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Do H, Choi HJ, Choi B, Son CN, Kim SH, Choi SR, Kim JH, Kim MJ, Shin K, Kim HO, Song R, Lee SW, Ahn JK, Lee SG, Lee CH, Son KM, Moon KW. Factors for achieving target serum uric acid levels after initiating urate-lowering therapy in patients with gout: results from the ULTRA registry. Sci Rep 2023; 13:20511. [PMID: 37993515 PMCID: PMC10665459 DOI: 10.1038/s41598-023-47790-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 11/18/2023] [Indexed: 11/24/2023] Open
Abstract
Achieving target serum uric acid (SUA) levels is important in gout management. Guidelines recommend lowering SUA levels to < 6 mg/dL; however, many patients fail to reach this target, even with uric acid-lowering therapy (ULT). This study investigated clinical characteristics of target SUA achievers among Korean patients with gout. This study used data from the ULTRA registry, a nationwide inception cohort established in September 2021 that enrolls patients with gout who initiate ULT. Demographic, clinical, and laboratory data were collected at baseline; the 6-month follow-up. Patients were divided into two groups: target achievers (SUA level < 6 mg/dL at 6 months) and non-achievers. The mean participant (N = 117) age was 56.1 years, and 88.0% were male. At 6 months, 83 patients (70.9%) reached target SUA levels. Target achievers had better drug adherence (≥ 80%) to ULT (97.6% vs. 76.5%; p < 0.01) than non-achievers. Target non-achievers had a higher percentage of a family history of gout (32.4% vs. 10.8%; p < 0.01) and less antihypertensive agent use (38.2% vs. 59.0%; p = 0.03) than target achievers. Multivariate regression analysis revealed that good adherence to ULT, the absence of a family history of gout, and antihypertensive agent use were key factors associated with achieving target SUA levels at 6 months.
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Affiliation(s)
- Hyunsue Do
- Division of Rheumatology, Department of Internal Medicine, Kangwon National University School of Medicine, 1 Kangwondaehak-gil, Chuncheon, 24341, South Korea
| | - Hyo Jin Choi
- Division of Rheumatology, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, South Korea
| | - Byoongyong Choi
- Division of Rheumatology, Department of Internal Medicine, Seoul Metropolitan Seoul Medical Center, Seoul, South Korea
| | - Chang-Nam Son
- Division of Rheumatology, Department of Internal Medicine, Eulji University School of Medicine, Uijeongbu, South Korea
| | - Sang-Hyon Kim
- Division of Rheumatology, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, South Korea
| | - Se Rim Choi
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Ji Hyoun Kim
- Division of Rheumatology, Department of Internal Medicine, Chungbuk National University Hospital, Cheongju, South Korea
| | - Min Jung Kim
- Division of Rheumatology, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Kichul Shin
- Division of Rheumatology, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Hyun-Ok Kim
- Division of Rheumatology, Department of Internal Medicine, Gyeongsang National University School of Medicine, Jinju, South Korea
| | - Ran Song
- Division of Rheumatology, Department of Internal Medicine, Kyung Hee University, Seoul, South Korea
| | - Sung Won Lee
- Division of Rheumatology, Department of Internal Medicine, Soon Chun Hyang University Hospital, Cheonan, South Korea
| | - Joong Kyong Ahn
- Division of Rheumatology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Seung-Geun Lee
- Division of Rheumatology, Department of Internal Medicine, Pusan National University School of Medicine, Pusan National University Hospital, Busan, South Korea
| | - Chang Hoon Lee
- Division of Rheumatology, Department of Internal Medicine, Wonkwang University School of Medicine, Iksan, South Korea
| | - Kyeong Min Son
- Division of Rheumatology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong-si, Gyeonggi-do, South Korea
| | - Ki Won Moon
- Division of Rheumatology, Department of Internal Medicine, Kangwon National University School of Medicine, 1 Kangwondaehak-gil, Chuncheon, 24341, South Korea.
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Hammam N, Li J, Kay J, Izadi Z, Yazdany J, Schmajuk G. Monitoring and Achievement of Target Serum Urate Among Gout Patients Receiving Long-Term Urate-Lowering Therapy in the American College of Rheumatology RISE Registry. Arthritis Care Res (Hoboken) 2023; 75:1544-1552. [PMID: 36039961 PMCID: PMC9971337 DOI: 10.1002/acr.25009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 08/11/2022] [Accepted: 08/25/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The American College of Rheumatology's (ACR) 2020 guidelines for the management of gout recommend using a treat-to-target approach to lower serum urate (SU). Using the ACR's Rheumatology Informatics System for Effectiveness registry, we examined the use of a treat-to-target approach among gout patients receiving long-term urate-lowering therapy (ULT) and followed longitudinally by rheumatologists. METHODS Included patients had one or more diagnoses for gout in 2018-2019 and continuous use of ULT for ≥12 months. We assessed the proportions of patients with SU monitoring and, among those tested, who achieved SU <6.0 mg/dl during the measurement year. Multilevel logistic regression adjusting for sociodemographics, comorbidities, region, and health care utilization was used to determine factors associated with SU monitoring and achievement of target SU. RESULTS A total of 9,560 were included. The mean ± SD age was 67.2 ± 12.7 years, 73.5% of patients were male, and 32.3% were non-White. Fifty-six percent of patients had at least 1 SU recorded during the measurement year; among patients with at least 1 SU recorded, 74% achieved the SU target. In multivariate analyses, non-White patients were slightly less likely to be tested or achieve a target SU. CONCLUSION Among gout patients receiving long-term ULT followed longitudinally by rheumatologists, more than half had a documented SU, and among those tested, three-quarters achieved the recommended SU target. Routine monitoring of SU is a first step toward improving quality of care for patients with gout.
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Affiliation(s)
- Nevin Hammam
- Division of Rheumatology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Jing Li
- Division of Rheumatology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Julia Kay
- Division of Rheumatology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Zara Izadi
- Division of Rheumatology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Jinoos Yazdany
- Division of Rheumatology, Department of Medicine, University of California San Francisco, San Francisco, CA
- Philip R. Lee Institute for Health Policy Research, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Gabriela Schmajuk
- Division of Rheumatology, Department of Medicine, University of California San Francisco, San Francisco, CA
- Philip R. Lee Institute for Health Policy Research, Department of Medicine, University of California San Francisco, San Francisco, CA
- San Francisco Veterans Affairs Medical Center, San Francisco, CA
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Singh JA, Edwards NL. Gout management and outcomes during established COVID-19 pandemic in 2020-2021: a cross-sectional Internet survey. Ther Adv Musculoskelet Dis 2022; 14:1759720X221096381. [PMID: 35586516 PMCID: PMC9109485 DOI: 10.1177/1759720x221096381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 04/04/2022] [Indexed: 11/16/2022] Open
Abstract
Objective To assess the management of gout in established COVID-19 pandemic. Methods We assessed medication use, health care utilization, gout-specific health-related quality of life (HRQOL), psychological distress using Patient Health Questionnaire-4 (PHQ-4), resilience, illness perception, and health literacy in people with physician-diagnosed self-reported gout in established COVID-19 pandemic in a cross-sectional Internet survey. Results Among the 130 survey respondents with gout, the mean age was 62.8 years, 65% were male, 83% were White, 59% were prescribed urate-lowering therapy (ULT), and health literacy was adequate in 80%. A third of survey respondents reported more difficulty with their gout management since September 2020. Gout-specific HRQOL deficits were evident. Moderate-severe psychological distress was seen in 22%, and resilience score was 6.5 [standard deviation (SD), 1.9; range, 0-8]. Adjusted for age and sex, compared with no/mild psychological distress, moderate-severe psychological distress was associated with significantly higher odds ratio (OR; 95% confidence interval) of more difficulty with (1) getting health care for gout in clinic, 3.7 (1.0, 13.2); emergency room/urgent care, 8.1 (1.4, 45.0); and in the hospital, 9.8 (1.6, 59.6); (2) getting gout flares treated, 6.6 (1.6, 26.8); (3) avoiding gout complications, 4.5 (1.2, 16.7); and (4) daily activities at home, 4.2 (1.3, 14.1), and performing work, 4.1 (1.2, 13.6). Conclusion Respondents with gout reported health care gaps, low rates of ULT prescription, high psychological distress, and HRQOL deficits during established COVID-19 pandemic. Moderate-severe psychological distress was associated with difficulties in health care access and gout management. Interventions to address these challenges in gout management are needed.
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Affiliation(s)
- Jasvinder A. Singh
- Department of Medicine, School of Medicine,
University of Alabama, Faculty Office Tower 805B, 510 20th Street S,
Birmingham, AL 35294, USA
- Medicine Service, Birmingham VA Medical Center,
Birmingham, AL, USA
- Division of Epidemiology at School of Public
Health, University of Alabama, Birmingham, AL, USA
| | - N. Lawrence Edwards
- Department of Medicine, Division of
Rheumatology, Immunology and Allergy, University of Florida, Gainesville,
FL, USA
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El Miedany Y, Gadallah NA, Mansour M, El Gaafary M, Mortada M, Eissa M, Hassan M, Hassan W, Tabra SA, Foad N, Ali R, Medhat B, Adel Y, Ghaleb R, Elkaraly N, Saber S, Galal S. Egyptian consensus on treat-to-target approach of gout: evidence-based clinical practice guidelines for the management of gout. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2022. [DOI: 10.1186/s43166-022-00123-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Abstract
Introduction
New therapies, management approaches, and evidence regarding the management of gout have become available over the past years. This triggered the need for an updated recommendation for gout management. Through an up-to-date consensus evidence-based clinical practice guideline for the management of gout including recommendations for management of gout flares, optimum usage of urate lowering therapy for chronic gout, as well as patient education and lifestyle guidance. A wide systematic literature review was performed, and evidence-based recommendations were extrapolated, based on 16-key questions identified according to population, intervention, comparator, and outcomes (PICO) approach. These were evaluated by a panel consisted of 17 rheumatology experts via online surveys over a 2-round Delphi process. The purpose of this study is to offer an updated, consensus-evidence-based, and in the meantime patient-focused, expert recommendations for the treat-to-target approach of gout management.
Results
Results revealed that after round 2 ended, a total of 30-recommendation items, categorized into 10 domains, were obtained. Agreement with the recommendations (rank 7–9) ranged from 90 to 100%. Consensus was reached (i.e., ≥ 75% of respondents strongly agreed or agreed) on the wording, the grade of recommendation, and level of evidence of all the 30 clinical standards identified by the scientific committee.
Conclusions
This guideline provides updated evidence-based recommendations for the prevention and treatment of acute as well as chronic gout. This guideline provides an approach for physicians and patients making decisions on the management of gout. It will also facilitate improvement and uniformity of care.
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OUP accepted manuscript. Rheumatology (Oxford) 2022; 61:4314-4323. [DOI: 10.1093/rheumatology/keac077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 01/04/2022] [Indexed: 11/13/2022] Open
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Tang B, Zeng X, Fan C. Significantly Better Efficacy for Acute Ankle Gouty Arthritis Through Arthroscopic Debridement Compared With Simple Drug Therapy: A Longitudinal Study With 1-Year Follow-up. J Clin Rheumatol 2022; 28:e69-e72. [PMID: 33315787 DOI: 10.1097/rhu.0000000000001608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to compare the clinical feasibility, efficacy, and cost economics of simple drug therapy with a combination therapy of arthroscopic debridement and drug treatment of ankle acute gout arthritis. METHODS Patients with acute ankle gout arthritis hospitalized in our department from January 2017 to August 2019 were included. Among them, 32 patients who received arthroscopic debridement in a special floating position and drug therapy were included into the observation group, and 24 patients who received drug treatment alone were included into the control group. The American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, the effective rate, the recurrent rate, stay of hospital, complications, and cost economics were compared between these 2 groups at postoperative 48 hours, discharge time, and 1 year. RESULTS The basic data and AOFAS ankle-hindfoot score before treatment showed no significant difference (p > 0.05) between these 2 groups. Compared with the control group, the observation group showed significantly higher AOFAS score at postoperative 48 hours (80.73 ± 9.15 vs 71.09 ± 8.54, p = 0.000), discharge time (87.73 ± 9.92 vs 77.71 ± 10.26, p = 0.000), and postoperative 1 year (85.92 ± 10.39 vs 76.36 ± 8.72, p = 0.000); lower recurrence rate (15.63% vs 25%, p = 0.382); significantly shorter length of hospitalization (4.92 ± 0.88 days vs 8.90 ± 0.73 days, p = 0.000); and significantly higher cost (¥8981.2 ± ¥740.2 vs ¥3558.3 ± ¥270.1, p = 0.000) during the discharge time. CONCLUSIONS Ankle gout arthritis could be systematically and safely managed with ankle arthroscopic technique in special floating position. In addition, compared with conservative drug therapy alone, ankle arthroscopic debridement combined with conservative drug therapy improved clinical efficacy, lowered recurrence rate, and shortened length of hospitalization.
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Affiliation(s)
- Bo Tang
- From the Sports Medicine Center, First People's Hospital of Xining City, Xining, Qinghai, China
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Singh JA, Joseph A, Baker J, Richman JS, Shaneyfelt T, Saag KG, Eisen S. SToRytelling to Improve Disease outcomes in Gout (STRIDE-GO): a multicenter, randomized controlled trial in African American veterans with gout. BMC Med 2021; 19:265. [PMID: 34749717 PMCID: PMC8576883 DOI: 10.1186/s12916-021-02135-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 09/20/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Urate-lowering therapy (ULT) adherence is low in gout, and few, if any, effective, low-cost, interventions are available. Our objective was to assess if a culturally appropriate gout-storytelling intervention is superior to an attention control for improving gout outcomes in African-Americans (AAs). METHODS In a 1-year, multicenter, randomized controlled trial, AA veterans with gout were randomized to gout-storytelling intervention vs. a stress reduction video (attention control group; 1:1 ratio). The primary outcome was ULT adherence measured with MEMSCap™, an electronic monitoring system that objectively measured ULT medication adherence. RESULTS The 306 male AA veterans with gout who met the eligibility criteria were randomized to the gout-storytelling intervention (n = 152) or stress reduction video (n = 154); 261/306 (85%) completed the 1-year study. The mean age was 64 years, body mass index was 33 kg/m2, and gout disease duration was 3 years. ULT adherence was similar in the intervention vs. control groups: 3 months, 73% versus 70%; 6 months, 69% versus 69%; 9 months, 66% versus 67%; and 12 months, 61% versus 64% (p > 0.05 each). Secondary outcomes (gout flares, serum urate and gout-specific health-related quality of life [HRQOL]) in the intervention versus control groups were similar at all time points except intervention group outcomes were better for the following: (1) number of gout flares at 9 months were fewer, 0.7 versus 1.3 in the previous month (p = 0.03); (2) lower/better scores on two gout specific HRQOL subscales: gout medication side effects at 3 months, 32.8 vs. 39.6 (p = 0.02); and unmet gout treatment need at 3 months, 30.9 vs. 38.2 (p = 0.003), and 6 months, 29.5 vs. 34.5 (p = 0.03), respectively. CONCLUSIONS A culturally appropriate gout-storytelling intervention was not superior to attention control for improving gout outcomes in AAs with gout. TRIAL REGISTRATION Registered at ClinicalTrials.gov NCT02741700.
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Affiliation(s)
- Jasvinder A Singh
- Medicine Service, VA Medical Center, 700 19th St S, Birmingham, AL, 35233, USA.
- Department of Medicine at School of Medicine, Faculty Office Tower 805B, 510 20th Street S, Birmingham, AL, 35294, USA.
- Division of Epidemiology at School of Public Health, University of Alabama at Birmingham, 1720 Second Ave South, Birmingham, AL, 35294-0022, USA.
| | - Amy Joseph
- Washington University School of Medicine, St. Louis, MO, USA
- St. Louis Veterans Affairs Medical Center, St. Louis, MO, USA
| | - Joshua Baker
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
- University of Pennsylvania, Philadelphia, PA, USA
| | - Joshua S Richman
- Medicine Service, VA Medical Center, 700 19th St S, Birmingham, AL, 35233, USA
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Terrence Shaneyfelt
- Medicine Service, VA Medical Center, 700 19th St S, Birmingham, AL, 35233, USA
| | - Kenneth G Saag
- Medicine Service, VA Medical Center, 700 19th St S, Birmingham, AL, 35233, USA
- Department of Medicine at School of Medicine, Faculty Office Tower 805B, 510 20th Street S, Birmingham, AL, 35294, USA
| | - Seth Eisen
- St. Louis Veterans Affairs Medical Center, St. Louis, MO, USA
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
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Murdoch R, Barry MJ, Choi HK, Hernandez D, Johnsen B, Labrador M, Reid S, Singh JA, Terkeltaub R, Vázquez Mellado J, Dalbeth N. Gout, Hyperuricaemia and Crystal-Associated Disease Network (G-CAN) common language definition of gout. RMD Open 2021; 7:rmdopen-2021-001623. [PMID: 33903281 PMCID: PMC8076916 DOI: 10.1136/rmdopen-2021-001623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/23/2021] [Accepted: 04/02/2021] [Indexed: 12/27/2022] Open
Abstract
Objective To develop a Gout, Hyperuricaemia and Crystal-Associated Disease Network (G-CAN) common language definition of gout, with the goal of increasing public understanding and awareness, and ensure consistent and understandable messages about gout. Methods A G-CAN working group that included patients, physicians and nongovernmental organisation (NGO) representatives was formed to develop a common language definition of gout for use with the public, media, healthcare providers and stakeholders. A literature search and interviews with patients, healthcare workers and stakeholders informed development of the definition. Following consultation with G-CAN members and partners, the definition was endorsed by the G-CAN board. Results The G-CAN common language definition of gout describes the epidemiology, pathophysiology, symptoms and impact, risk factors, comorbidities, management and healthcare and workforce considerations. Detailed information is provided to support the content of the definition. After the publication of the English-language version, the definition will be available for translation into other languages by G-CAN members. Conclusion G-CAN has developed a concise and easily understandable statement describing gout in language that can be used in conversations with the lay public, media, NGOs, funders, healthcare providers and other stakeholders.
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Affiliation(s)
- Rachel Murdoch
- Department of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Michael J Barry
- Department of Primary Care, Harvard Medical School, Boston, Massachusetts, USA
| | - Hyon K Choi
- Division of Rheumatology Allergy and Immunology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Brianne Johnsen
- Division of Rheumatology Allergy and Immunology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Manuel Labrador
- Department of Rheumatology, Hospital General de México, Ciudad de Mexico, Mexico
| | - Susan Reid
- Department of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Jasvinder A Singh
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Medicine Service, Birmingham VA Medical Center, Birmingham, Alabama, USA
| | - Robert Terkeltaub
- Department of Rheumatology, University of California San Diego, La Jolla, California, USA
| | | | - Nicola Dalbeth
- Department of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
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Singh JA, Richards JS, Chang E, Toupin-April K, Barton JL. Shared decision-making in gout treatment: a national study of rheumatology provider opinion and practice. Clin Rheumatol 2021; 40:693-700. [PMID: 32997317 PMCID: PMC7856219 DOI: 10.1007/s10067-020-05421-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 09/08/2020] [Accepted: 09/17/2020] [Indexed: 11/28/2022]
Abstract
To assess rheumatologists' views and practices related to shared decision-making (SDM) in gout treatment. We performed a cross-sectional electronic survey of rheumatologists at U.S. Veterans Affairs (VA) medical centers, assessing views and practices related to SDM in gout. Of the 154 VA rheumatology providers eligible, 90 responded (response rate, 58%). Fifty-eight percent were female, the mean age was 51 years (standard deviation, 9.6), 42% had > 20 years of experience in medical practice. Rheumatologists reported routinely offering a choice to their patients for (1) starting urate-lowering therapy (ULT) for gout vs. doing nothing (70%); (2) choosing NSAIDs, corticosteroids, or colchicine for the treatment of acute flares (67%); and (3) choosing NSAIDs, corticosteroids, or colchicine for anti-inflammatory prophylaxis when starting ULT (51%). Very few rheumatologists offered choice regarding (4) choosing allopurinol vs. febuxostat as the first ULT (16%) and (5) taking daily ULT long-term vs. intermittently (15%). Rheumatologists perceived that a large proportion of patients were often or sometimes unsure of the best choice for these five decisions, 34%, 76%, 76%, 52%, and 54%, respectively. Similar proportions of rheumatologists felt that patients were uninformed about both medication benefits and risks, unclear about the personal importance of the benefits and risks, and unsupported in decision-making. For the five decisions respectively, rheumatologists supported SDM with patients in 76%, 56%, 58%, 27%, and 25%. The majority of VA rheumatologists incorporated SDM in several gout treatment decisions. Rheumatologists also recognized that patients need better support to participate in SDM in gout. Key Points: • Rheumatologists offered shared decision-making to gout patients for 3 key treatment decisions. • Rheumatologists perceived that many patients were unsure of the best choice for these decisions. • Rheumatologists felt that patients were uninformed about medication benefits/risks and unsupported in decision-making.
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Affiliation(s)
- Jasvinder A Singh
- Medicine Service, Birmingham VA Medical Center, 700 19th St S, AL, 35233, Birmingham, USA.
- Department of Medicine at School of Medicine, University of Alabama at Birmingham, 510 20th Street South, Birmingham, AL, 35294, United States.
- Division of Epidemiology at School of Public Health, University of Alabama at Birmingham, 1720 Second Ave South, Birmingham, AL, 35294-0022, USA.
- University of Alabama at Birmingham, Faculty Office Tower 805B, 510 20th Street S, Birmingham, AL, 35294-0022, USA.
| | | | | | - Karine Toupin-April
- School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Jennifer L Barton
- VA Portland Health Care System, Oregon Health & Science University, Portland, OR, USA
- Department of Medicine, Oregon Health & Science University, Portland, OR, USA
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Abstract
PURPOSE OF REVIEW Although gout is a common, well-recognized, and extensively researched rheumatologic disease, it continues to be underappreciated and undertreated. Although the prevalence of gout has been rising over the past several decades, adherence to urate lowering therapy continues to be suboptimal. Recent studies have underscored the potential success of guideline-directed therapy. RECENT FINDINGS Adherence to gout treatment continues to be suboptimal according to multinational metaanalyses. Moreover, studies measuring adherence are prone to overestimation and each methodologic approach has intrinsic limitations. Adherence may be analyzed from the perspective of patient adherence to taking a medication, or provider adherence to treatment guidelines. In addition to considering traditional risk factors, adherence should be viewed through the lens of healthcare disparities. The RAmP-Up trial and Nottingham Gout Treatment trial demonstrate the success of protocolized gout treatment using existing guidelines for reference. SUMMARY Standardized gout treatment protocols should be established for all primary care and specialty practices. Two successful methods of improving adherence include using nonphysician providers to coordinate urate lowering therapy titration and monitoring serum urate. Having more frequent outpatient visits to focus on direct patient care and education has also been successful.
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Singh JA, Richman J, Yang S, Bridges SL, Saag K. Allopurinol adherence and its predictors in gout: a national cohort study in US veterans. LANCET RHEUMATOLOGY 2020; 2:e281-e291. [PMID: 33215163 DOI: 10.1016/s2665-9913(20)30029-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
| | - Joshua Richman
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Shuo Yang
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - S Lou Bridges
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kenneth Saag
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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12
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Robinson PC. Gout models of care: The next step is to facilitate implementation. Int J Rheum Dis 2020; 23:1115-1116. [DOI: 10.1111/1756-185x.13900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 06/03/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Philip C. Robinson
- University of Queensland Faculty of Medicine Brisbane Qld Australia
- Royal Brisbane & Women’s Hospital Metro North Hospital & Health Service Brisbane Qld Australia
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13
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Nikolov NP, Seymour S, Neuner R, Hsueh YH, Andraca-Carrera E, Mistry K. Underscoring the Importance of Allopurinol in Treating Gout: Results of a Food and Drug Administration-Mandated Safety Trial. Arthritis Rheumatol 2020; 72:877-878. [PMID: 32460423 DOI: 10.1002/art.41266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 03/18/2020] [Indexed: 11/06/2022]
Affiliation(s)
- Nikolay P Nikolov
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD
| | - Sally Seymour
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD
| | - Rosemarie Neuner
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD
| | - Ya-Hui Hsueh
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD
| | | | - Kusum Mistry
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD
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14
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Kim A, Kim Y, Kim GT, Ahn E, So MW, Lee SG. Comparison of persistence rates between allopurinol and febuxostat as first-line urate-lowering therapy in patients with gout: an 8-year retrospective cohort study. Clin Rheumatol 2020; 39:3769-3776. [PMID: 32458236 DOI: 10.1007/s10067-020-05161-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/04/2020] [Accepted: 05/08/2020] [Indexed: 12/27/2022]
Abstract
INTRODUCTION/OBJECTIVES Lifelong urate-lowering therapy (ULT) with xanthine oxidase inhibitors (XOIs), such as allopurinol and febuxostat, is the cornerstone of gout treatment. This study aimed to compare drug persistence between allopurinol and febuxostat as first-line ULT in patients with gout in real practice. METHOD In this retrospective cohort study, we evaluated 602 patients with gout in whom allopurinol or febuxostat was newly initiated from December 2011 to November 2018 at a tertiary rheumatology centre. Persistence was defined as the duration from the first description date to the end of treatment with XOIs or the end of the study period (November 2019). RESULTS Among the 602 gout patients, the mean age was 60.2 years and 234 (38.9%) patients had tophi. Allopurinol and febuxostat were started in 237 (39.3%) and 365 (60.6%) patients, respectively. During the study period, 282 (46.8%) patients stopped taking XOIs, and the most common reason for XOI withdrawal was poor health literacy (61.3%). The 1- and 5-year persistence rates of XOIs were 67.2% and 40.9%, respectively. In the Kaplan-Meier analysis, persistence rates of allopurinol were significantly lower than those of febuxostat (p < 0.001). In the multivariable Cox regression model, allopurinol use was a significant risk factor for discontinuation of XOIs (HR = 2.01, p < 0.001). In addition, the presence of tophi and symptom duration < 24 months was independently associated with a higher risk of XOI withdrawal. CONCLUSIONS Long-term persistence of XOIs was suboptimal, and allopurinol had worse persistence rates than febuxostat among patients with gout. Key Points • Long-term persistence of xanthine oxidase inhibitors (XOIs) as first-line urate-lowering therapy (ULT) among patients with gout was suboptimal, and the major reason for XOI discontinuation was poor health literacy in our study. • We demonstrated that allopurinol had worse persistence rates than febuxostat among patients with gout, suggesting that febuxostat is a better option for long-term ULT in light of medication adherence in a real-world setting. • Patients with gout with tophi and shorter symptom duration were found to be at high risk for poor persistence of XOIs.
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Affiliation(s)
- Aran Kim
- Division of Rheumatology, Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, 179 Gudeok-Ro, Seo-Gu, Busan, 49241, South Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, South Korea
| | - Yunkyung Kim
- Division of Rheumatology, Department of Internal Medicine, Kosin University College of Medicine, Busan, South Korea
| | - Geun-Tae Kim
- Division of Rheumatology, Department of Internal Medicine, Kosin University College of Medicine, Busan, South Korea
| | - Eunyoung Ahn
- Division of Rheumatology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Min Wook So
- Division of Rheumatology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Seung-Geun Lee
- Division of Rheumatology, Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, 179 Gudeok-Ro, Seo-Gu, Busan, 49241, South Korea. .,Biomedical Research Institute, Pusan National University Hospital, Busan, South Korea.
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Abstract
PURPOSE OF REVIEW Recent studies have produced evidence regarding the patient perspectives in gout including from disease experience to disease outcomes. Therefore, an overview on the topic can help improve our understanding of the patient experience. RECENT FINDINGS This article explores several aspects of the patient perspective including the impact of gout on a patient's life, patient knowledge and beliefs regarding gout and its treatments, patient-perceived barriers to optimal medication adherence in gout and patient's perception of their gout. This article also summarizes any evidence of the association of patient perceptions to patient outcomes in gout. SUMMARY A recognition of patient perspectives in gout has the potential to positively impact clinical care for gout. Discussion of disease impact, misperceptions about benefits/harms of urate-lowering therapy (ULT), and patient values/preferences regarding pharmacological and nonpharmacological treatments can lead to a better shared decision-making and improved outcomes in gout. These findings emphasize the importance of inclusion of patient perspective not only in clinical care and quality improvement and research initiatives but also in the design and implementation of the research agenda in gout. Inclusion of patient-reported outcomes in clinical research is likely to improve its relevance to patients with gout.
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Affiliation(s)
- Jasvinder A Singh
- Medicine Service, VA Medical Center.,Department of Medicine at the School of Medicine, University of Alabama at Birmingham (UAB), Birmingham.,Department of Epidemiology at the UAB School of Public Health, Birmingham, USA
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16
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Variation in methods, results and reporting in electronic health record-based studies evaluating routine care in gout: A systematic review. PLoS One 2019; 14:e0224272. [PMID: 31648282 PMCID: PMC6812805 DOI: 10.1371/journal.pone.0224272] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 10/09/2019] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To perform a systematic review examining the variation in methods, results, reporting and risk of bias in electronic health record (EHR)-based studies evaluating management of a common musculoskeletal disease, gout. METHODS Two reviewers systematically searched MEDLINE, Scopus, Web of Science, CINAHL, PubMed, EMBASE and Google Scholar for all EHR-based studies published by February 2019 investigating gout pharmacological treatment. Information was extracted on study design, eligibility criteria, definitions, medication usage, effectiveness and safety data, comprehensiveness of reporting (RECORD), and Cochrane risk of bias (registered PROSPERO CRD42017065195). RESULTS We screened 5,603 titles/abstracts, 613 full-texts and selected 75 studies including 1.9M gout patients. Gout diagnosis was defined in 26 ways across the studies, most commonly using a single diagnostic code (n = 31, 41.3%). 48.4% did not specify a disease-free period before 'incident' diagnosis. Medication use was suboptimal and varied with disease definition while results regarding effectiveness and safety were broadly similar across studies despite variability in inclusion criteria. Comprehensiveness of reporting was variable, ranging from 73% (55/75) appropriately discussing the limitations of EHR data use, to 5% (4/75) reporting on key data cleaning steps. Risk of bias was generally low. CONCLUSION The wide variation in case definitions and medication-related analysis among EHR-based studies has implications for reported medication use. This is amplified by variable reporting comprehensiveness and the limited consideration of EHR-relevant biases (e.g. data adequacy) in study assessment tools. We recommend accounting for these biases and performing a sensitivity analysis on case definitions, and suggest changes to assessment tools to foster this.
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17
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Singh JA, Yang S, Saag KG. Factors Influencing the Effectiveness of Allopurinol in Achieving and Sustaining Target Serum Urate in a US Veterans Affairs Gout Cohort. J Rheumatol 2019; 47:449-460. [PMID: 31416925 DOI: 10.3899/jrheum.190522] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2019] [Indexed: 01/18/2023]
Abstract
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.
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Affiliation(s)
- Jasvinder A Singh
- From the Birmingham Veterans Affairs Medical Center; Department of Medicine at the School of Medicine, and Department of Epidemiology at the School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA. .,J.A. Singh, MBBS, MPH, Birmingham Veterans Affairs Medical Center, and Department of Medicine at the School of Medicine, and Department of Epidemiology at the School of Public Health, University of Alabama at Birmingham; S. Yang, MS, Department of Epidemiology at the School of Public Health, University of Alabama at Birmingham; K.G. Saag, MD, MSc, Department of Medicine at the School of Medicine, University of Alabama at Birmingham.
| | - Shuo Yang
- From the Birmingham Veterans Affairs Medical Center; Department of Medicine at the School of Medicine, and Department of Epidemiology at the School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA.,J.A. Singh, MBBS, MPH, Birmingham Veterans Affairs Medical Center, and Department of Medicine at the School of Medicine, and Department of Epidemiology at the School of Public Health, University of Alabama at Birmingham; S. Yang, MS, Department of Epidemiology at the School of Public Health, University of Alabama at Birmingham; K.G. Saag, MD, MSc, Department of Medicine at the School of Medicine, University of Alabama at Birmingham
| | - Kenneth G Saag
- From the Birmingham Veterans Affairs Medical Center; Department of Medicine at the School of Medicine, and Department of Epidemiology at the School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA.,J.A. Singh, MBBS, MPH, Birmingham Veterans Affairs Medical Center, and Department of Medicine at the School of Medicine, and Department of Epidemiology at the School of Public Health, University of Alabama at Birmingham; S. Yang, MS, Department of Epidemiology at the School of Public Health, University of Alabama at Birmingham; K.G. Saag, MD, MSc, Department of Medicine at the School of Medicine, University of Alabama at Birmingham
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18
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Adherence and Outcomes with Urate-Lowering Therapy: A Site-Randomized Trial. Am J Med 2019; 132:354-361. [PMID: 30503879 PMCID: PMC6399023 DOI: 10.1016/j.amjmed.2018.11.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 11/16/2018] [Accepted: 11/19/2018] [Indexed: 12/22/2022]
Abstract
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.
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19
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Mirmiran R, Bush T, Cerra MM, Grambart S, Kauschinger E, Younger M, Zychowicz M. Joint Clinical Consensus Statement of the American College of Foot and Ankle Surgeons® and the American Association of Nurse Practitioners®: Etiology, Diagnosis, and Treatment Consensus for Gouty Arthritis of the Foot and Ankle. J Foot Ankle Surg 2019; 57:1207-1217. [PMID: 30368431 DOI: 10.1053/j.jfas.2018.08.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Gout is a condition that commonly affects the foot and ankle, and practitioners who treat these structures should be aware of the methods to diagnose and treat this form of arthritis. Practitioners also need to recognize extra-articular manifestations of the disease. Although the acutely red, hot, swollen joint is a common presentation, chronic tophaceous gout can be associated with pain, nodule formation, and cutaneous compromise. Since the underlying causes that lead to excessive monosodium urate deposition may be treatable, early and accurate diagnosis can be very beneficial and may even prevent articular degeneration.
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Affiliation(s)
- Roya Mirmiran
- Foot and Ankle Surgeon, Department of Surgery, Sutter Medical Group, Sacramento, CA.
| | - Tom Bush
- Associate Professor and Assistant Dean for Practice, University of North Carolina at Chapel Hill Schools of Nursing and Medicine, Chapel Hill, NC
| | - Michele M Cerra
- Director of the Duke NP/PA Rheumatology Fellowship Program & Faculty, Department of Medicine, Duke University School of Medicine, NC
| | - Sean Grambart
- Foot and Ankle Surgeon, Carle Physician Group, Department of Surgery, Champaign, IL
| | - Elaine Kauschinger
- Clinical Assistant Professor, Duke University School of Nursing, Durham, NC
| | - Melissa Younger
- Podiatric Research Fellow, Penn Presbyterian Medical Center, Philadelphia, PA
| | - Michael Zychowicz
- Professor and Director of MSN Program & Lead Faculty in Orthopedic NP Specialty, Duke University School of Nursing, Durham, NC
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20
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Levy G, Shi JM, Cheetham TC, Rashid N. Urate-Lowering Therapy in Moderate to Severe Chronic Kidney Disease. Perm J 2019; 22:17-142. [PMID: 30201087 DOI: 10.7812/tpp/17-142] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Gerald Levy
- Rheumatologist at the Downey Medical Center in CA
| | - Jiaxiao M Shi
- Researcher in Research and Evaluation for the Southern California Permanente Medical Group in Pasadena
| | - T Craig Cheetham
- Research Scientist in the College of Pharmacy at Western University of Health Sciences in Pomona, CA
| | - Nazia Rashid
- Researcher in Research and Evaluation in Drug Information Services for the Southern California Permanente Medical Group in Pasadena
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21
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Engel B, Just J, Bleckwenn M, Weckbecker K. Treatment Options for Gout. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 114:215-222. [PMID: 28434436 DOI: 10.3238/arztebl.2017.0215] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 07/21/2016] [Accepted: 12/29/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND 1-2% of adults in Germany suffer from gout. Gout is one of the few rheumatological diseases that can be cured. It arises through the deposition of uric acid crystals in joints as a result of hyperuricemia. Painful redness and swelling of the affected joints are typical findings. Multiple pertinent guidelines and treatment recommendations have been published, but there is reason to believe that patients with gout are not always treated accordingly. METHODS This review is based on relevant publications from the years 2000-2016 that were retrieved by a selective search in the Cochrane and PubMed databases. RESULTS In a person with normal renal function, asymptomatic hyperuricemia is not an indication for treatment to lower the serum uric acid level. The drugs of first choice for acute gouty arthritis are nonsteroidal antiinflammatory drugs (NSAID), corticosteroids, and colchicine. Treatment with xanthine oxidase inhibitors (XOI) or uricosuric drugs is indicated for patients with a recurrent or severe course; the target uric acid value is <6 mg/dL. Long-term treatment should be initiated only after resolution of the acute attack. For patients with refractory gout, lesinurad (approved in February 2016) in combination with XOI is a new treatment option that can be considered. Comprehensive patient education and counseling is an important component of the treatment of patients with gout. Regular laboratory follow-up is necessary as well. CONCLUSION The prevalence of gout is rising around the world. Patients with gout could benefit greatly from consistent implementation of the existing treatment guidelines and recommendations. In the future, controlled trials should be conducted to determine the best time to start treatment and the optimal target level for the serum uric acid concentration in terms of a risk/benefit analysis.
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Affiliation(s)
- Bettina Engel
- Institute of General Practice and Family Medicine, University Hospital Bonn
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22
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Mirmiran R, Bush T, Cerra MM, Grambart S, Kauschinger E, Younger M, Zychowicz M. Joint Clinical Consensus Statement of the American College of Foot and Ankle Surgeons® and the American Association of Nurse Practitioners™: Etiology, Diagnosis, and Treatment Consensus for Gouty Arthritis of the Foot and Ankle. J Nurse Pract 2018. [DOI: 10.1016/j.nurpra.2018.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Engel B, Gomm W, Broich K, Maier W, Weckbecker K, Haenisch B. Hyperuricemia and dementia - a case-control study. BMC Neurol 2018; 18:131. [PMID: 30170563 PMCID: PMC6117937 DOI: 10.1186/s12883-018-1136-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 08/22/2018] [Indexed: 12/31/2022] Open
Abstract
Background There is evidence that uric acid may have antioxidant and neuroprotective effects and might therefore alter the risk for neurodegenerative diseases such as dementia. So far, the relation between serum uric acid (SUA) levels or hyperuricemia and dementia remains elusive. Most studies focused on the disease or SUA levels. Effects of anti-hyperuricemic treatment have not been considered yet. This study investigated the association between hyperuricemia and dementia taking into account anti-hyperuricemic treatment. Methods We used longitudinal German public health insurance data and analyzed the association between hyperuricemia with and without different treatment options and dementia in a case-control design. Applying logistic regression the analysis was adjusted for several potential confounders including various comorbidities and polypharmacy. Results We identified 27,528 cases and 110,112 matched controls of which 22% had a diagnosis of hyperuricemia or gout and 17% received anti-hyperuricemic drugs. For patients with a diagnosis of hyperuricemia we found a slightly reduced risk for dementia (adjusted odds ratio [OR] 0.94, 95% confidence interval [CI] 0.89 to 0.98). The risk reduction was more pronounced for patients treated with anti-hyperuricemic drugs (adjusted OR 0.89, 95% CI 0.85 to 0.94, for regular treatment). Conclusions Our results showed a slight reduction for dementia risk in patients with hyperuricemia, both with and without anti-hyperuricemic treatment.
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Affiliation(s)
- Bettina Engel
- Institute of General Practice and Family Medicine, University of Bonn, Bonn, Germany.,Department of Health Services Research, Division of General Medicine, University of Oldenburg, Oldenburg, Germany
| | - Willy Gomm
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
| | - Karl Broich
- Federal Institute for Drugs and Medical Devices (BfArM), Kurt-Georg-Kiesinger-Allee 3, D-53175, Bonn, Germany
| | - Wolfgang Maier
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany.,Department of Psychiatry, University of Bonn, Bonn, Germany
| | - Klaus Weckbecker
- Institute of General Practice and Family Medicine, University of Bonn, Bonn, Germany
| | - Britta Haenisch
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany. .,Federal Institute for Drugs and Medical Devices (BfArM), Kurt-Georg-Kiesinger-Allee 3, D-53175, Bonn, Germany. .,Center for Translational Medicine, University of Bonn, Bonn, Germany.
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Goals of gout treatment: a patient perspective. Clin Rheumatol 2018; 37:2557-2566. [PMID: 30078087 DOI: 10.1007/s10067-018-4243-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 07/14/2018] [Accepted: 07/25/2018] [Indexed: 01/13/2023]
Abstract
To assess the goals of gout treatment from a patient perspective, a convenience sample of consecutive patients with doctor-diagnosed gout seen at a community-based outpatient clinic were invited. Sex-stratified nominal groups were conducted until saturation was achieved. Responses were collected verbatim, discussed, and rank-ordered by each participant. Thirty-six patients with doctor-diagnosed gout participated in 12 nominal groups: 6 male only, 5 female only, and 1 group with both. Mean age was 61.9 years (SD, 12.3); mean gout duration was 13.3 years (SD, 12.5); 53% were men, 64% African-American, 42% retired, 47% currently married, 87% were using either allopurinol and/or febuxostat, and 40% had had no gout flares in the last 6 months. The top 5 treatment goals accounted for 91% of all votes and included the following: (1) prevent and better manage flare-ups and improve function (25%), (2) eliminate flare-ups/disease remission (30%), (3) diet and activity modification/lifestyle change (13%), (4) patient education and public awareness (12%), and (5) medication management and minimization of side effects (11%). When examining the top-rated concern for each nominal group, the first two goals were nominated by four groups each, diet/activity modification and medication management by 1 group each, and patient education by 3 groups. There were no differences evident by sex in top-ranked treatment goal. People with gout identified and rank-ordered treatment goals relevant to them. Providers of gout care need to be cognizant of these goals. Disease management concordant with these treatment goals might lead to a more satisfied, informed patient.
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Singh JA, Cleveland JD. Comparative effectiveness of allopurinol versus febuxostat for preventing incident dementia in older adults: a propensity-matched analysis. Arthritis Res Ther 2018; 20:167. [PMID: 30075731 PMCID: PMC6091090 DOI: 10.1186/s13075-018-1663-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 07/09/2018] [Indexed: 12/22/2022] Open
Abstract
Background The purpose of this study was to assess the comparative effectiveness of allopurinol versus febuxostat for preventing incident dementia in older adults. Methods In a retrospective cohort study using Medicare claims data, we included patients newly treated with allopurinol or febuxostat (baseline period of 365 days without either medication). We used 5:1 propensity-matched Cox regression analyses to compare the hazard ratio (HR) of incident dementia with allopurinol versus febuxostat use and with allopurinol/febuxostat dose and duration. Results Crude rates of incident dementia per 100,000 person-days were lower with higher daily dose: allopurinol less than 200, 200 to 299, and at least 300 mg/day with 12, 9, and 8 and febuxostat 40 and 80 mg/day with 9 and 8, respectively. In propensity-matched analyses, compared with allopurinol use, febuxostat use was not significantly different, and the HR of incident dementia was 0.79 (95% confidence interval (CI) 0.61, 1.03). Compared with allopurinol less than 200 mg/day, higher allopurinol doses (200 to 299 and at least 300 mg/day) and the febuxostat 40 mg/day dose were each associated with lower HRs of dementia: 0.80 (95% CI 0.64, 0.98), 0.59 (95% CI 0.50, 0.71), and 0.64 (95% CI 0.47, 0.86), respectively. Compared with allopurinol use for 1 to 180 days, longer allopurinol or febuxostat use durations were not significantly associated with differences in HR of dementia (range of 0.76 to 1.14). Conclusions A dose-related reduction in the risk of dementia in older adults was noted with higher allopurinol dose and with febuxostat 40 mg daily dose. Future studies need to examine the mechanism of this benefit. Electronic supplementary material The online version of this article (10.1186/s13075-018-1663-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jasvinder A Singh
- Medicine Service, VA Medical Center, 510, 20th Street South, FOT 805B, Birmingham, AL, 35233, USA. .,Department of Medicine at School of Medicine, University of Alabama at Birmingham, 20th Street South, FOT 805B, Birmingham, AL, 35294-0022, USA. .,Division of Epidemiology at School of Public Health, University of Alabama at Birmingham, 1720 Second Avenue South, Birmingham, AL, 35294-0022, USA. .,University of Alabama, Faculty Office Tower 805B, 510 20th Street South, Birmingham, AL, 35294-0022, USA.
| | - John D Cleveland
- Department of Medicine at School of Medicine, University of Alabama at Birmingham, 20th Street South, FOT 805B, Birmingham, AL, 35294-0022, USA
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Singh JA, Cleveland JD. Gout and the risk of incident atrial fibrillation in older adults: a study of US Medicare data. RMD Open 2018; 4:e000712. [PMID: 30018808 PMCID: PMC6045725 DOI: 10.1136/rmdopen-2018-000712] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 05/30/2018] [Accepted: 06/21/2018] [Indexed: 12/11/2022] Open
Abstract
Objective To assess the association of gout with new-onset atrial fibrillation (AF) in the elderly. Methods We used the 5% Medicare data from 2005 to 2012 to assess whether a diagnosis of gout was associated with incident AF. We used multivariable Cox regression adjusted for demographics, Charlson-Romano comorbidity index, common cardiovascular medications, allopurinol and febuxostat use, to calculate hazard ratios (HRs) and 95% confidence intervals (CIs). Results Among 1 647 812 eligible people, 9.8% had incident AF. The mean age was 75 years, 42% were male, 86% were white and the mean Charlson-Romano index score was 1.52. We noted 10 604 incident AF cases in people with gout and 150 486 incident AF cases in people without gout. The crude incidence rates of AF in people with and without gout were 43.4 vs 16.3 per 1000 patient-years, respectively. After multivariable-adjustment, gout was associated with a higher HR of incident AF, 1.92 (95% CI 1.88 to 1.96), with minimal attenuation of HR in sensitivity models that replaced the Charlson-Romano index score with a categorical variable, HR was 1.91 (95% CI 1.87 to 1.95). In another model that adjusted for AF-specific risk factors including hypertension, hyperlipidaemia and coronary artery disease and individual Charlson-Romano index comorbidities, the HR was slightly attenuated at 1.71 (95% CI 1.67 to 1.75). Older age, male sex, white race and higher Charlson-Romano index score were each associated with higher hazard of incident AF. Conclusion A diagnosis of gout almost doubled the risk of incident AF in the elderly. Future studies should explore the pathogenesis of this association.
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Affiliation(s)
- Jasvinder A Singh
- Medicine Service, VA Medical Center, Birmingham, Alabama, USA.,Department of Medicine at School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Division of Epidemiology at School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - John D Cleveland
- Department of Medicine at School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Coburn BW, Michaud K, Bergman DA, Mikuls TR. Allopurinol Dose Escalation and Mortality Among Patients With Gout: A National Propensity-Matched Cohort Study. Arthritis Rheumatol 2018. [PMID: 29513934 DOI: 10.1002/art.40486] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Observational data suggest that hyperuricemia and gout are associated with increased mortality, while allopurinol use is associated with reduced mortality. In addition, the protective effect of allopurinol may be dose dependent. The aim of the current study was to determine whether allopurinol dose escalation is associated with cause-specific mortality in patients with gout. METHODS In this 10-year observational, active-comparator study of US Veterans with gout who initiated treatment with allopurinol, propensity score matching, Cox proportional hazards models, and competing risks regression analyses were used to assess differences in cause-specific mortality between patients whose allopurinol dose was escalated (dose escalators) and those whose allopurinol dose was not escalated or was reduced (non-escalators) over a 2-year period. RESULTS Among the 6,428 dose escalators and 6,428 matched non-escalators, there were 2,867 deaths during the observation period (40.4 deaths per 1,000 person-years). Dose escalators experienced an increase in all-cause mortality (hazard ratio [HR] 1.08, 95% confidence interval [95% CI] 1.01-1.17), with the effect sizes being similar for incidence of cardiovascular-related deaths (HR 1.08, 95% CI 0.97-1.21) and cancer-related deaths (HR 1.06, 95% CI 0.88-1.27), although neither reached statistical significance. Dose escalation to achieve the goal of lowering the serum urate (SU) level to <6.0 mg/dl was infrequent. At 2 years, 10% of dose escalators were receiving a final daily dose of >300 mg and 31% had achieved the SU goal. In a sensitivity analysis limited to dose escalators achieving the SU goal, there was a nonsignificant reduction of 7% in the hazard of cardiovascular-related mortality (HR 0.93, 95% CI 0.76-1.14). CONCLUSION This is the largest study to date to investigate the effects of allopurinol use on mortality and is the first to use a rigorous active-comparator design. Dose escalation was associated with a small (<10%) increase in all-cause mortality, thus showing that a strategy of allopurinol dose escalation, which in current real-life practice is characterized by limited dose increases, is unlikely to improve the survival of patients with gout.
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Affiliation(s)
- Brian W Coburn
- Veterans Affairs Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, Omaha
| | - Kaleb Michaud
- University of Nebraska Medical Center, Omaha, and National Data Bank for Rheumatic Diseases, Wichita, Kansas
| | | | - Ted R Mikuls
- Veterans Affairs Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, Omaha
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Lee S, So MW, Ahn E. Long-term adherence and persistence with febuxostat among male patients with gout in a routine clinical setting. Mod Rheumatol 2018; 29:662-668. [PMID: 29856667 DOI: 10.1080/14397595.2018.1483293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Objectives: To assess long-term adherence and persistence to febuxostat (FBX) and factors that might contribute to non-adherence and non-persistence to FBX in male patients with gout during a 3-year period. Methods: Adherence to FBX was assessed by the clinic nurses through pill counts at the scheduled visits and non-adherence was defined as less than 80% of the prescribed dose taken. Non-persistence was defined as discontinuation of FBX longer than 60 days. Results: A total of 220 patients were recruited. The percentage of adherence and persistence was 71.8% and 80.9% at 1 year, 65.5% and 68.2% at 2 years and 58.2% and 56.4% at 3 years, respectively. The logistic regression analysis identified high income status, current smoking, absence of hypertension and previous history of non-persistence with urate-lowering therapy (ULT) as the independent factors associated with non-adherence, and the unmarried, absence of hypertension and previous history of non-persistence with ULT as the independent factors associated with non-persistence. Conclusion: Variable risk factors that are correlated with poor adherence or persistence and easily assessed can be used to identify patients at a particular risk of poor adherence or persistence.
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Affiliation(s)
- Sunggun Lee
- a Department of Internal Medicine, Division of Rheumatology, Haeundae Paik Hospital , Inje University College of Medicine , Busan , Korea
| | - Min Wook So
- b Department of Internal Medicine, Division of Rheumatology , Pusan National University Yangsan Hospital , Gyeongnam , Korea
| | - Eunyoung Ahn
- b Department of Internal Medicine, Division of Rheumatology , Pusan National University Yangsan Hospital , Gyeongnam , Korea
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FitzGerald JD, Mikuls TR, Neogi T, Singh JA, Robbins M, Khanna PP, Turner AS, Myslinski R, Suter LG. Development of the American College of Rheumatology Electronic Clinical Quality Measures for Gout. Arthritis Care Res (Hoboken) 2018; 70:659-671. [DOI: 10.1002/acr.23500] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 12/12/2016] [Indexed: 01/22/2023]
Affiliation(s)
| | - Ted R. Mikuls
- VA Nebraska-Western Iowa Health Care System; and University of Nebraska Medical Center; Omaha
| | - Tuhina Neogi
- Boston University School of Medicine; Boston Massachusetts
| | - Jasvinder A. Singh
- Birmingham Veterans Affairs Medical Center; and University of Alabama at Birmingham
| | - Mark Robbins
- Harvard Vanguard Medical Association; Somerville Massachusetts
| | - Puja P. Khanna
- University of Michigan; and VA Ann Arbor Healthcare System; Ann Arbor Michigan
| | | | | | - Lisa G. Suter
- Yale University, New Haven, Connecticut; and West Haven Veterans Affairs Medical Center; West Haven Connecticut
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Scheepers LE, van Onna M, Stehouwer CD, Singh JA, Arts IC, Boonen A. Medication adherence among patients with gout: A systematic review and meta-analysis. Semin Arthritis Rheum 2018; 47:689-702. [DOI: 10.1016/j.semarthrit.2017.09.007] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 08/29/2017] [Accepted: 09/20/2017] [Indexed: 12/11/2022]
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Singh JA, Cleveland J. Allopurinol and the risk of incident peripheral arterial disease in the elderly: a US Medicare claims data study. Rheumatology (Oxford) 2018; 57:451-461. [PMID: 29106674 DOI: 10.1093/rheumatology/kex232] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Indexed: 12/14/2022] Open
Abstract
Objective The aim was to examine whether allopurinol use is independently associated with a reduction in the risk of incident peripheral arterial disease (PAD) in the US elderly. Methods We used the 5% random Medicare sample from 2006 to 2012 to examine the association of allopurinol use and duration of use with the risk or hazard of incident PAD in a retrospective cohort study using a new user design. Multivariable Cox regression models adjusted for demographics, co-morbidity, cardiac medications and cardiac conditions. Hazard ratios (HRs) and 95% CIs were calculated. Results We identified 26 985 episodes of incident allopurinol use in 25 282 beneficiaries; 3167 allopurinol use episodes (12%) ended in incident PAD. In multivariable-adjusted analyses, allopurinol use was associated with an HR of 0.88 (95% CI: 0.81, 0.95) for incident PAD, as was female gender, HR 0.84 (95% CI: 0.78, 0.90). In a separate multivariable-adjusted model, compared with no allopurinol use, longer durations of allopurinol use were associated with lower HR of PAD: 181 days to 2 years, 0.88 (95% CI: 0.79, 0.97); and >2 years, 0.75 (95% CI: 0.63, 0.89). Other factors significantly associated with a higher HR of PAD were age 75 to < 85 and ⩾85 years, higher Charlson index score and black race. Sensitivity analyses that adjusted for cardiac conditions and medications confirmed these findings, with minimal to no attenuation of HRs. Conclusion New allopurinol use was independently associated with a lower risk of PAD in the elderly. Longer allopurinol use durations seemed more protective. Mechanisms of the protective effect need to be investigated in future studies.
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Affiliation(s)
- Jasvinder A Singh
- Medicine Service, VA Medical Center, University of Alabama at Birmingham, Birmingham, AL, USA.,Department of Medicine at School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.,Division of Epidemiology at School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - John Cleveland
- Department of Medicine at School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Singh JA, Herbey I, Bharat A, Dinnella JE, Pullman-Mooar S, Eisen S, Ivankova N. Gout Self-Management in African American Veterans: A Qualitative Exploration of Challenges and Solutions From Patients' Perspectives. Arthritis Care Res (Hoboken) 2017; 69:1724-1732. [PMID: 28118526 DOI: 10.1002/acr.23202] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Accepted: 01/17/2017] [Indexed: 11/10/2022]
Abstract
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.
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Affiliation(s)
- Jasvinder A Singh
- VA Medical Center and University of Alabama at Birmingham, and Mayo Clinic College of Medicine, Rochester, Minnesota
| | | | | | - Janet E Dinnella
- Philadelphia VA Medical Center and University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sally Pullman-Mooar
- Philadelphia VA Medical Center and University of Pennsylvania, Philadelphia, Pennsylvania
| | - Seth Eisen
- Washington University School of Medicine and St. Louis VA Medical Center, St. Louis, Missouri
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Singh JA, Cleveland JD. Comparative effectiveness of allopurinol versus febuxostat for preventing incident renal disease in older adults: an analysis of Medicare claims data. Ann Rheum Dis 2017; 76:1669-1678. [PMID: 28584186 DOI: 10.1136/annrheumdis-2017-211210] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 04/24/2017] [Accepted: 04/30/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess the comparative effectiveness of allopurinol versus febuxostat for preventing incident renal disease in elderly. METHODS In a retrospective cohort study using 2006-2012 Medicare claims data, we included patients newly treated with allopurinol or febuxostat (baseline period of 183 days without either medication). We used 5:1 propensity-matched Cox regression analyses to compare the HR of incident renal disease with allopurinol use (and dose) versus febuxostat (reference). Sensitivity analyses included multivariable-adjusted regression models. RESULTS There were 31 465 new allopurinol or febuxostat treatment episodes in 26 443 patients; 8570 ended in incident renal disease. Crude rates of incident renal disease per 1000 person-years were 192 with allopurinol versus 338 with febuxostat. Crude rates of incident renal disease per 1000 person-years were lower with higher daily dose: allopurinol <200, 200-299 and ≥300 mg/day with 238, 176 and 155; and febuxostat 40 and 80 mg/day with 341 and 326, respectively. In propensity-matched analyses, compared with febuxostat, allopurinol use was associated with lower HR of incident renal disease, 0.61 (95% CI 0.49 to 0.77). Compared with febuxostat 40 mg/day, allopurinol doses <200, 200-299 and ≥300 mg/day were associated with lower HR of incident renal disease, 0.75 (95% CI 0.65 to 0.86), 0.61 (95% CI 0.52 to 0.73) and 0.48 (95% CI 0.41 to 0.55), respectively. Sensitivity analyses using multivariable-adjusted regression confirmed these findings. CONCLUSIONS Allopurinol was associated with a lower risk of incident renal disease in elderly patients than febuxostat. Future studies need to examine the mechanism of this potential renal benefit of allopurinol.
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Affiliation(s)
- Jasvinder A Singh
- Medicine Service, VA Medical Center, Birmingham, Alabama, USA.,Department of Medicine at School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Division of Epidemiology at School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - John D Cleveland
- Department of Medicine at School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Singh JA, Bharat A, Khanna D, Aquino-Beaton C, Persselin JE, Duffy E, Elashoff D, Khanna PP. Health care utilization in patients with gout: a prospective multicenter cohort study. BMC Musculoskelet Disord 2017; 18:233. [PMID: 28569193 PMCID: PMC5452408 DOI: 10.1186/s12891-017-1573-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 05/11/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND All published studies of health care utilization in gout have been cross-sectional to date, and most used a patient-reported diagnosis of gout. Our objective was to assess health care utilization and its predictors in patients with physician-confirmed gout in a prospective cohort study. METHODS In a multi-center prospective cohort study of U.S. veterans with rheumatologist-confirmed gout (N = 186; two centers), we assessed patient self-reported overall and gout-specific health care utilization with the Gout Assessment Questionnaire (GAQ) every 3-months for a 9-month period. Comparisons were made using the student's t test or the chi-square, Wilcoxon rank sum test or Fisher exact test, as appropriate. Mixed effects Poisson regression was used to assess potential correlates of gout-related health care utilization. RESULTS Mean age was 64.6 years, 98% were men, 13% Hispanic or Latino, 32% were African-American, 6% did not graduate high school, mean serum urate was 8.3 and mean Deyo-Charlson score was 3.1. During the past year, mean gout-related visits were as follows: rheumatologist, 1.5; primary care physician, 2 visits; ≥1 inpatient visits, 7%; ≥1 ER visits, 26%; and urgent care/walk-in visit, 33%. In longitudinal analyses, African-American race and gout flares in the last 3 months were associated with significantly higher rate ratio of gout-related outpatient visits. African-American race and lack of college education were associated with significantly higher rate ratio for gout-related urgent visits and overnight stays. CONCLUSIONS African-American race and recent gout flares were associated with higher outpatient utilization and African-American race and no college education with higher urgent or inpatient utilization. Future studies should examine whether modifiable predictors of utilization can be targeted to reduce healthcare utilization in patients with gout.
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Affiliation(s)
- Jasvinder A Singh
- Department of Medicine at School of Medicine, and Division of Epidemiology at School of Public Health, University of Alabama at Birmingham (UAB), Faculty Office Tower 805B, 510 20th Street S, Birmingham, 35294, AL, USA. .,Medicine Service, Birmingham VA Medical Center, Birmingham, AL, USA. .,Department of Orthopedic Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA.
| | - Aseem Bharat
- Medicine Service, Birmingham VA Medical Center, Birmingham, AL, USA
| | | | | | - Jay E Persselin
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Erin Duffy
- University of California, Los Angeles, CA, USA
| | | | - Puja P Khanna
- University of Michigan, Ann Arbor, MI, USA.,VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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The rate of adherence to urate-lowering therapy and associated factors in Chinese gout patients: a cross-sectional study. Rheumatol Int 2017; 37:1187-1194. [DOI: 10.1007/s00296-017-3746-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 05/17/2017] [Indexed: 12/27/2022]
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Singh JA. Lesinurad combination therapy with allopurinol in gout: do CLEAR studies make the treatment of gout clearer? Ann Rheum Dis 2016; 76:779-781. [DOI: 10.1136/annrheumdis-2016-210519] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 11/12/2016] [Accepted: 12/08/2016] [Indexed: 12/13/2022]
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Singh JA, Uhlig T. Chasing crystals out of the body: will treat to serum urate target for gout help us get there? Ann Rheum Dis 2016; 76:629-631. [PMID: 28031165 DOI: 10.1136/annrheumdis-2016-210436] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 11/12/2016] [Accepted: 12/03/2016] [Indexed: 11/04/2022]
Affiliation(s)
- Jasvinder A Singh
- Birmingham VA Medical Center, Birmingham, Alabama, USA.,Department of Medicine, School of Medicine, University of Alabama, Birmingham, Alabama, USA.,Division of Epidemiology at the School of Public Health, University of Alabama, Birmingham, Alabama, USA
| | - Till Uhlig
- National Advisory Unit on Rehabilitation in Rheumatology, Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
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Hughes JC, Wallace JL, Bryant CL, Salvig BE, Fourakre TN, Stone WJ. Monitoring of Urate-Lowering Therapy Among US Veterans Following the 2012 American College of Rheumatology Guidelines for Management of Gout. Ann Pharmacother 2016; 51:301-306. [PMID: 27881692 DOI: 10.1177/1060028016679848] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND With the prevalence of and hospitalizations for gout increasing, optimizing care for patients with gout is imperative. The 2012 American College of Rheumatology gout guidelines emphasize that timely monitoring is key to achieving serum urate (SUA) goals. Few studies have examined this metric following the 2012 update, and to our knowledge, none have examined a veteran population. OBJECTIVE To evaluate adherence to urate-lowering therapy (ULT) monitoring guidelines in a veteran population. METHODS This is a single-center, multisite, retrospective chart review of US veterans receiving ULT for gout within the VA (Veterans Affairs) Tennessee Valley Healthcare System from January 1, 2013, to June 30, 2015. The primary end point was percentage of patients with a SUA within 6 months of initial xanthine oxidase inhibitor prescription. Secondary end points included percentage of patients with SUA <6 mg/dL and percentage of patients with uptitration following SUA above goal. RESULTS A total of 601 patients met inclusion criteria for the study; after application of exclusion criteria, 505 were analyzed. Of these, 295 patients (58%) did not have a SUA drawn within 6 months, and 162 patients (32%) reached the end of the study period without SUA measured. Of 226 patients with SUA above goal on initial check, 64 (28%) had timely dose adjustment, whereas 143 patients (63%) had no adjustment. A total of 161 patients (32%) had a SUA at goal within the study period. CONCLUSIONS Rates of ULT monitoring at a major VA medical center were suboptimal, and improved adherence to guideline recommendations is needed.
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Affiliation(s)
| | - Jessica L Wallace
- 1 VA Tennessee Valley Healthcare System, Nashville, TN, USA.,2 Lipscomb University College of Pharmacy, Nashville, TN, USA
| | | | - Brent E Salvig
- 3 VA Tennessee Valley Healthcare System, Murfreesboro, TN, USA
| | - T Neal Fourakre
- 3 VA Tennessee Valley Healthcare System, Murfreesboro, TN, USA
| | - William J Stone
- 1 VA Tennessee Valley Healthcare System, Nashville, TN, USA.,4 Vanderbilt University School of Medicine, Nashville, TN, USA
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Singh JA, Yu S. Allopurinol reduces the risk of myocardial infarction (MI) in the elderly: a study of Medicare claims. Arthritis Res Ther 2016; 18:209. [PMID: 27655429 PMCID: PMC5032238 DOI: 10.1186/s13075-016-1111-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 09/05/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Previous observational studies that have examined the association of allopurinol with myocardial infarction (MI) have provided contradictory results. One study showed that allopurinol reduced the risk, while another study showed an increased risk with allopurinol. Therefore, our objective was to assess whether allopurinol use is associated with a reduction in the risk of MI in the elderly. METHOD We used the 2006-2012 5 % random sample of Medicare beneficiaries to study the association of new allopurinol initiation and the risk of incident MI in a cohort study. Multivariable-adjusted Cox regression models adjusted for age, gender, race, and Charlson index, in addition to various cardio-protective medications (beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, diuretics, statins). We calculated hazard ratios (HRs) with 95 % confidence intervals (CIs). Sensitivity analyses adjusted for coronary artery disease (CAD) risk factors, including hypertension, hyperlipidemia, diabetes, and smoking. RESULTS Of the 29,298 episodes of incident allopurinol use, 1544 were associated with incident MI (5.3 % episodes). Allopurinol use was associated with reduced hazards of MI, with a HR of 0.85 (95 % CI, 0.77 to 0.95). Compared to no allopurinol use, longer durations of allopurinol use were associated with a lower HR of MI: 1-180 days, 0.98 (95 % CI, 0.84 to 1.14); 181 days to 2 years, 0.83 (95 % CI, 0.72 to 0.95); and >2 years, 0.70 (95 % CI, 0.56 to 0.88). Other factors associated with a higher hazard of MI were: age 75 to <85 years and ≥85 years, male gender, higher Charlson index score, and the use of an ACE inhibitor. Adjustment for CAD risk factors confirmed these findings. CONCLUSION Incident allopurinol use was associated with a reduction in the risk of incident MI in the elderly. Longer durations of allopurinol use reduced the risk of incident MI incrementally. Future studies should assess the underlying mechanisms for MI prevention and assess the risk-benefit ratio for allopurinol use.
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Affiliation(s)
- Jasvinder A Singh
- Medicine Service, Birmingham VA Medical Center, Birmingham, AL, USA. .,Department of Medicine at School of Medicine, and Division of Epidemiology at School of Public Health, University of Alabama at Birmingham (UAB), Faculty Office Tower 805B, 510 20th Street S, Birmingham, AL, 35294, USA. .,Department of Orthopedic Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA.
| | - Shaohua Yu
- Department of Medicine at School of Medicine, and Division of Epidemiology at School of Public Health, University of Alabama at Birmingham (UAB), Faculty Office Tower 805B, 510 20th Street S, Birmingham, AL, 35294, USA
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Singh JA, Yu S. Allopurinol and the risk of stroke in older adults receiving medicare. BMC Neurol 2016; 16:164. [PMID: 27604082 PMCID: PMC5015204 DOI: 10.1186/s12883-016-0692-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 08/29/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Previous studies of allopurinol and stroke risk have provided contradictory findings, ranging from a protective effect to an increased risk. Our objective was to assess whether allopurinol use is associated with the risk of stroke in the elderly. METHODS We used the 5 % random sample of Medicare beneficiaries from 2006-2012 to study the association of new allopurinol initiation and incident stroke. We used multivariable-adjusted Cox regression models adjusted for age, gender, race, Charlson index, and cardio-protective medications (beta-blockers, ACE inhibitors, diuretics, statins) to calculate hazards ratio (HR) with 95 % confidence intervals (CI). Sensitivity analyses adjusted for coronary artery disease (CAD) risk factors including hypertension, hyperlipidemia, diabetes, and smoking instead of Charlson index. RESULTS Among 28,488 eligible episodes of incident allopurinol, 2,177 ended in incident stroke (7.6 % episodes). In multivariable-adjusted analyses, allopurinol use was associated with 9 % lower hazard ratio for stoke, 0.91 (95 % CI, 0.83 to 0.99). Compared to no allopurinol use, allopurinol use durations of 181 days to 2 years, 0.88 (95 % CI, 0.78 to 0.99) and >2 years, 0.79 (95 % CI, 0.65 to 0.96) were significantly associated with lower multivariable-adjusted hazard of stroke. Sensitivity analyses adjusted for CAD risk factors confirmed these findings. In subgroup analyses, significant associations were noted between allopurinol use and the risk of ischemic stroke, 0.89 (95 % CI, 0.81 to 0.98); associations were not significant for hemorrhagic stroke, 1.01 (95 % CI, 0.79 to 1.29). CONCLUSIONS Allopurinol use is associated with lower risk of stroke overall, more specifically ischemic stroke. This association is evident after 6-months of allopurinol use, and the hazard reduction increases with longer duration of use. Future studies need to examine underlying mechanisms.
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Affiliation(s)
- Jasvinder A. Singh
- Medicine Service, Birmingham VA Medical Center, Birmingham, AL USA
- Department of Medicine at School of Medicine, University of Alabama at Birmingham (UAB), Birmingham, AL USA
- Division of Epidemiology at School of Public Health, University of Alabama at Birmingham (UAB), Birmingham, AL USA
- Department of Orthopedic Surgery, Mayo Clinic College of Medicine, Rochester, MN USA
- University of Alabama, Faculty Office Tower 805B, 510 20th Street S, Birmingham, AL 35294 USA
| | - Shaohua Yu
- Department of Medicine at School of Medicine, University of Alabama at Birmingham (UAB), Birmingham, AL USA
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Abstract
OBJECTIVE The objective of this study was to assess the real-world comparative effectiveness of continuing on allopurinol versus switching to febuxostat. METHODS In a retrospective claims data study of enrollees in health plans affiliated with Optum, we evaluated patients from February 1, 2009, to May 31, 2012, with a gout diagnosis, a pharmacy claim for allopurinol or febuxostat, and at least 1 serum uric acid (SUA) result available during the follow-up period. Univariate and multivariable-adjusted analyses (controlling for patient demographics and clinical factors) assessed the likelihood of SUA lowering and achievement of target SUA of less than 6.0 mg/dL or less than 5.0 mg/dL in allopurinol continuers versus febuxostat switchers. RESULTS The final study population included 748 subjects who switched to febuxostat from allopurinol and 4795 continuing users of allopurinol. The most common doses of allopurinol were 300 mg/d or less in 95% of allopurinol continuers and 93% of febuxostat switchers (prior to switching); the most common dose of febuxostat was 40 mg/d, in 77% of febuxostat switchers (after switching). Compared with allopurinol continuers, febuxostat switchers had greater (1) mean preindex SUA, 8.0 mg/dL versus 6.6 mg/dL (P < 0.001); (2) likelihood of postindex SUA of less than 6.0 mg/dL, 62.2% versus 58.7% (P = 0.072); (3) likelihood of postindex SUA of less than 5.0 mg/dL, 38.9% versus 29.6% (P < 0.001); and (4) decrease in SUA, 1.8 (SD, 2.2) mg/dL versus 0.4 (SD, 1.7) mg/dL (P < 0.001). In multivariable-adjusted analyses, compared with allopurinol continuers, febuxostat switchers had significantly higher likelihood of achieving SUA of less than 6.0 mg/dL (40% higher) and SUA of less than 5.0 mg/dL (83% higher). CONCLUSIONS In this "real-world" setting, many patients with gout not surprisingly were not treated with maximum permitted doses of allopurinol. Patients switched to febuxostat were more likely to achieve target SUA levels than those who continued on generally stable doses of allopurinol.
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Shmerling RH. Editorial: The Ethics of Recent Gout Trials. Arthritis Rheumatol 2016; 68:2057-60. [DOI: 10.1002/art.39723] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 04/14/2016] [Indexed: 11/10/2022]
Affiliation(s)
- Robert H. Shmerling
- Beth Israel Deaconess Medical Center, Boston, Massachusetts; Chair, American College of Rheumatology Committee on Ethics and Conflicts of Interest
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Coburn BW, Cheetham TC, Rashid N, Chang JM, Levy GD, Kerimian A, Low KJ, Redden DT, Bridges SL, Saag KG, Curtis JR, Mikuls TR. Rationale and design of the randomized evaluation of an Ambulatory Care Pharmacist-Led Intervention to Optimize Urate Lowering Pathways (RAmP-UP) Study. Contemp Clin Trials 2016; 50:106-15. [PMID: 27449546 DOI: 10.1016/j.cct.2016.07.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 07/12/2016] [Accepted: 07/17/2016] [Indexed: 01/08/2023]
Abstract
BACKGROUND Despite the availability of effective therapies, most gout patients achieve suboptimal treatment outcomes. Current best practices suggest gradual dose-escalation of urate lowering therapy and serial serum urate (sUA) measurement to achieve sUA<6.0mg/dl. However, this strategy is not routinely used. Here we present the study design rationale and development for a pharmacist-led intervention to promote sUA goal attainment. METHODS To overcome barriers in achieving optimal outcomes, we planned and implemented the Randomized Evaluation of an Ambulatory Care Pharmacist-Led Intervention to Optimize Urate Lowering Pathways (RAmP-UP) study. This is a large pragmatic cluster-randomized trial designed to assess a highly automated, pharmacist-led intervention to optimize allopurinol treatment in gout. Ambulatory clinics (n=101) from a large health system were randomized to deliver either the pharmacist-led intervention or usual care to gout patients over the age of 18years newly initiating allopurinol. All participants received educational materials and could opt-out of the study. For intervention sites, pharmacists conducted outreach primarily via an automated telephone interactive voice recognition system. The outreach, guided by a gout care algorithm developed for this study, systematically promoted adherence assessment, facilitated sUA testing, provided education, and adjusted allopurinol dosing. The primary study outcomes are achievement of sUA<6.0mg/dl and treatment adherence determined after one year. With follow-up ongoing, study results will be reported subsequently. CONCLUSION Ambulatory care pharmacists and automated calling technology represent potentially important, underutilized resources for improving health outcomes for gout patients.
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Affiliation(s)
- Brian W Coburn
- Division of Rheumatology, University of Nebraska Medical Center, Omaha, NE, United States
| | - T Craig Cheetham
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Nazia Rashid
- Drug Information Services, Kaiser Permanente Southern California, Downey, CA, United States
| | - John M Chang
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Gerald D Levy
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Artak Kerimian
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Kimberly J Low
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - David T Redden
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - S Louis Bridges
- Division of Rheumatology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Kenneth G Saag
- Division of Rheumatology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Jeffrey R Curtis
- Division of Rheumatology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Ted R Mikuls
- Division of Rheumatology, University of Nebraska Medical Center, Omaha, NE, United States; Medicine, Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE, United States.
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Coburn BW, Bendlin KA, Sayles H, Hentzen KS, Hrdy MM, Mikuls TR. Target Serum Urate: Do Gout Patients Know Their Goal? Arthritis Care Res (Hoboken) 2016; 68:1028-35. [DOI: 10.1002/acr.22785] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 09/28/2015] [Accepted: 11/03/2015] [Indexed: 11/10/2022]
Affiliation(s)
- Brian W. Coburn
- Veterans Affairs Nebraska, Western Iowa Health Care System, and University of Nebraska Medical Center; Omaha Nebraska
| | - Kayli A. Bendlin
- Veterans Affairs Nebraska, Western Iowa Health Care System; Omaha Nebraska
| | - Harlan Sayles
- Veterans Affairs Nebraska, Western Iowa Health Care System, and University of Nebraska Medical Center; Omaha Nebraska
| | - Kathryn S. Hentzen
- Veterans Affairs Nebraska, Western Iowa Health Care System; Omaha Nebraska
| | - Michaela M. Hrdy
- Veterans Affairs Nebraska, Western Iowa Health Care System; Omaha Nebraska
| | - Ted R. Mikuls
- Veterans Affairs Nebraska, Western Iowa Health Care System, and University of Nebraska Medical Center; Omaha Nebraska
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Singh JA, Yu S. Are allopurinol dose and duration of use nephroprotective in the elderly? A Medicare claims study of allopurinol use and incident renal failure. Ann Rheum Dis 2016; 76:133-139. [PMID: 27296322 DOI: 10.1136/annrheumdis-2015-209046] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 04/17/2016] [Accepted: 04/24/2016] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To assess the effect of allopurinol dose/duration on the risk of renal failure in the elderly with allopurinol use. METHODS We used the 5% random Medicare claims data from 2006 to 2012. Multivariable-adjusted Cox regression analyses assessed the association of allopurinol dose/duration with subsequent risk of developing incident renal failure or end-stage renal disease (ESRD) (no prior diagnosis in last 183 days) in allopurinol users, controlling for age, sex, race and Charlson-Romano comorbidity index. HRs with 95% CIs were calculated. Sensitivity analyses considered a longer baseline period (365 days), controlled for gout or used more specific codes. RESULTS Among the 30 022 allopurinol treatment episodes, 8314 incident renal failure episodes occurred. Compared with 1-199 mg/day, allopurinol dose of 200-299 mg/day (HR 0.81; 95% CI 0.75 to 0.87) and ≥300 mg/day, 0.71 (0.67 to 0.76), had significantly lower hazard of renal failure in multivariable-adjustment model, confirmed in multiple sensitivity analyses. Longer allopurinol use duration was significantly associated with lower hazards in sensitivity analyses (365-day look-back; reference, <0.5 year): 0.5-1 year, 1.00 (0.88, 1.15); >1-2 years, 0.85 (0.73 to 0.99); and >2 years, 0.81 (0.67 to 0.98). Allopurinol ≥300 mg/day was also associated with significantly lower risk of acute renal failure and ESRD with HR of 0.89 (0.83 to 0.94) and 0.57 (0.46 to 0.71), respectively. CONCLUSIONS Higher allopurinol dose is independently protective against incident renal failure in the elderly allopurinol users. A longer duration of allopurinol use may be associated with lower risk of incident renal failure. Potential mechanisms of these effects need to be examined.
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Affiliation(s)
- Jasvinder A Singh
- Medicine Service, Birmingham VA Medical Center, Birmingham, Alabama, USA.,Division of Epidemiology, Department of Medicine School of Medicine, School of Public Health, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA.,Department of Orthopedic Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Shaohua Yu
- Division of Epidemiology, Department of Medicine School of Medicine, School of Public Health, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
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Singh JA, Yu S. Allopurinol and the risk of atrial fibrillation in the elderly: a study using Medicare data. Ann Rheum Dis 2016; 76:72-78. [PMID: 27165177 DOI: 10.1136/annrheumdis-2015-209008] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 02/21/2016] [Accepted: 03/20/2016] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To assess the effect of allopurinol use on the risk of incident atrial fibrillation (AF) in the elderly. METHODS We used the 5% random Medicare Claims data from 2006 to 2012 to examine the association of allopurinol use and incident AF in a cohort of patients with an absence of AF at baseline (at least 365 days). Multivariable-adjusted Cox regression analyses compared allopurinol exposed and non-exposed periods for the risk of AF, controlling for age, sex, race, Charlson-Romano comorbidity index and use of statins, diuretics, ACE inhibitors and β-blockers. HR with 95% CIs was calculated. Sensitivity analyses considered a longer baseline period (365 days vs 183 days) and individual comorbidities. RESULTS There were 9244 episodes of incident allopurinol use in 8569 beneficiaries, of which 1366 episodes (14.8%) had incident AF. In multivariable-adjusted analyses, allopurinol use was associated with an HR of 0.83 (95% CI 0.74 to 0.93) for incident AF. In a separate multivariable-adjusted model, compared with no allopurinol use, longer allopurinol use durations were associated with a lower HR of AF: 180 days-2 years, 0.85 (95% CI 0.73 to 0.99) and >2 years, 0.65 (95% CI 0.52 to 0.82). Other factors significantly associated with a higher hazard of AF were: age 75-<85 years and ≥85 years, higher Charlson index score and current β-blocker use. Sensitivity analyses confirmed these findings with minimal/no attenuation of HRs. CONCLUSIONS Allopurinol use was associated with a reduced risk of incident AF in the elderly, especially its use for >6 months duration. Future studies should assess the mechanisms underlying this beneficial effect of allopurinol.
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Affiliation(s)
- Jasvinder A Singh
- Medicine Service, Birmingham VA Medical Center, Birmingham, Alabama, USA.,Department of Medicine at School of Medicine, and Division of Epidemiology at School of Public Health, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA.,Department of Orthopedic Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Shaohua Yu
- Department of Medicine at School of Medicine, and Division of Epidemiology at School of Public Health, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
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Lee S, So MW. Adherence with urate-lowering therapies among male patients with gout in a routine clinical setting. Mod Rheumatol 2016; 26:950-955. [DOI: 10.3109/14397595.2016.1170914] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Sunggun Lee
- Division of Rheumatology, Department of Internal Medicine, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea and
| | - Min Wook So
- Division of Rheumatology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Gyeongnam, Korea
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An internet survey of common treatments used by patients with gout including cherry extract and juice and other dietary supplements. J Clin Rheumatol 2016; 21:225-6. [PMID: 26010189 DOI: 10.1097/rhu.0000000000000246] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Schlesinger N, Etzel CJ, Greenberg J, Kremer J, Harrold LR. Gout Prophylaxis Evaluated According to the 2012 American College of Rheumatology Guidelines: Analysis from the CORRONA Gout Registry. J Rheumatol 2016; 43:924-30. [PMID: 26980578 DOI: 10.3899/jrheum.150345] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2016] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
- Naomi Schlesinger
- From the Division of Rheumatology, Department of Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey; Corrona LLC, Southborough, Massachusetts; Department of Epidemiology, University of Texas MD Anderson Cancer Center, Houston, Texas; Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, New York; the Center for Rheumatology, Albany Medical College, Albany, New York; Department of Orthopedics, University of Massachusetts Medical School, Worcester, Massachusetts, USA.N. Schlesinger, MD, Professor of Medicine and Chief, Division of Rheumatology, Department of Medicine, Rutgers-Robert Wood Johnson Medical School; C.J. Etzel, PhD, Corrona LLC, and the Department of Epidemiology, University of Texas MD Anderson Cancer Center; J. Greenberg, MD, MPH, Associate Professor, Division of Rheumatology, Department of Medicine, New York University School of Medicine, and Corrona LLC; J. Kremer, MD, Director, the Center for Rheumatology, Albany Medical College; L.R. Harrold, MD, MPH, Associate Professor, Department of Orthopedics, University of Massachusetts Medical School.
| | - Carol J Etzel
- From the Division of Rheumatology, Department of Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey; Corrona LLC, Southborough, Massachusetts; Department of Epidemiology, University of Texas MD Anderson Cancer Center, Houston, Texas; Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, New York; the Center for Rheumatology, Albany Medical College, Albany, New York; Department of Orthopedics, University of Massachusetts Medical School, Worcester, Massachusetts, USA.N. Schlesinger, MD, Professor of Medicine and Chief, Division of Rheumatology, Department of Medicine, Rutgers-Robert Wood Johnson Medical School; C.J. Etzel, PhD, Corrona LLC, and the Department of Epidemiology, University of Texas MD Anderson Cancer Center; J. Greenberg, MD, MPH, Associate Professor, Division of Rheumatology, Department of Medicine, New York University School of Medicine, and Corrona LLC; J. Kremer, MD, Director, the Center for Rheumatology, Albany Medical College; L.R. Harrold, MD, MPH, Associate Professor, Department of Orthopedics, University of Massachusetts Medical School
| | - Jeff Greenberg
- From the Division of Rheumatology, Department of Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey; Corrona LLC, Southborough, Massachusetts; Department of Epidemiology, University of Texas MD Anderson Cancer Center, Houston, Texas; Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, New York; the Center for Rheumatology, Albany Medical College, Albany, New York; Department of Orthopedics, University of Massachusetts Medical School, Worcester, Massachusetts, USA.N. Schlesinger, MD, Professor of Medicine and Chief, Division of Rheumatology, Department of Medicine, Rutgers-Robert Wood Johnson Medical School; C.J. Etzel, PhD, Corrona LLC, and the Department of Epidemiology, University of Texas MD Anderson Cancer Center; J. Greenberg, MD, MPH, Associate Professor, Division of Rheumatology, Department of Medicine, New York University School of Medicine, and Corrona LLC; J. Kremer, MD, Director, the Center for Rheumatology, Albany Medical College; L.R. Harrold, MD, MPH, Associate Professor, Department of Orthopedics, University of Massachusetts Medical School
| | - Joel Kremer
- From the Division of Rheumatology, Department of Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey; Corrona LLC, Southborough, Massachusetts; Department of Epidemiology, University of Texas MD Anderson Cancer Center, Houston, Texas; Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, New York; the Center for Rheumatology, Albany Medical College, Albany, New York; Department of Orthopedics, University of Massachusetts Medical School, Worcester, Massachusetts, USA.N. Schlesinger, MD, Professor of Medicine and Chief, Division of Rheumatology, Department of Medicine, Rutgers-Robert Wood Johnson Medical School; C.J. Etzel, PhD, Corrona LLC, and the Department of Epidemiology, University of Texas MD Anderson Cancer Center; J. Greenberg, MD, MPH, Associate Professor, Division of Rheumatology, Department of Medicine, New York University School of Medicine, and Corrona LLC; J. Kremer, MD, Director, the Center for Rheumatology, Albany Medical College; L.R. Harrold, MD, MPH, Associate Professor, Department of Orthopedics, University of Massachusetts Medical School
| | - Leslie R Harrold
- From the Division of Rheumatology, Department of Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey; Corrona LLC, Southborough, Massachusetts; Department of Epidemiology, University of Texas MD Anderson Cancer Center, Houston, Texas; Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, New York; the Center for Rheumatology, Albany Medical College, Albany, New York; Department of Orthopedics, University of Massachusetts Medical School, Worcester, Massachusetts, USA.N. Schlesinger, MD, Professor of Medicine and Chief, Division of Rheumatology, Department of Medicine, Rutgers-Robert Wood Johnson Medical School; C.J. Etzel, PhD, Corrona LLC, and the Department of Epidemiology, University of Texas MD Anderson Cancer Center; J. Greenberg, MD, MPH, Associate Professor, Division of Rheumatology, Department of Medicine, New York University School of Medicine, and Corrona LLC; J. Kremer, MD, Director, the Center for Rheumatology, Albany Medical College; L.R. Harrold, MD, MPH, Associate Professor, Department of Orthopedics, University of Massachusetts Medical School
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Tan CSL, Teng GG, Chong KJ, Cheung PP, Lim AYN, Wee HL, Santosa A. Utility of the Morisky Medication Adherence Scale in gout: a prospective study. Patient Prefer Adherence 2016; 10:2449-2457. [PMID: 27980395 PMCID: PMC5144895 DOI: 10.2147/ppa.s119719] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The outcomes of any chronic illness often depend on patients' adherence with their treatment. A tool is lacking to assess adherence in gout that is standardized, allows real-time feedback, and is easy to understand. OBJECTIVE We set out to evaluate the utility of the 8-item Morisky Medication Adherence Scale (MMAS-8) in monitoring medication adherence in a multiethnic Asian gout cohort on urate-lowering therapy (ULT). METHODS This cohort study recruited patients with gout where baseline and 6-monthly clinical data, self-report of adherence, and health status by Gout Impact Scale (GIS) and EuroQoL-5 dimension 3 levels were collected. Those who received at least 9 months of ULT were analyzed. Convergent and construct validities of MMAS-8 were evaluated against medication possession ratio (MPR) and known groups, clinical outcomes, and patient-reported outcomes. Internal consistency and test-retest reliability were assessed using Cronbach's alpha and intraclass correlation coefficient (ICC), respectively. RESULTS Of 91 patients, 92.3% were male, 72.5% Chinese with mean age 53.5 years. MMAS-8 (mean 6.17) and MPR (mean 96.3%) were poorly correlated (r=0.069, P=0.521). MMAS-8 did not differ between those who did or did not achieve target serum urate (SU) <360 µmol/L (P=0.852); or among those whose SU improved, stagnated, or worsened during follow-up (P=0.777). Adherence was associated with age (β=0.256, P=0.015) and education level (P=0.011) but not comorbidities, polypharmacy, or flare frequency. Concerns for medication side effects and anxiety or depression were associated with lower MMAS-8 (P<0.005). Internal consistency was acceptable (α=0.725) and test-retest reliability was satisfactory (ICC =0.70, 95% confidence interval [CI] 0.36-0.88). CONCLUSION MMAS-8 had limited construct validity in assessing medication adherence to ULT in our gout patients. Nevertheless, it identified patients bothered or worried about ULT side effects, and those with underlying anxiety or depression, for whom targeted education and coping support may be useful.
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Affiliation(s)
- CSL Tan
- University Medicine Cluster, Division of Rheumatology, National University Health System
| | - GG Teng
- University Medicine Cluster, Division of Rheumatology, National University Health System
- Department of Medicine, Yong Loo Lin School of Medicine
| | - KJ Chong
- Department of Medicine, Yong Loo Lin School of Medicine
| | - PP Cheung
- University Medicine Cluster, Division of Rheumatology, National University Health System
- Department of Medicine, Yong Loo Lin School of Medicine
| | - AYN Lim
- University Medicine Cluster, Division of Rheumatology, National University Health System
- Department of Medicine, Yong Loo Lin School of Medicine
| | - HL Wee
- Department of Pharmacy, Faculty of Science
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - A Santosa
- University Medicine Cluster, Division of Rheumatology, National University Health System
- Department of Medicine, Yong Loo Lin School of Medicine
- Correspondence: A Santosa, University Medicine Cluster, Division of Rheumatology, National University Health System, Level 10 Tower Block, 1E Lower Kent Ridge Road, Singapore 119228, Singapore, Fax +65 6872 4130, Email
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