Africa, Europe, and Asia. Adults (n = 1315, 18–80 yrs) with gout, who were initiating or continuing ULT, were randomized to treatment with weekly subcutaneous injections of rilonacept 160 mg or placebo for 16 weeks followed by a 4-week safety followup. The primary endpoint was safety, assessed by adverse events (AE) and laboratory values. Efficacy was a secondary endpoint.

Results.

Demographic and clinical characteristics were similar between treatments; predominantly male (87.8%), mean age 52.7 ± 11.3 years. Patients with ≥ 1 AE were 66.6% with rilonacept versus 59.1% placebo, with slightly more AE-related withdrawals with rilonacept (4.7% vs 3.0%) because of the greater incidence of injection site reactions (15.2% rilonacept, 3.3% placebo). Serious AE were similar in both groups, as were serious infections (0.9% placebo, 0.5% rilonacept); no tuberculosis or opportunistic infections occurred. Most common AE were headache, arthralgia, injection site erythema, accidental overdose, and pain in extremity. Of the 6 deaths, only 1 in the placebo group was considered treatment-related. At Week 16, rilonacept resulted in 70.3% fewer gout flares per patient (p < 0.0001), fewer patients with ≥ 1 and ≥ 2 gout flares (p < 0.0001), and 64.9% fewer gout flare days (p < 0.0001) relative to placebo.

Conclusion.

Weekly subcutaneous administration of rilonacept 160 mg showed no new safety signals. The safety profile was consistent with previous studies. Rilonacept also significantly reduced the risk of gout flares. Clinicaltrials.gov identifier NCT00856206; EudraCT No. 2008-007784-16.

Cost-effectiveness of febuxostat in chronic gout

Our objective was to evaluate data on the cost-effectiveness of febuxostat compared with standard clinical practice with allopurinol in patients with gout that was presented to the Scottish Medicines Consortium (SMC) in 2010. A Markov health-state model estimated the direct health-related costs and clinical benefits expressed as quality-adjusted life-years (QALYs). Adults with chronic gout and established hyperuricaemia received treatment sequences of daily doses of allopurinol 300 mg alone or allopurinol 300 mg followed by febuxostat 80 mg/120 mg. The proportion of patients achieving the target serum uric acid (sUA) level of less than 6 mg/dl (0.36 mmol/l) was linked to the utility per sUA level to generate an incremental cost-effectiveness ratio (ICER). Second-line therapy with febuxostat 80 mg/120 mg versus with allopurinol alone resulted in an ICER of £3,578 per QALY over a 5-year time horizon. Additional univariate analyses showed that ICER values were robust and ranged from £2,550 to £7,165 per QALY when different parameters (e.g., low- and high-dose allopurinol titrations and variations in treatment-induced flare rates) were varied. Febuxostat reduces sUA below the European League Against Rheumatism target of 0.36 mmol/l (6 mg/dl) in significantly more patients with gout than allopurinol in its most frequently prescribed dose of 300 mg per day. The SMC accepted febuxostat as cost-effective as a suitable second-line option for urate-lowering therapy for the treatment of patients with chronic hyperuricaemia in conditions where urate deposition has already occurred (including a history or presence of tophus and/or gouty arthritis) when treatment with allopurinol was inadequate, not tolerated, or contraindicated.

Achieving serum urate goal: a comparative effectiveness study between allopurinol and febuxostat

BACKGROUND

Febuxostat is recommended as 1 of 2 first-line urate-lowering therapies (ULT) for treating gout in the 2012 American College of Rheumatology Guidelines. Several efficacy trials have compared febuxostat with allopurinol treatment, but real-world comparative data are limited.

METHODS

We compared effectiveness of the 2 agents in reaching serum urate (sUA) level goal (< 6 mg/dL) within 6 months (main endpoint), factors impacting the likelihood of reaching goal, and outcomes in allopurinol patients who were switched to febuxostat therapy after failing to reach sUA level goal. Data from the General Electric Electronic Medical Record database on adult patients with newly diagnosed gout, who had started treatment with allopurinol or febuxostat in 2009 or thereafter were analyzed. Descriptive statistics, bivariate analyses, and logistic regressions were used.

RESULTS

Allopurinol (n = 17 199) and febuxostat (n = 1190) patients had a mean ± standard deviation (SD) age of 63.7 (± 13.37) years; most patients were men and white. Average daily medication doses (mg) in the first 6 months were 184.9 ± 96.7 and 48.4 ± 15.8 for allopurinol- and febuxostat-treated patients, respectively; 4.8% of allopurinol-treated patients switched to febuxostat, whereas 25.7% of febuxostat-treated patients switched to allopurinol. Febuxostat patients had lower estimated glomerular filtration rate levels, more diabetes mellitus, or tophi at baseline (P < 0.05) and 29.2% and 42.2% of patients in the allopurinol and febuxostat groups achieved goal sUA levels (P < 0.0001). Febuxostat was significantly more effective in patients reaching sUA goal (adjusted odds ratio, 1.73; 95% CI, 1.48-2.01). Older patients and women had greater likelihood of reaching sUA goal level; however, patients with higher Charlson Comorbidity Index scores, blacks, or those with estimated glomerular filtration rates between 15 to ≤ 60 mL/min had reduced likelihood of attaining goal (P < 0.05). Among allopurinol-treated patients who were switched to febuxostat after failing to reach goal, 244 (48.3%) reached goal on febuxostat (median = 62.5 days), with an average 39% sUA level reduction achieved within 6 months. Patients who did not reach goal had a 14.3% sUA level reduction.

CONCLUSIONS

The real-life data support the effectiveness of febuxostat in managing patients with gout.

Gout: joints and beyond, epidemiology, clinical features, treatment and co-morbidities

Gout is a common inflammatory arthritis precipitated by an inflammatory reaction to urate crystals in the joint. Gout is increasingly being recognised as a disease primarily of urate overload with arthritis being a consequence of this pathological accumulation. It is associated with a number of important co-morbidities including chronic kidney disease, obesity, diabetes and cardiovascular disease. The prevalence of gout is increasing around the world. Significant progress has been made in determining the genetic basis for both gout and hyperuricaemia. Environmental risk factors for gout have been identified as certain foods, alcohol and several medications. There is, however, little evidence that changing these environmental risks improves gout on an individual level. Treatment of gout encompasses two strategies: firstly treatment of inflammatory arthritis with non-steroidal anti-inflammatories, corticosteroids, colchicine or interleukin-1 inhibitors. The second and most important strategy is urate lowering, to a target of 0.36 mmol/L (6 mg/dL) or potentially lower in those with tophi (collections of crystalline urate subcutaneously). Along with urate lowering, adequate and prolonged gout flare prophylaxis is required to prevent the precipitation of acute attacks. Newer urate lowering agents are in development and have the potential to significantly expand the potential treatment options. Education of patients regarding the importance of life long urate lowering therapy and prophylaxis of acute attacks is critical to treatment success as adherence with medication is low in chronic diseases in general but especially in gout.

The emerging role of biotechnological drugs in the treatment of gout

One of the most important therapeutic advances obtained in the field of rheumatology is the availability of the so-called bio(techno)logical drugs, which have deeply changed treatment perspectives in diseases such as rheumatoid arthritis and ankylosing spondylitis. According to the steadily increasing attention on gout, due to well-established prognostic and epidemiology implications, in the last 5 years, the same change of perspective has been observed also for this disease. In fact, several bio(techno)logical agents have been investigated both for the management of the articular gout symptoms, targeting mainly interleukin-1β, as well as urate-lowering therapies such as recombinant uricases. Among the IL-1β inhibitors, the majority of studies involve drugs such as anakinra, canakinumab, and rilonacept, but other compounds are under development. Moreover, other potential targets have been suggested, as, for example, the TNF alpha and IL-6, even if data obtained are less robust than those of IL-1β inhibitors. Regarding urate-lowering therapies, the recombinant uricases pegloticase and rasburicase clearly showed their effectiveness in gout patients. Also in this case, new compounds are under development. The aim of this review is to focus on the various aspects of different bio(techno)logical drugs in gouty patients.

A revised estimate of the burden of illness of gout

Background

Gout is a chronic, inflammatory arthritis characterized by painful and debilitating acute/episodic flares. Until recently, gout has been regarded as a minor medical problem, in part because the associated economic burden has not been appreciated. Previous literature on this subject focused on the costs associated with acute episodes of gout rather than on the long-term medical and economic implications of this chronic disorder.

Objective

Our aim was to estimate the current impact of gout in the United States with respect to disability and economic costs.

Methods

The following data sources were used: published data on the incremental economic burden of gout; statistics from the US Census Bureau and the US Bureau of Labor Statistics; and recent epidemiological and clinical literature concerning the course, treatment, and outcomes of the disease. Disability is expressed as days of lost productivity. Charges for gout-related treatments were used as direct cost inputs.

Results

Gout affects an estimated 8 million Americans, among whom those working have an average of almost 5 more absence days annually than workers without gout. On average, the incremental annual cost of care for a gout patient is estimated at >$3000 compared with a nongouty individual. Even though comorbidities common in gout patients account for a portion of this increased economic burden, the total annual cost attributable to gout patients in the United States is likely in the tens of billions of dollars and comparable to those of other major chronic disorders, such as migraine and Parkinson’s disease.

Conclusions

The economic burden of gout is most readily assessable in patients whose acute arthritic flares result in emergency department visits, bedridden days, and episodic loss of productivity. Chronic progression of the disease can also result in long-term impairment of function and health-related quality of life, but the contribution of chronic gout to the economic burden is more difficult to quantitate because gout is frequently associated with serious cardiovascular, metabolic, and renal comorbidities. Recent demonstration that successful gout management can reverse functional deficits in many chronic gout patients, however, supports the views that chronic gout contributes substantially to the medical and thus economic costs of these patients and that early and aggressive efforts to improve gout outcomes are likely to reduce the associated economic burden.

The effect of gout on health-related quality of life, work productivity, resource use and clinical outcomes among patients with hypertension

Although gout has been found to be associated with health-related quality of life (HRQoL), few studies have examined the burden of gout in the presence of concomitant cardiometabolic conditions. The present study evaluated the effect of gout on HRQoL and work productivity among patients with hypertension. Data from the 2010 National Health and Wellness Survey were obtained for respondents ≥18 years of age who had self-reported, physician-diagnosed hypertension or blood pressure levels ≥140/90 mmHg (≥130/80 mmHg for those with physician-diagnosed diabetes or chronic kidney disease). Bivariate analysis was used to evaluate differences between patients with and without self-reported comorbid gout. Generalized linear models were used to evaluate differences in productivity (using the Work Productivity and Activity Impairment scale) and HRQoL (using the physical component summary [PCS], mental component summary and health utilities from the SF-12v2 health survey). As uric acid levels may influence other organ systems, core modeling did not include comorbidities other than osteoarthritis and depression as covariates. Sensitivity analyses were controlled for the Charlson comorbidity index. A total of 22,686 patients with self-reported hypertension met study eligibility requirements. Of these, 4.51% reported having gout. These patients were older, more likely to be male and have insurance through Veteran Affairs (all p-values < 0.05). Patients with comorbid gout reported lower levels of mental component summary scores (47.25 vs 48.93), PCS scores (39.06 vs 43.78) and health utilities (0.68 vs 0.73; all p-values < 0.05). For both PCS and health utilities, differences between groups exceeded clinically meaningful cutoffs. Sensitivity analyses conducted on PCS and health utilities uncovered slightly smaller, but statistically significant and clinically meaningful, effects (p-values < 0.05). The effect of gout on overall work impairment (23.33 vs 17.40% with and without comorbid gout, respectively) remained after controlling for the Charlson comorbidity index. Significantly greater impairment in daily activities (38.96 vs 28.32%; p < 0.05) was also observed among patients with comorbid gout. Results demonstrate that gout has significant and clinically meaningful impact on work productivity, physical HRQoL and utilities independent of other health conditions.

The Work Instability Scale predicts absenteeism in people with gout and suggests a higher risk for those in manual occupations

BACKGROUND

Gout occurs in working-age people and may be associated with significant work disability. There are no longitudinal studies to examine risk factors for work disability in people with gout.

OBJECTIVES

The purpose of this study was to determine the validity of the Work Instability Scale (WIS) in patients with gout and to see if baseline WIS scores predicted future work absences.

METHODS

We conducted a longitudinal, cohort study with patients who had gout for less than 10 years. Sick leave over the previous 3 months was recorded by patient recall at baseline and at 12 months. Self-report health status measures and disease characteristics including C-reactive protein and serum urate were measured at baseline. Work Instability Scale scores were fitted to a Rasch model, and nonparametric statistics were used to determine associations between disease features or future sick leave and WIS scores.

RESULTS

One hundred seventy-six participants were recruited, and follow-up information was available for 133 (76%). The WIS instrument showed satisfactory internal, construct, and predictive validity. Participants in nonmanual occupations had lower (better) WIS scores (median, 0 vs. 5.5; P < 0.001). Only 7% of working participants reported any sick leave in the 3 months before the 12-month follow-up. Work Instability Scale scores were associated with future sick leave: a cutoff of 4.5 was found to have the best combined sensitivity (88%) and specificity (72%) for predicting at least 1 day of sick leave.

CONCLUSIONS

The WIS instrument can identify people with gout who have a higher risk of future work disability and might be a useful guide to targeted vocational counseling or job modification, especially in people in manual occupations. However, further research is required to confirm these findings and to refine the instrument for optimal performance in this population.

Gout-related health care utilization in US emergency departments, 2006 through 2008

OBJECTIVE

To characterize gout-related emergency department (ED) utilization using a nationally representative sample and to examine factors associated with the frequency and charges of gout-related ED visits.

METHODS

Using the National Emergency Department Sample data from 2006-2008, the weighted national frequency of gout visits was calculated along with the median ED charge and total national ED-related charges. Associations of several patient- and facility-level factors were examined with the occurrence of gout visits using multivariable logistic regression and with ED-related charges using multivariable linear regression.

RESULTS

Gout was the primary indication for 168,410 ED visits in 2006, 171,743 visits in 2007, and 174,823 visits in 2008, accounting for ∼0.2% of all visits annually and generating ED charges of more than $128 million in 2006, $144 million in 2007, and $166 million in 2008. Age, male sex, household income <$39,000, private insurance, and hospital locations in nonmetropolitan areas and the southern US were associated with an increased propensity for ED utilization in gout. Higher ED-related charges for gout were associated with female sex, age, a higher number of coded diagnoses, and a metropolitan residence.

CONCLUSION

Gout accounts for a substantial proportion of ED visits, leading to significant health care charges. Effective strategies to reduce gout burden in EDs could potentially benefit by targeting groups characterized by factors demonstrated to be related to a higher ED utilization in gout as identified by our study.

Racial and gender disparities among patients with gout

Gout affects 8.3 million Americans according to NHANES 2007-2008, approximately 3.9 % of the US population. Gout has substantial effect on physical function, productivity, health-related quality of life (HRQOL), and health care costs. Uncontrolled gout is also associated with significant use of emergency care services. Women are less likely to have gout than men, but in the postmenopausal years the gender difference in disease incidence decreases. Compared with whites, racial and/or ethnic minorities, especially blacks, have higher prevalence of gout. Blacks are also less likely to receive quality gout care, leading to disproportionate morbidity. Women are less likely than men to receive allopurinol, and less likely to undergo joint aspirations for crystal analysis to establish diagnosis, but those on urate-lowering therapy are as likely as, or more likely than, men to undergo serum urate check within six months of initiation. Although a few studies provide the knowledge related to gender and race and/or ethnicity disparities for gout, several knowledge gaps exist in gout epidemiology and outcomes differences by gender and race and/or ethnicity. These should be investigated in future studies.

Rilonacept in the treatment of acute gouty arthritis: a randomized, controlled clinical trial using indomethacin as the active comparator

Introduction

In phase-3 clinical trials, the interleukin (IL-1) blocker, rilonacept (IL-1 Trap), demonstrated efficacy for gout flare prevention during initiation of urate-lowering therapy. This trial evaluated rilonacept added to a standard-of-care, indomethacin, for treatment of acute gout flares.

Methods

Adults, aged 18-70 years, with gout presenting within 48 hours of flare onset and having at least moderate pain as well as swelling and tenderness in the index joint were randomized to subcutaneous (SC) rilonacept 320 mg at baseline plus oral indomethacin 50 mg TID for 3 days followed by 25 mg TID for up to 9 days (n = 74); SC placebo at baseline plus oral indomethacin as above (n = 76); or SC rilonacept 320 mg at baseline plus oral placebo (n = 75). The primary efficacy endpoint was change in pain in the index joint (patient-reported using a Likert scale (0 = none; 4 = extreme)) from baseline to the average of values at 24, 48 and 72 hours (composite time point) for rilonacept plus indomethacin versus indomethacin alone. Comparison of rilonacept monotherapy with indomethacin monotherapy was dependent on demonstration of significance for the primary endpoint. Safety evaluation included clinical laboratory and adverse event (AE) assessments.

Results

Patient characteristics were comparable among the groups; the population was predominantly male (94.1%), white (75.7%), with mean ± SD age of 50.3 ± 10.6 years. All treatment groups reported within-group pain reductions from baseline (P < 0.0001). Although primary endpoint pain reduction was greater with rilonacept plus indomethacin (-1.55 ± 0.92) relative to indomethacin alone (-1.40 ± 0.96), the difference was not statistically significant (P = 0.33), so formal comparison between monotherapy groups was not performed. Pain reduction over the 72-hour period with rilonacept alone (-0.69 ± 0.97) was less than that in the other groups, but pain reduction was similar among groups at 72 hours. Treatment with rilonacept was well-tolerated with no reported serious AEs related to rilonacept. Across all groups, the most frequent AEs were headache and dizziness.

Conclusions

Although generally well-tolerated, rilonacept in combination with indomethacin and rilonacept alone did not provide additional pain relief over 72 hours relative to indomethacin alone in patients with acute gout flare.

Trial registration

ClinicalTrials.gov registration number NCT00855920.

Rilonacept (interleukin-1 trap) for prevention of gout flares during initiation of uric acid-lowering therapy: results from a phase III randomized, double-blind, placebo-controlled, confirmatory efficacy study

OBJECTIVE

To evaluate the efficacy and safety of the interleukin-1 inhibitor rilonacept (interleukin-1 Trap) for gout flare prevention during initiation of uric acid-lowering therapy (ULT).

METHODS

In total, 241 adult patients with gout, ≥2 gout flares within the past year, and a serum urate level ≥7.5 mg/dl were initiated on allopurinol 300 mg daily and randomly allocated in a 1:1:1 ratio to receive 16 once-weekly subcutaneous injections of placebo, rilonacept 80 mg, or rilonacept 160 mg, with a double (loading) dose on day 1. Allopurinol was titrated to achieve a serum urate level of <6.0 mg/dl. The study was powered for the primary efficacy end point, the number of gout flares per patient through week 16.

RESULTS

More patients in the rilonacept groups (80.0% in the rilonacept 80 mg group, 86.4% in the rilonacept 160 mg group) completed the study than in the placebo group (72.5%; P < 0.05 for the rilonacept 160 mg group versus the placebo group). Over 16 weeks, the mean number of gout flares per patient was significantly reduced by rilonacept treatment (placebo: 1.06, rilonacept 80 mg: 0.29 [P < 0.001], rilonacept 160 mg: 0.21 [P < 0.001]). Significantly lower proportions of patients reported ≥1 gout flares with rilonacept 80 mg (18.8%) and rilonacept 160 mg (16.3%) relative to placebo (46.8%; P < 0.001 for both). Except for injection site reactions (1.3% in the placebo group versus 8.8% in the rilonacept 80 mg group [P = 0.0635, post hoc analysis] and 19.8% in the rilonacept 160 mg group [P = 0.0001, post hoc analysis]), the incidence of adverse events was generally balanced among the treatment groups.

CONCLUSION

Rilonacept markedly reduced the occurrence of gout flares associated with the initiation of ULT. The efficacy and safety profile suggests that rilonacept may have the potential to improve long-term disease control for some patients by improving adherence to ULT by reducing flares during the first months after ULT initiation.

Tophi and frequent gout flares are associated with impairments to quality of life, productivity, and increased healthcare resource use: Results from a cross-sectional survey

Background

The prevalence of gout is increasing, and most research on the associated burden has focused on serum urate (sUA) levels. The present study quantifies the impact of the presence of tophi and frequency of acute gout attacks on health-related quality of life (HRQOL), productivity, and healthcare resource utilization.

Methods

Patients with self-reported gout (n = 620; 338 in US and 282 across France, Germany, and UK) were contacted based on inclusion in the 2010 US and EU National Health and Wellness Surveys (Kantar Health) and the Lightspeed Research ailment panel. Respondents were categorized into mutually-exclusive groups based on number of gout flares experienced in the past 12 months (0/don’t recall, 1–2, 3, 4–5, 6+), current presence of tophi (none, 1+, or not sure), and sUA level awareness (yes, no). HRQOL (SF-12v2), healthcare provider visits in the last 6 months, and work productivity and activity impairment (WPAI) were compared across groups.

Results

Most patients were males, mean age of 61 years, who reported experiencing at least one acute gout flare in the past 12 months, and 12.3% (n = 76) reported presence of tophi. Among the 27.7% (n = 172) of patients who were aware of their sUA levels, higher sUA was associated with more flares and tophi. Decreased HRQOL was associated with more frequent flares and presence of tophi. In multivariable models predicting outcomes based on presence of tophi and number of flares, both flares (≥4) and tophi (≥1) were associated with HRQOL decrements on physical and mental component summary scores and health utilities (all p < 0.05), after adjustment for age, gender, and time since diagnosis. Flares were also associated with greater activity impairment.

Conclusions

Impairments associated with gout flares and presence of tophi, across patients in the US and EU, underscore the importance of effective management of this potentially curable condition.