Long-term Treatment of Gout Is Suboptimal

Diana Swift

December 26, 2014

Only a minority of patients with gout whose disease indications made them candidates for long-term urate-lowering therapy were treated according to current recommendations, reports a research letter published in the December 23 issue of JAMA.

The researchers found that only a third of general practitioners in the United Kingdom prescribed urate-lowering therapy to appropriate candidates. Therefore, the authors recommend that urate-lowering treatment be included in information given to patients with gout at the time of first diagnosis.

According to Ralph Schumacher, MD, emeritus professor of medicine, University of Pennsylvania, Philadelphia, who was not involved in the study, the US situation mirrors the UK pattern. "Urate-lowering treatment is underprescribed here because most gout patients consult primary care physicians for acute attacks, and they are too busy to really address the long-term implications of high uric acid levels," he told Medscape Medical News. "They treat the attacks adequately, but once these are over, they have other things to worry about in their patients, like diabetes and heart disease, so they tend to ignore the long term."

In his view, early education is key. "What they need to do after the attack is over is to get the patient educated about the disease and get them on a drug like allopurinol to get the uric acid lowered," Dr Schumacher said.

For patients with more severe gout or related conditions, current guidelines recommend long-term treatment to lower blood levels of urate (a metabolite derived from uric acid), thereby preventing crystal deposition and encouraging crystal dissolution. After first diagnosis, however, it remains unclear just when this treatment should be started, write Chang-Fu Kuo, MD, consultant rheumatologist, Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan, Taiwan, and colleagues.

The researchers investigated the timing of eligibility for and the prescription of urate-lowering treatment after initial diagnosis in 52,164 patients presenting with incident gout from 1997 to 2010. This sample came from the UK Clinical Practice Research Datalink, which contains medical information on about 8% of the British population recorded from 486 English general practices.

The mean age of the patients at diagnosis was 62.5 years, and 73% of the participants were men. Median time to development of the first treatment indication was 5 months (interquartile range, 0 - 29 months). Indications for treatment were acute recurring gout attacks within the first year of diagnosis, tophi, urolithiasis, chronic kidney disease, and diuretic use at diagnosis. The mean follow-up was 6 years (interquartile range, 4 - 9 years).

Almost half of patients (44%) fulfilled indications for urate-lowering therapy at baseline, and 87% were eligible within 5 years of diagnosis, yet only a minority received appropriate drug therapy at any point. The median prescription rate was 32.5% (interquartile range, 26.3% - 39.3%; range, 0% - 100%).

The probability of patients' fulfilling any of the indications for treatment was cumulative, ranging from 44.26% (95% confidence interval [CI], 43.83% - 44.69%) at 0 years from diagnosis and 61.02% (95% CI, 60.60% - 61.44%) at 1 year to 86.81% (95% CI, 86.49% - 87.13%) at 5 years and 94.27% (95% CI, 93.98% - 94.56%) at 10 years.

The cumulative probabilities for prescription at the same times were 0%, 16.90% (95% CI, 16.58% - 17.22%), 30.39% (95% CI, 29.90% - 30.81%), and 40.52% (95% CI, 39.96% - 41.08%).

The hazard ratios for treatment indications during the first year after diagnosis were as follows: acute attacks, 1.60 (95% CI, 1.55 - 1.65); tophi, 1.87 (95% CI, 1.56 - 2.24); chronic kidney disease, 1.67 (95% CI, 1.60 - 1.74); and diuretic use at diagnosis, 1.57 (95% CI, 1.51 - 1.63).

"Patient- and practice-level factors accounted for 7.82% and 13.49%, respectively, of total prescription variance," the authors write. The former factors included sex, age, race, and socioeconomic variables; the latter included numbers of total patients and patients with gout, median birth year, sex ratio, practice region, and socioeconomic status. Factors accounting for the remaining nearly 80% of variance may not have been recorded in the database.

"Recognized barriers to care include suboptimal patient and physician knowledge of gout, its treatment and clinical recommendations, and patient and physician preferences for treatment," the authors write.

This study was funded by the National Science Council of Taiwan and Chang Gung Memorial Hospital and supported by the University of Nottingham and an Arthritis Research UK clinician scientist award. One coauthor has reported receiving personal fees from Daiichi Sankyo. Another coauthor reported receiving personal fees from AstraZeneca, Menarini, Nordic Biosciences, Novartis, and Pfizer for work on gout and osteoarthritis advisory boards. The authors and Dr Schumacher have disclosed no relevant financial relationships.

JAMA. 2014;312:2684-2686. Extract

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