Urate-lowering Therapy In Gout Patients Research Articles

Development of a patient decision aid for the initiation of urate-lowering therapy in gout patients

AimShared decision-making improves patients’ experiences with care, satisfaction with management decisions and possibly health outcomes. This study describes the development of a decision aid (DA) that supports patients with gout...

Anti-gout Medications and Risk of Cardiovascular Disease: A Nested Case-Control Study.

Introduction: Gout is the leading cause of inflammatory arthritis and is also correlated with multiple comorbidities, including cardiovascular disease (CVD), whose future risk can be lowered by urate-lowering therapy (ULT) in gout patients. It is, however, still not clear whether its effect is associated with the days of usage and the adherence rate of ULT.Methods: Data were collected from Taiwan's National Health Insurance Research Database. The study period was from 1999/1/1 to 2013/12/31. In addition, patients with newly diagnosed gout from 2000 to 2012 and usage of antigout preparations (allopurinol or benzbromarone) within half a year among age ≥20 years old were enrolled in the study. The outcome of interest is CVD. New diagnosis of CVD after half a year of diagnosis of gout was included in the CVD group. Moreover, conditional logistic regression was used to evaluate the odds ratio of CVD in relation to the days of usage and to the adherence rate of ULT after the adjustment for potentially confounding variables.Results: A total of 3,706 gout patients with and without CVD have been included in the final analysis after a 1:1 propensity score that matched for age, sex, comorbidities, aspirin, and statin. The days of usage of allopurinol was <180 days and benzbromarone, in its turn, presupposed a higher risk of CVD. The adherence rate of allopurinol and benzbromarone at ≥ 0.7 both have a lower CVD risk: allopurinol (adjusted OR: 0.66 95% CI: 0.46–0.96), benzbromarone (adjusted OR: 0.68 95% CI: 0.50–0.91). The subgroup analysis revealed an adherence rate of ≥0.7 of ULT with a lower CVD was only found to be present in males and at age <65. Furthermore, the correlations were more pronounced in the ischemic heart disease subgroup than in the cerebrovascular disease group.Conclusion: This study reveals that gout patients taking ULT (allopurinol and benzbromarone) with an adherence rate of ≥0.7 are at a lower risk of developing CVD, especially with a younger age (<65) and if they are male. On top of this, the benefit is more pronounced in ischemic heart disease. Despite further prospective trials needing to be warranted to confirm our findings, health care providers may, bearing these conclusions in mind, emphasize the importance of adherence to ULT in gout patients.

Predictors of poor response to urate-lowering therapy in patients with gout and hyperuricemia: a post-hoc analysis of a multicenter randomized trial

Clinical guidelines have recommended a target of serum uric acid (SUA) level below 6.0mg/dL for the urate-lowering therapy (ULT) of gout patients, but there are still a high proportion of patients failing to achieve the therapeutic target above. This study aimed to identify possible predictors of poor response to ULT in gout patients. We performed a post-hoc analysis of a multicenter randomized double-blind trial which assessed the efficacy of febuxostat in patients with hyperuricemia (serum urate level ≥ 8.0mg/dL) and gout. Demographic characters and baseline data including SUA levels were collected. Poor response to ULT was defined as average SUA after ULT was more than 6.0mg/dL. Factors associated with poor response to ULT in gout patients were analyzed, and multivariate logistic regression analysis was also carried out to find out those independent predictors. A total of 370 patients were enrolled in this post-hoc analysis. Compared with those with good response to ULT, patients with poor response to ULT had younger age (P < 0.001), higher proportion of obesity (P = 0.003), higher proportion of statins use (P = 0.019), higher body mass index (BMI) (P < 0.001), higher baseline SUA (P < 0.001), higher proportion of males (P = 0.001), higher alanine transaminase (P < 0.001), higher aspartate transaminase (P = 0.017), higher total cholesterol (P = 0.005), higher triglyceride (P = 0.042), and higher low density lipoprotein (P = 0.037). Multivariate logistic regression analysis showed that younger age (odds ratio (OR) = 0.965, 95% CI 0.943-0.987, P = 0.002), higher BMI (OR = 1.133, 95% CI 1.049-1.224, P = 0.001), higher baseline SUA (OR = 1.006, 95% CI 1.002-1.009, P = 0.001), and no application of febuxostat therapy (OR = 0.41, 95% CI 0.25-0.68, P < 0.001) were independent predictors of poor response to ULT in patients with gout. In patients with gout and hyperuricemia, younger age, higher BMI, and higher baseline SUA are predictors of poor response to ULT. These findings could help physicians better identify patients who may fail in ULT and give individualized treatment precisely. The trial was registered at chinadrugtrials.org.cn in 2012 (CTR20130172).Key Points• A post-hoc analysis of a multicenter randomized double-blind trial which assessed the efficacy of febuxostat in patients with hyperuricemia and gout was performed.• Multivariate logistic regression analysis showed that younger age, higher BMI, and higher baseline SUA are predictors of poor response to urate-lowering therapy.

PMS14 - Budget Impact of a Fixed-Dose Combination Therapy of Lesinurad and Allopurinol for Second-Line Gout Therapy: A US Commercial Health Plan Perspective

Estimate budget impact on US commercial payers adopting fixed-dose combination therapy of lesinurad and allopurinol (L/A) as second-line urate-lowering therapy in gout patients for whom allopurinol (ALLO) therapy has failed. This budget impact model used a Markov model to estimate costs, survival, and discontinuation in a 1-million-member health plan. Model parameters were derived from CLEAR 1 and CLEAR 2 Phase III trials of lesinurad, published literature, and market share estimates. The model population included patients failing first-line ALLO monotherapy; the time horizon is 5 years. A scenario based on ALLO therapy was compared with a future scenario in which L/A is provided to a portion of ALLO patients not meeting sUA goal. The uptake of L/A population was assumed to increase from 1.2% to 5.2% over 5 years. Annual and cumulative incremental costs were reported as total cost, per-member per-month (PMPM) cost, and cost-per-treated patient per year. One-way sensitivity analysis, to identify parameters that most influence the model, was conducted (±10% variation for each model parameter). US payer perspective for commercial health care plans is modeled. A total of 8205 patients would be treated with second-line therapy in treatment mixes with and without L/A, respectively. The budget impact of L/A is estimated to be $231,451 in the first year and $1,049,637 in the fifth year, for a cumulative 5-year incremental cost of $3,473,891. Cumulative 5-year cost-per-treated gout patient per year was $107, and cumulative incremental 5-year PMPM was estimated at $0.06. Sensitivity analysis indicated the model was most sensitive to L/A cost and L/A market shares, each affecting PMPM by approximately $0.01. From the commercial payer perspective, adding L/A as a second-line gout therapy to a hypothetical 1 million–person health plan over a 5-year time horizon results in cumulative total incremental PMPM costs of approximately $0.06.

Role of dual-energy CT in the diagnosis and follow-up of gout: systematic analysis of the literature.

The aim of this systematic review was to determine the potential role of dual-energy CT in the diagnosis and follow-up of gout with regard to the Outcome Measures in Rheumatology (OMERACT) filter. A systematic analysis of the literature was conducted using the MEDLINE and Cochrane databases and published abstracts of international congresses, according to the criteria of the OMERACT filter: feasibility, reproducibility, validity versus laboratory (serum urate, MSU synovial fluid aspirate) and other imaging modalities for gout, and its sensitivity to change in patients on urate lowering therapy (ULT). Thirty-two articles were found representing a total of 1502 patients. The data on feasibility showed that the examination took little time and involved low levels of radiation but had current limited availability. Intra- and inter-observer reproducibility was excellent, with intra-class correlation coefficients > 0.9. Validity in comparison with polarized-light microscopy showed good sensitivity and specificity (> 80%). The diagnostic performance was better than that of radiography and conventional CT-scan and at least equivalent to that of ultrasonography. The sensitivity to change varied with effect sizes from 0.05 (low) to 1.24 (high) for decrease in the tophus volume following different ULT in gout patients. Dual-energy CT-scan is a reproducible and accurate imaging modality for the diagnosis of gout, particularly for tophaceous gout (intra- or extra-articular). It can become a second-line imaging modality of choice in cases of diagnostic doubt, such as ultrasonography. Its role remains uncertain in the follow-up of gout patients treated with ULT and needs further clarification.

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

ObjectiveTo evaluate the efficacy and safety of the initiation time of urate-lowering treatments (ULT) in gout patients. MethodWe retrospectively reviewed patients who were diagnosed with gout and were treated with ULT for at least 3years. They were divided into two groups: group 1: 123patients initiating ULT during an acute attack of gout; group 2: 457patients prescribed ULT after an acute attack. Both demographic and clinical characteristics associated with gout were analyzed. ResultsComparing patients in group 1 versus group 2: the former exhibited a shorter duration of gout (6.3±2.1 vs. 8.9±3.3years). At the baseline, there was no significant difference in mean serum urate (SU; 7.8±1.4mg/dL vs. 7.9±1.9mg/dL, respectively). SU target levels (<6.0mg/dL) were achieved by 66.7 and 65.6% of the patients, respectively. The duration from initiation of ULT until the SU target was attained was lower in group 1 than in group 2. During the first 12weeks, patients on ULT in group 1 had higher attack rates than those in group 2. The incidence of chronic kidney disease increased in percentage in group 1 was lower than in group 2. ConclusionsOur survey revealed that in patients experiencing acute gout, initiation of ULT decreased the time required to reach the target SU and the incidence of CKD, but the attack rate was greater in the first 12weeks.

Can racial disparities in optimal gout treatment be reduced? Evidence from a randomized trial.

There is a disproportionate burden of gout in African-Americans in the U.S. due to a higher disease prevalence and lower likelihood of receiving urate-lowering therapy (ULT), compared to Caucasians. There is an absence of strong data as to whether the response to ULT differs by race/ethnicity. BMC Musculoskeletal Disorders recently published a secondary analyses of the CONFIRMS trial, a large randomized controlled, double-blind trial of 2,269 gout patients. The authors reported that the likelihood of achieving the primary study efficacy end-point of achieving serum urate < 6 mg/dl was similar between African-Americans and Caucasians, for all three treatment arms (Febuxostat 40 mg and 80 mg and allopurinol 300/200 mg). More importantly, rates were similar in subgroups of patients with mild or moderate renal insufficiency. Adverse event rates were similar, as were the rates of gout flares. These findings constitute a convincing evidence to pursue aggressive ULT in gout patients, regardless of race/ethnicity. This approach will likely help to narrow the documented racial disparities in gout care.Please see related article: http://www.biomedcentral.com/1471-2474/13/15