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Doumen M, Diricks L, Hermans J, Bertrand D, De Meyst E, Westhovens R, Verschueren P. Definitions of rheumatoid arthritis flare and how they relate to patients' perspectives: A scoping review of qualitative and quantitative evidence. Semin Arthritis Rheum 2024; 67:152481. [PMID: 38815403 DOI: 10.1016/j.semarthrit.2024.152481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 04/23/2024] [Accepted: 05/23/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Rheumatoid arthritis (RA) is characterized by intermittent flares of disease activity with a significant impact on patients' lives. However, distinguishing flare from daily symptom variation may be approached differently by patients and healthcare providers, potentially hampering shared decision-making when treating RA. OBJECTIVES To provide a comprehensive overview of RA flare definitions reported in the published literature, and to compare these with patients' perceptions of the flare concept according to qualitative evidence. METHODS A systematic search was conducted on August 30th, 2022, and updated on September 30th, 2023, for both quantitative and qualitative studies reporting "flare" or related terms in the context of RA. We searched the following databases: Pubmed, EMBASE, Web of Science, Cochrane Library, and CINAHL. Definitions of RA flare reported in quantitative studies were summarized descriptively. In parallel, a thematic synthesis of qualitative studies was performed to outline patients' views on the concept of flare, and to compare these with the currently used definitions. RESULTS Among 32,864 potentially eligible records, 304 studies were included, 5 of which used qualitative/mixed methods to study patients' perceptions of flare. Remarkably, 62 different definitions for RA flare were reported, with many studies reporting more than one. The most commonly used definitions (54 %) were based on disease activity indices, with DAS28-based definitions the most widely applied (84 %). For each of the disease activity indices, several different cutoffs to define flares were used. Various definitions based on physician report were applied in 24 % of cases, while patient-reported criteria represented only 15 % of the applied definitions. Thematic synthesis of the qualitative/mixed-methods studies highlighted the multidimensional impact of flares on patients' lives, resulting in five sequential overarching themes: "Living with RA: a balancing act", "Flare: a disturbance of this balance", "The biopsychosocial impact of flares", "Self-management: the first line of defense", and "Medical help: the last resort". In turn, these five themes were underpinned by a central theme of "Uncertainty and variability". CONCLUSION We found a striking heterogeneity regarding the conceptualization and measurement of RA flare in the published literature. Although qualitative evidence highlighted the considerable impact of flares on patients' wellbeing, the majority of reported flare definitions were not based on patient report. There is a need to bridge this gap by aligning patients' and healthcare professionals' views on what distinguishes a flare from acceptable symptom variability when living with RA.
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Affiliation(s)
- Michaël Doumen
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium; Rheumatology, University Hospitals Leuven, Leuven, Belgium.
| | - Lotte Diricks
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium
| | - Joppe Hermans
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium
| | - Delphine Bertrand
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium
| | - Elias De Meyst
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium; Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - René Westhovens
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium; Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - Patrick Verschueren
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium; Rheumatology, University Hospitals Leuven, Leuven, Belgium
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Crum KL, Choudhry NK, Fontanet C, Sears ES, Hanken K, Lauffenburger JC, Mastrorilli J, Oduol T, Vine S, Bhatkhande G, Oran R, Robertson T, Wood W, Feldman CH. Leveraging Habits to Improve Adherence to Gout Medications: A Qualitative Study. ACR Open Rheumatol 2024. [PMID: 39010675 DOI: 10.1002/acr2.11706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 04/01/2024] [Accepted: 05/24/2024] [Indexed: 07/17/2024] Open
Abstract
OBJECTIVE This study investigates patients' medication-taking routines and the feasibility of harnessing habit formation through context cues and rewards to improve medication adherence. METHODS Semistructured qualitative interviews with patients with gout from an urban health care system were conducted to explore typical medication-taking behavior, experiences using electronic pill bottles, barriers to adherence, existing context cues, and potential cues and rewards for habit-forming behavior. Medication-taking patterns were recorded for six weeks using electronic pill bottles before interviews to inform discussion. Transcribed interviews were analyzed to generate themes using codes developed by the study team, with representative quotations selected as illustrations. RESULTS We conducted interviews with 15 individuals (mean age 60.6 [SD 20.3] years, three women [20%], and nine White patients [60%]). Pill bottle-recorded adherence to urate-lowering therapy (ULT) was high (mean 0.91 [SD 0.10]), and one patient was experiencing an active gout flare. Five key themes emerged: (1) reasons for nonadherence, (2) internal and external motivations for adherence, (3) structured routines around taking medications, (4) rewards for good medication adherence, and (5) the role of pill cap technology in medication-taking. CONCLUSION The importance of a predictable, structured routine in which participants could incorporate their medication-taking behavior emerged as a key factor that promoted consistent adherence. Further, identifying context cues and reminders seemed to promote incorporation of medication-taking into routines. Therefore, habit-based interventions that use context cues to establish routines around medication-taking may be a feasible strategy to improve adherence in patients with chronic conditions such as gout.
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Affiliation(s)
- Katherine L Crum
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Niteesh K Choudhry
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Constance Fontanet
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
| | | | - Kaitlin Hanken
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | - Theresa Oduol
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Seanna Vine
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Gauri Bhatkhande
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | - Wendy Wood
- University of Southern California, Los Angeles
| | - Candace H Feldman
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Sun H, Wang X, Li Y, Shen Y, Zhang L, Xu Y, Liu J, Fan X. Targeting Liver Xor by GalNAc-siRNA Is an Effective Strategy for Hyperuricemia Therapy. Pharmaceutics 2024; 16:938. [PMID: 39065635 PMCID: PMC11279964 DOI: 10.3390/pharmaceutics16070938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 06/25/2024] [Accepted: 07/05/2024] [Indexed: 07/28/2024] Open
Abstract
Hyperuricemia, i.e., increased plasma uric acid concentration, is a common problem in clinical practice, leading to gout or nephrolithiasis, and is associated with other disorders, such as metabolic syndrome, cardiovascular disease, and chronic renal disease. Xanthine oxidoreductase (XOR) is a critical rate-limiting enzyme involved in uric acid synthesis and a promising target for hyperuricemia therapy. However, XOR inhibitors currently face clinical problems such as a short half-life and side effects. Here, we found that specifically targeting liver Xor with GalNAc-siRNAs had a good therapeutic effect on hyperuricemia. First, siRNAs were designed to target various sites in the homologous region between Homo sapiens and Mus musculus Xor mRNA and were screened in primary mouse hepatocytes. Then, the siRNAs were modified to increase their stability in vivo and conjugated with GalNAc for liver-specific delivery. The effects of GalNAc-siRNAs were evaluated in three hyperuricemia mouse models, including potassium oxonate and hypoxanthine administration in WT and humanized XDH mice and Uox knockout mice. Febuxostat, a specific XOR inhibitor used for hyperuricemia treatment, was used as a positive control. Targeting liver Xor with GalNAc-siRNAs by subcutaneous administration reduced plasma uric acid levels, uric acid accumulation in the kidney, renal inflammation, and fibrosis, thereby alleviating kidney damage in hyperuricemia mouse models without hepatoxicity. The results demonstrated that targeting liver Xor with GalNAc-siRNAs was a promising strategy for hyperuricemia therapy.
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Affiliation(s)
- Huiyan Sun
- Department of Biochemistry and Molecular Cell Biology, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Xinxia Wang
- Department of Biochemistry and Molecular Cell Biology, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Yongqiang Li
- Shanghai Synvida Biotechnology Co., Ltd., Shanghai 201203, China
| | - Yingzhi Shen
- Department of Biochemistry and Molecular Cell Biology, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Lin Zhang
- Department of Biochemistry and Molecular Cell Biology, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Yingjie Xu
- Department of Biochemistry and Molecular Cell Biology, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Junling Liu
- Department of Biochemistry and Molecular Cell Biology, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
- Shanghai Synvida Biotechnology Co., Ltd., Shanghai 201203, China
| | - Xuemei Fan
- Department of Biochemistry and Molecular Cell Biology, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
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Qi H, Sun M, Terkeltaub R, Merriman TR, Chen H, Li Z, Ji A, Xue X, Sun W, Wang C, Li X, He Y, Cui L, Dalbeth N, Li C. Hyperuricemia Subtypes Classified According to Renal Uric Acid Handling Manifesting Distinct Phenotypic and Genetic Profiles in People With Gout. Arthritis Rheumatol 2024; 76:1130-1140. [PMID: 38412854 DOI: 10.1002/art.42838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 02/19/2024] [Accepted: 02/26/2024] [Indexed: 02/29/2024]
Abstract
OBJECTIVE Hyperuricemia can be stratified into four subtypes according to renal uric acid handling. The aim of this study was to comprehensively describe the biologic characteristics (including genetic background) of clinically defined hyperuricemia subtypes in two large geographically independent gout cohorts. METHODS Hyperuricemia subtype was defined as renal uric acid overload (ROL), renal uric acid underexcretion (RUE), combined, or renal normal. Twenty single nucleotide polymorphisms (SNPs) previously identified as gout risk loci or associated with serum urate (SU) concentration in the East Asian population were genotyped. Weighted polygenic risk scores were calculated to assess the cumulative effect of genetic risks on the subtypes. RESULTS Of the 4,873 participants, 8.8% had an ROL subtype, 60.9% RUE subtype, 23.1% combined subtype, and 7.2% normal subtype. The ROL subtype was independently associated with older age at onset, lower SU, tophi, and diabetes mellitus; RUE was associated with lower body mass index (BMI) and non-diabetes mellitus; the combined subtype was associated with younger age at onset, higher BMI, SU, estimated glomerular filtration rate (eGFR), and smoking; and the normal subtype was independently associated with older age at onset, lower SU, and eGFR. Thirteen SNPs were associated with gout with 6 shared loci and subtype-dependent risk loci patterns. High polygenic risk scores were associated with ROL subtype (odds ratio [OR] = 9.63, 95% confidence interval [95% CI] 4.53-15.12), RUE subtype (OR = 2.18, 95% CI 1.57-3.03), and combined subtype (OR = 6.32, 95% CI 4.22-9.48) compared with low polygenic risk scores. CONCLUSION Hyperuricemia subtypes classified according to renal uric acid handling have subtype-specific clinical and genetic features, suggesting subtype-unique pathophysiologic mechanisms.
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Affiliation(s)
- Han Qi
- The Affiliated Hospital of Qingdao University, Qingdao University, and Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Qingdao, China
| | - Mingshu Sun
- The Affiliated Hospital of Qingdao University, Qingdao, China
| | | | - Tony R Merriman
- Qingdao University, Qingdao, China, and University of Alabama Birmingham
| | | | - Zhiqiang Li
- The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Aichang Ji
- The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xiaomei Xue
- The Affiliated Hospital of Qingdao University, Qingdao University, and Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Qingdao, China
| | - Wenyan Sun
- The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Can Wang
- The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xinde Li
- The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yuwei He
- The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Lingling Cui
- The Affiliated Hospital of Qingdao University, Qingdao, China
| | | | - Changgui Li
- The Affiliated Hospital of Qingdao University, Qingdao University, and Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Qingdao, China
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Sutherland C, Gaffo AL. Investigating gout flares: beyond a definition. Curr Opin Rheumatol 2024; 36:309-313. [PMID: 38695425 DOI: 10.1097/bor.0000000000001024] [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: 05/24/2024]
Abstract
PURPOSE OF REVIEW Gout flares are a paramount component of disease burden inflicted by gout onto the patient. Furthermore, they are included in the core domain set for long-term gout studies recognized by Outcome Measures in Rheumatology. Along with a validated classification criterion for gout, gout investigators have turned their efforts into defining and characterizing the gout flare. This brief review will summarize the efforts that have been done to define and characterize a gout flare in clinical studies. RECENT FINDINGS Recent findings include a validated definition of a gout flare that has been utilized in novel clinical studies, use of technology to monitor for gout flares and their effects on patient life, and qualitative analyses into the disease burden that a patient undergoes. SUMMARY Although guidelines for core outcome domains have been well established, there is question in methods of measuring and reporting gout flares in long-term trials. Furthermore, there is question as to the effectiveness of the agreed upon instruments' abilities to fully capture the disease burden experienced by patients with gout. A combination of outcome measurements including binary data (gout flare present or absent) along with a comprehensive measurement of disease burden over time would theoretically provide a more accurate description of the disease and serve as a basis for intervention development.
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Affiliation(s)
| | - Angelo L Gaffo
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham
- Birmingham VA Medical Center, Birmingham, Alabama, USA
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Dainty KN, Thibau IJC, Amog K, Drucker AM, Wyke M, Begolka WS. Towards a patient-centred definition for atopic dermatitis flare: a qualitative study of adults with atopic dermatitis. Br J Dermatol 2024; 191:82-91. [PMID: 38287887 DOI: 10.1093/bjd/ljae037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/19/2024] [Accepted: 01/19/2024] [Indexed: 01/31/2024]
Abstract
BACKGROUND The term 'flare' is used across multiple diseases, including atopic dermatitis (AD), to describe increased disease activity. While several definitions of an AD flare have been proposed, no single definition of AD flare is widely accepted and it is unclear what the term 'AD flare' means from the patient perspective. OBJECTIVES To understand AD flares from the adult patient perspective and to explore how adults with AD define an AD flare. METHODS Participants were adults with AD recruited from the National Eczema Association Ambassadors programme, a volunteer patient-engagement programme. They participated in online focus groups to discuss how they describe AD flares from their perspective, how they define its start and stop, and how they relate to existing definitions of flare. Using a grounded theory approach, transcripts were analysed and coded using an iterative process to identify concepts to support a patient-centred conceptual framework of 'flare'. RESULTS Six 90-min focus groups of 3-8 participants each were conducted with 29 US adults (≥ 18 years of age) with AD who had at least one self-reported AD flare in the past year. When participants were presented with examples of previously published definitions of AD flare, participants found them problematic and unrelatable. Specifically, they felt that flare is hard to quantify or put on a numerical scale, definitions cannot solely be about skin symptoms and clinical verbiage does not resonate with patients' lived experiences. Concepts identified by patients as important to a definition of flare were changes from patient's baseline/patient's normal, mental/emotional/social consequences, physical changes in skin, attention needed/all-consuming focus, itch-scratch-burn cycle and control/loss of control/quality of life. Figuring out the trigger that initiated a flare was an underlying concept of the experience of flare but was not considered a contributor to the definition. CONCLUSIONS The results highlight the complexity and diversity of AD flare experiences from the adult patient perspective. Previously published definitions of AD flares did not resonate with patients, suggesting a need for a patient-centred flare definition to support care conversations and AD management.
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Affiliation(s)
- Katie N Dainty
- Research and Innovation, North York General Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, ON, Canada
| | | | - Krystle Amog
- Research and Innovation, North York General Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, ON, Canada
| | - Aaron M Drucker
- Women's College Research Institute and Department of Medicine, Women's College Hospital, Toronto, ON, Canada
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Matthew Wyke
- Department of Internal Medicine, University of Miami/Jackson Memorial Hospital, FL, USA
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Ni Z, Xiao Q, Xia Z, Kuang K, Yin B, Peng D. Electroacupuncture for acute gouty arthritis: a systematic review and meta-analysis of randomized controlled trials. Front Immunol 2024; 14:1295154. [PMID: 38239361 PMCID: PMC10794621 DOI: 10.3389/fimmu.2023.1295154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 12/11/2023] [Indexed: 01/22/2024] Open
Abstract
Acute gouty arthritis (AGA) is a metabolic disorder in which recurrent pain episodes can severely affect the quality of life of gout sufferers. Electroacupuncture (EA) is a non-pharmacologic therapy. This systematic review aimed to assess the efficacy and safety of electroacupuncture in treating acute gouty arthritis. We searched eight Chinese and English databases from inception to July 30, 2023, and 242 studies were retrieved. Finally, 15 randomized controlled trials (n=1076) were included in a meta-analysis using Review Manager V.5.4.1. meta-analysis results included efficacy rate, visual rating scale (VAS) for pain, serum uric acid level (SUA), immediate analgesic effect, and incidence of adverse events. Electroacupuncture (or combined non-pharmacologic) treatment of AGA was significantly different from treatment with conventional medications (RR = 1.14, 95% confidence interval CI = 1.10 to 1.19, P < 0.00001). The analgesic effect of the electroacupuncture group was superior to that of conventional Western drug treatment (MD = -2.26, 95% CI = -2.71 to -1.81, P < 0.00001). The electroacupuncture group was better at lowering serum uric acid than the conventional western drug group (MD =-31.60, CI -44.24 to -18.96], P < 0.00001). In addition, electroacupuncture combined with Western drugs had better immediate analgesic effects than conventional Western drug treatment (MD = -1.85, CI -2.65 to -1.05, P < 0.00001). Five studies reported adverse events in the electroacupuncture group versus the drug group, including 19 cases of gastrointestinal symptoms and 6 cases of neurological symptoms (RR = 0.20, 95% CI = 0.04 to 0.88, P = 0.03). Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=450037, identifier CRD42023450037.
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Affiliation(s)
- Zhichao Ni
- College of Acupuncture-Moxibustion and Tuina, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Qinwen Xiao
- West China Second University Hospital, Sichuan University, Chengdu, China
| | - Zihao Xia
- College of Acupuncture-Moxibustion and Tuina, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Kunlin Kuang
- College of Acupuncture-Moxibustion and Tuina, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Bingzun Yin
- College of Acupuncture-Moxibustion and Tuina, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Dezhong Peng
- College of Acupuncture-Moxibustion and Tuina, Chengdu University of Traditional Chinese Medicine, Chengdu, China
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Yoshida K, Cai T, Bessette LG, Kim E, Lee SB, Zabotka LE, Sun A, Mastrorilli JM, Oduol TA, Liu J, Solomon DH, Kim SC, Desai RJ, Liao KP. Improving the accuracy of automated gout flare ascertainment using natural language processing of electronic health records and linked Medicare claims data. Pharmacoepidemiol Drug Saf 2024; 33:e5684. [PMID: 37654015 PMCID: PMC10873073 DOI: 10.1002/pds.5684] [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: 09/07/2022] [Revised: 06/20/2023] [Accepted: 08/12/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND We aimed to determine whether integrating concepts from the notes from the electronic health record (EHR) data using natural language processing (NLP) could improve the identification of gout flares. METHODS Using Medicare claims linked with EHR, we selected gout patients who initiated the urate-lowering therapy (ULT). Patients' 12-month baseline period and on-treatment follow-up were segmented into 1-month units. We retrieved EHR notes for months with gout diagnosis codes and processed notes for NLP concepts. We selected a random sample of 500 patients and reviewed each of their notes for the presence of a physician-documented gout flare. Months containing at least 1 note mentioning gout flares were considered months with events. We used 60% of patients to train predictive models with LASSO. We evaluated the models by the area under the curve (AUC) in the validation data and examined positive/negative predictive values (P/NPV). RESULTS We extracted and labeled 839 months of follow-up (280 with gout flares). The claims-only model selected 20 variables (AUC = 0.69). The NLP concept-only model selected 15 (AUC = 0.69). The combined model selected 32 claims variables and 13 NLP concepts (AUC = 0.73). The claims-only model had a PPV of 0.64 [0.50, 0.77] and an NPV of 0.71 [0.65, 0.76], whereas the combined model had a PPV of 0.76 [0.61, 0.88] and an NPV of 0.71 [0.65, 0.76]. CONCLUSION Adding NLP concept variables to claims variables resulted in a small improvement in the identification of gout flares. Our data-driven claims-only model and our combined claims/NLP-concept model outperformed existing rule-based claims algorithms reliant on medication use, diagnosis, and procedure codes.
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Affiliation(s)
- Kazuki Yoshida
- Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- OM1, Inc, Boston, MA, USA
| | - Tianrun Cai
- Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Lily G. Bessette
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Erin Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Su Been Lee
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Luke E. Zabotka
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Alec Sun
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Julianna M. Mastrorilli
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Theresa A. Oduol
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Jun Liu
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Daniel H. Solomon
- Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Seoyoung C. Kim
- Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Rishi J. Desai
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Katherine P. Liao
- Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
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9
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Qi H, Sun M, Terkeltaub R, Xue X, Li X, Cui L, He Y, Yan F, Sun R, Chen Y, Jia Z, Cheng X, Ma L, Liu T, Dalbeth N, Li C. Response to febuxostat according to clinical subtypes of hyperuricemia: a prospective cohort study in primary gout. Arthritis Res Ther 2023; 25:241. [PMID: 38082308 PMCID: PMC10712161 DOI: 10.1186/s13075-023-03228-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 12/02/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND While xanthine oxidase inhibitors target uric acid production, renal urate underexcretion is the predominant subtypes in gout. This study was to compare treatment response to the XOI febuxostat in a gout cohort according to clinical subtypes of hyperuricemia. METHODS A prospective cohort study was conducted to compare the efficacy and safety of febuxostat (initially 20 mg daily, escalating to 40 mg daily if not at target) in 644 gout patients with the three major clinical subtypes for 12 weeks. Hyperuricemia was defined as the renal overload subtype, the renal underexcretion subtype, or the combined subtype based on UUE > or ≤ 600 mg/d/1.73 m2 and FEUA < or ≥ 5.5%. The primary endpoint was the rate of achieving serum urate (SU) < 6 mg/dL at week 12. RESULTS Fewer participants with combined subtype achieved the SU target, 45.5% compared with 64.8% with overload subtype (P = 0.007), and 56.6% with underexcretion subtype (P = 0.022). More participants with combined subtype (82%) had febuxostat escalated to 40 mg than those with overload (62%, P = 0.001) or underexcretion subtype (68%, P = 0.001). In all participants, combined subtype hyperuricemia (OR = 0.64, 95%CI 0.41-0.99, P = 0.048) and baseline SU (OR = 0.74, 95%CI 0.62-0.89, P = 0.001) were independently associated with lower rates of achieving SU target. CONCLUSIONS People with combined subtype have a lower response to febuxostat, compared to those with either overload or underexcretion subtype. Assessment of hyperuricemia subtype may provide useful clinical data in predicting febuxostat response.
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Affiliation(s)
- Han Qi
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, China
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, China
- Institute of Metabolic Diseases, Qingdao University, Qingdao, China
- Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Qingdao, China
| | - Mingshu Sun
- Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Qingdao, China
- Department of Rheumatology, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Robert Terkeltaub
- VA San Diego VA Healthcare Center, University of California San Diego, La Jolla, CA, USA
| | - Xiaomei Xue
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, China
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xinde Li
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Lingling Cui
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yuwei He
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Fei Yan
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, China
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Ruixia Sun
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Ying Chen
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Zhaotong Jia
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xiaoyu Cheng
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Lidan Ma
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Tian Liu
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Nicola Dalbeth
- Department of Medicine, University of Auckland, Auckland, New Zealand.
| | - Changgui Li
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, China.
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, China.
- Institute of Metabolic Diseases, Qingdao University, Qingdao, China.
- Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Qingdao, China.
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10
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Wang C, Sun W, Dalbeth N, Wang Z, Wang X, Ji X, Xue X, Han L, Cui L, Li X, Liu Z, Ji A, He Y, Sun M, Li C. Efficacy and safety of tart cherry supplementary citrate mixture on gout patients: a prospective, randomized, controlled study. Arthritis Res Ther 2023; 25:164. [PMID: 37679816 PMCID: PMC10483724 DOI: 10.1186/s13075-023-03152-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 08/27/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND Low urine pH, which may be mediated by metabolic syndrome (MetS), is common in gout. Tart cherries are shown to improve MetS symptoms and possess anti-inflammatory properties. However, the efficacy of tart cherry supplements on urine pH has yet to be studied. OBJECTIVES This study aimed to investigate the efficacy and safety of tart cherry supplementary citrate (TaCCi) mixture on urine pH, serum urate (sUA), C-reactive protein (CRP), and gout flares in gout patients initiating urate-lowering therapy (ULT), in comparison to citrate mixture and sodium bicarbonate. METHODS A prospective, randomized (1:1:1), open-label, parallel-controlled trial was conducted among 282 men with gout and fasting urine pH ≤ 6, who were initiating ULT with febuxostat (initially 20 mg daily, escalating to 40 mg daily if serum urate ≥ 360 μmol/L). Participants were randomized to groups taking either sodium bicarbonate, citrate mixture, or TaCCi mixture. All participants were followed every 4 weeks until week 12. Urine pH and sUA were co-primary outcomes, with various biochemical and clinical secondary endpoints. RESULTS Urine pH increased to a similar extent in all three groups. SUA levels declined in all three groups as well, with no significant differences observed between the groups. At week 12, the TaCCi mixture group exhibited a greater reduction in the urine albumin/creatinine ratio (UACR) compared to the other two groups (p < 0.05). Participants taking TaCCi mixture or citrate mixture experienced fewer gout flares than those in the sodium bicarbonate group over the study period (p < 0.05). Additionally, the TaCCi mixture group had a lower CRP level at week 12 relative to the other two groups (p < 0.01). Adverse events were similar across all three groups. CONCLUSION The TaCCi mixture had similar efficacy and safety on urine alkalization and sUA-lowering as the citrate mixture and sodium bicarbonate in patients with gout. However, the TaCCi mixture resulted in greater improvements in UACR and CRP, which suggests that tart cherry supplements may provide additional benefits for renal protection and reduce inflammation in gout, particularly when starting ULT. TRIAL REGISTRATION This project was registered in ChiCTR ( www.chictr.org.cn ), with the registration number: ChiCTR2100050749.
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Affiliation(s)
- Can Wang
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, China
- Institute of Metabolic Diseases, Qingdao University, Qingdao, China
- Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Qingdao, China
| | - Wenyan Sun
- Institute of Metabolic Diseases, Qingdao University, Qingdao, China
| | - Nicola Dalbeth
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Zhongjun Wang
- Department of Clinical Laboratory, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xuefeng Wang
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, China
- Institute of Metabolic Diseases, Qingdao University, Qingdao, China
- Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Qingdao, China
| | - Xiaopeng Ji
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, China
- Institute of Metabolic Diseases, Qingdao University, Qingdao, China
- Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Qingdao, China
| | - Xiaomei Xue
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, China
- Institute of Metabolic Diseases, Qingdao University, Qingdao, China
- Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Qingdao, China
| | - Lin Han
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, China
- Institute of Metabolic Diseases, Qingdao University, Qingdao, China
- Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Qingdao, China
| | - Lingling Cui
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, China
- Institute of Metabolic Diseases, Qingdao University, Qingdao, China
- Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Qingdao, China
| | - Xinde Li
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, China
- Institute of Metabolic Diseases, Qingdao University, Qingdao, China
- Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Qingdao, China
| | - Zhen Liu
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, China
- Institute of Metabolic Diseases, Qingdao University, Qingdao, China
- Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Qingdao, China
| | - Aichang Ji
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, China
- Institute of Metabolic Diseases, Qingdao University, Qingdao, China
- Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Qingdao, China
| | - Yuwei He
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, China
- Institute of Metabolic Diseases, Qingdao University, Qingdao, China
- Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Qingdao, China
| | - Mingshu Sun
- Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Qingdao, China.
- Department of Rheumatology, the Affiliated Hospital of Qingdao University, Qingdao, China.
| | - Changgui Li
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, China.
- Institute of Metabolic Diseases, Qingdao University, Qingdao, China.
- Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Qingdao, China.
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11
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Jackson LE, Annapureddy N, Hansen ME, Saag KG, Booth J, Rosas G, Foster PJ, Mudano A, Sun D, Osborne JD, Bongartz T, Hess E, Lawrence C, Dunkel L, Danila MI. Development and Validation of an Emergency Department Electronic Medical Record Gout Flare Alert. Arthritis Care Res (Hoboken) 2023; 75:1821-1829. [PMID: 36408730 PMCID: PMC10500930 DOI: 10.1002/acr.25061] [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: 03/21/2022] [Revised: 09/21/2022] [Accepted: 11/17/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Patients with acute gout are frequently treated in the emergency department (ED) and represent a typically underresourced and understudied population. A key limitation for gout research in the ED is the timely ability to identify acute gout patients. Our goal was to refine a multicriteria, electronic medical record alert for gout flares and to determine its diagnostic characteristics in the ED. METHODS The gout flare alert used electronic medical record data from ED nursing notes and was triggered by the term 'gout' preceding past medical history in the chief complaint, the term 'gout' and a musculoskeletal problem in the chief complaint, or the term 'gout' in the problem list and a musculoskeletal chief complaint. We validated its diagnostic properties to assess presence/absence of gout through manual medical record review using adjudicated expert consensus as the gold standard. RESULTS In January 2020, we analyzed 202 patient records from 2 university-based EDs; from these records, 57 patients were identified by our gout flare alert, and 145 were identified by other means as potentially having an acute gout flare. The gout flare alert's positive predictive value was 47% (95% confidence interval [95% CI] 34-60%), negative predictive value was 94% (95% CI 90-98%), sensitivity was 75% (95% CI 61-89%), and specificity was 82% (95% CI 76-88%). The diagnostic properties were similar at both institutions. CONCLUSION Our multicomponent gout flare alert had reasonable sensitivity and specificity, albeit a modest positive predictive value. An electronic gout flare alert may help enable the conduct of gout research in the ED setting.
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Affiliation(s)
- Lesley E. Jackson
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Narender Annapureddy
- Department of Rheumatology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Megan E. Hansen
- Department of Rheumatology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kenneth G. Saag
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - James Booth
- Department of Emergency Medicine, University of Alabama School of Medicine, Birmingham, AL, USA
| | - Giovanna Rosas
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Phillip J. Foster
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Amy Mudano
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Dongmei Sun
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - John D. Osborne
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Tim Bongartz
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Erik Hess
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Colleen Lawrence
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Leah Dunkel
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Maria I. Danila
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
- Birmingham VA Medical Center, Birmingham, AL, USA
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12
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Botson JK, Tesser JRP, Bennett R, Kenney HM, Peloso PM, Obermeyer K, Song Y, LaMoreaux B, Zhao L, Xin Y, Chamberlain J, Ramanathan S, Weinblatt ME, Peterson J. A multicentre, efficacy and safety study of methotrexate to increase response rates in patients with uncontrolled gout receiving pegloticase (MIRROR): 12-month efficacy, safety, immunogenicity, and pharmacokinetic findings during long-term extension of an open-label study. Arthritis Res Ther 2022; 24:208. [PMID: 36008814 PMCID: PMC9404640 DOI: 10.1186/s13075-022-02865-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 07/13/2022] [Indexed: 11/30/2022] Open
Abstract
Background Publications suggest immunomodulation co-therapy improves responder rates in uncontrolled/refractory gout patients undergoing pegloticase treatment. The MIRROR open-label trial showed a 6-month pegloticase + methotrexate co-therapy responder rate of 79%, compared to an established 42% pegloticase monotherapy responder rate. Longer-term efficacy/safety data are presented here. Methods Uncontrolled gout patients (serum urate [SU] ≥ 6 mg/dL and SU ≥ 6 mg/dL despite urate-lowering therapy [ULT], ULT intolerance, or functionally-limiting tophi) were included. Patients with immunocompromised status, G6PD deficiency, severe kidney disease, or methotrexate contraindication were excluded. Oral methotrexate (15 mg/week) and folic acid (1 mg/day) were administered 4 weeks before and during pegloticase therapy. Twelve-month responder rate (SU < 6 mg/dL for ≥ 80% during month 12), 52-week change from baseline in SU, and extended safety were examined. Efficacy analyses were performed for patients receiving ≥ 1 pegloticase infusion. Pharmacokinetics (PK)/anti-drug antibodies (ADAs) were examined and related to efficacy/safety findings. Results Fourteen patients were included (all male, 49.3 ± 8.7 years, 13.8 ± 7.4-year gout history, pre-therapy SU 9.2 ± 2.5 mg/dL). Three patients were non-responders and discontinued study treatment before 24 weeks, one patient exited the study per protocol at 24 weeks (enrolled prior to treatment extension amendment), and 10 remained in the study through week 52. Of the 10, 8 completed 52 weeks of pegloticase + methotrexate and were 12-month responders. The remaining two discontinued pegloticase + methotrexate at week 24 (met treatment goals) and stayed in the study under observation (allopurinol prescribed at physicians’ discretion); one remained a responder at 12 months. At 52 weeks, change from baseline in SU was − 8.2 ± 4.1 mg/dL (SU 1.1 ± 2.4 mg/dL, n = 10). Gout flares were common early in treatment but progressively decreased while on therapy (weeks 1–12, 13/14 [92.9%]; weeks 36–52, 2/8 [25.0%]). One patient recovered from sepsis (serious AE). Two non-responders developed high ADA titers; fewer patients had trough concentrations (Cmin) below the quantitation limit (BQL), and the median Cmin was higher (1.03 µg/mL vs. BQL) than pegloticase monotherapy trials. Conclusions Pegloticase + methotrexate co-therapy was well-tolerated over 12 months, with sustained SU lowering, progressive gout flare reduction, and no new safety concerns. Antibody/PK findings suggest methotrexate attenuates ADA formation, coincident with higher treatment response rates. Trial registration ClinicalTrials.gov, NCT03635957. Registered on 17 August 2018.
Supplementary Information The online version contains supplementary material available at 10.1186/s13075-022-02865-z.
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Affiliation(s)
- John K Botson
- Orthopedic Physicians Alaska, 3801 Lake Otis Parkway, Suite 300, Anchorage, AK, 99508, USA.
| | - John R P Tesser
- Arizona Arthritis & Rheumatology Associates, 4550 East Bell Road, Phoenix, AZ, 85032, USA
| | - Ralph Bennett
- Arizona Arthritis & Rheumatology Associates, 4550 East Bell Road, Phoenix, AZ, 85032, USA
| | - Howard M Kenney
- Arthritis Northwest, PLLC, 105 West 8th Avenue, Suite 6080W, Spokane, WA, 99204, USA
| | - Paul M Peloso
- Horizon Therapeutics Plc, 1 Horizon Way, Deerfield, IL, 60015, USA
| | - Katie Obermeyer
- Horizon Therapeutics Plc, 1 Horizon Way, Deerfield, IL, 60015, USA
| | - Yang Song
- Horizon Therapeutics Plc, 2 Tower Place, South San Francisco, CA, 94080, USA
| | - Brian LaMoreaux
- Horizon Therapeutics Plc, 1 Horizon Way, Deerfield, IL, 60015, USA
| | - Lin Zhao
- Horizon Therapeutics Plc, 1 Horizon Way, Deerfield, IL, 60015, USA
| | - Yan Xin
- Horizon Therapeutics Plc, 2 Tower Place, South San Francisco, CA, 94080, USA
| | - Jason Chamberlain
- Horizon Therapeutics Plc, 2 Tower Place, South San Francisco, CA, 94080, USA
| | - Srini Ramanathan
- Horizon Therapeutics Plc, 2 Tower Place, South San Francisco, CA, 94080, USA
| | - Michael E Weinblatt
- Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Jeff Peterson
- Western Washington Medical Group Arthritis Clinic, 1909 214th Street SE, Suite 211, Bothell, WA, 98021, USA
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13
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Uhlig T, Karoliussen LF, Sexton J, Kvien TK, Haavardsholm EA, Perez-Ruiz F, Hammer HB. One- and 2-year flare rates after treat-to-target and tight-control therapy of gout: results from the NOR-Gout study. Arthritis Res Ther 2022; 24:88. [PMID: 35443675 PMCID: PMC9020166 DOI: 10.1186/s13075-022-02772-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 03/30/2022] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES To explore the frequency and predictors of flares over 2 years during a treat-to-target strategy with urate-lowering therapy (ULT) in patients with gout. METHODS In the treat-to-target, tight control NOR-Gout study patients started ULT with escalating doses of allopurinol. Flares were recorded over 2 years. Baseline predictors of flares during months 9-12 in year 1 and during year 2 were analyzed by multivariable logistic regression. RESULTS Of 211 patients included (mean age 56.4 years, disease duration 7.8 years, 95% males), 81% (150/186) of patients experienced at least one gout flare during the first year and 26% (45/173) during the second year. The highest frequency of flares in the first year was seen during months 3-6 (46.8% of patients). Baseline crystal depositions detected by ultrasound and by dual-energy computed tomography (DECT) were the only variables which predicted flares both during the first period of interest at months 9-12 (OR 1.033; 95% CI 1.010-1.057, and OR 1.056; 95% CI 1.007-1.108) and also in year 2. Baseline subcutaneous tophi (OR 2.42, 95% CI 1.50-5.59) and prior use of colchicine at baseline (OR 2.48, 95% CI 1.28-4.79) were independent predictors of flares during months 9-12, whereas self-efficacy for pain was a protective predictor (OR 0.98 per unit, 95% CI 0.964-0.996). CONCLUSIONS In patients with gout, flares remain frequent during the first year of a treat-to-target ULT strategy, especially during months 3-6, but are much less frequent during year 2. Baseline crystal depositions predict flares over 2 years, supporting ULT early during disease course. TRIAL REGISTRATION ACTRN12618001372279.
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Affiliation(s)
- Till Uhlig
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Box 23, Vinderen, N-0319, Oslo, Norway. .,Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Lars F Karoliussen
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Box 23, Vinderen, N-0319, Oslo, Norway
| | - Joe Sexton
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Box 23, Vinderen, N-0319, Oslo, Norway
| | - Tore K Kvien
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Box 23, Vinderen, N-0319, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Espen A Haavardsholm
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Box 23, Vinderen, N-0319, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Fernando Perez-Ruiz
- Osakidetza, OSI EE-Cruces, Division of Rheumatology, Cruces University Hospital, Baracaldo, Spain.,Biocruces-Bizkaia Health Research Institute, Baracaldo, Spain.,Medicine Department, Medicine School, University of the Basque Country, Leioa, Spain
| | - Hilde Berner Hammer
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Box 23, Vinderen, N-0319, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
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14
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Park HK, Lee SJ. Treatment of gouty arthritis is associated with restoring the gut microbiota and promoting the production of short-chain fatty acids. Arthritis Res Ther 2022; 24:51. [PMID: 35183234 PMCID: PMC8857835 DOI: 10.1186/s13075-022-02742-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 02/08/2022] [Indexed: 12/15/2022] Open
Abstract
Introduction Although factors initiating the inflammatory response to monosodium urate crystals have been identified, the role of the gut microbiota and their metabolites on gout remains unknown. This study aimed to investigate the changes in both gut microbiota and short-chain fatty acids (SCFAs) according to inflammatory states of gout in the same patients. Methods This study enrolled 20 patients with gout in the acute state who had active joints and were followed up until the recovery state with no active joints. Blood and fecal samples were simultaneously collected within 3 days for each disease state. The stool microbiome was analyzed using 16S rRNA sequencing, and serum SCFAs were measured by gas chromatography-mass spectrometry. Differences in the gut microbiome and serum SCFAs were compared between the acute and recovery states. Results Beta diversity of the microbiome was significantly different between the acute and recovery states in terms of weighted UniFrac distance. In the recovery state, Prevotellaceae (p = 0.006) and the genus Prevotella (p = 0.009) were significantly enriched, whereas Enterobacteriaceae (p = 0.019) and its derivative genus Shigella (p = 0.023) were significantly decreased compared to the acute state. Similarly, the levels of acetate were dramatically increased in the recovery state compared to the acute state (p < 0.010). The levels of propionate and butyrate tended to increase but without statistical significance. Conclusion Substantial alterations of bacterial composition with the promotion of SCFA formation (especially acetate) were found after treatment in patients with gouty arthritis. Supplementary Information The online version contains supplementary material available at 10.1186/s13075-022-02742-9.
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15
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Singh JA. Disease modification in gout: a qualitative study of gout expert rheumatologists. Rheumatol Adv Pract 2022; 6:rkab107. [PMID: 35028499 DOI: 10.1093/rap/rkab107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 12/17/2021] [Indexed: 01/21/2023] Open
Abstract
Objective The aim was to examine the views of health-care providers regarding disease modification in gout, with the potential to derive a provisional set of domains for disease modification in gout. Methods A qualitative nominal group study was performed with 20 gout experts (15 expert/expert panel members of the 2012 and/or 2020 ACR gout guidelines and/or 2015 ACR/EULAR gout classification criteria) about what constitutes disease modification in gout: 'What sorts of things do you think constitute a change in the course of disease in gout? (positive); what are all the ways in which gout as a disease can be modified?' Results Decrease in gout flares was rated number one rank in all six nominal groups as indicative of disease modification in gout, followed by serum urate lowering, which was rated number one rank in one of the six nominal groups (tied score with flares in one nominal group). Other components of gout disease modification were to improve quality of life/productivity; restore function; reduce/eliminate pain; reduce tophi burden; and joint preservation or resolution of joint damage. Potential additional components that were not ranked in the top three votes within each nominal group were: decreasing health-care cost/utilization; reducing cardiovascular/renal morbidity/mortality; and stopping formation of urate crystals. Conclusion This qualitative study provides a provisional set of domains for disease modification in gout. Future studies for the development of thresholds for disease modification domains and wider consensus on this definition are needed.
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Affiliation(s)
- Jasvinder A Singh
- Medicine Service, Birmingham VA Medical Center.,Department of Medicine at School of Medicine, and Division of Epidemiology at School of Public Health, University of Alabama, Birmingham, AL, USA
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16
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Singh JA. SToRytelliing to Improve Disease outcomes in Gout (STRIDE-GO) in African American veterans with gout: a trial study protocol. Trials 2021; 22:879. [PMID: 34863255 PMCID: PMC8645140 DOI: 10.1186/s13063-021-05847-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 11/20/2021] [Indexed: 11/28/2022] Open
Abstract
Objective Medication adherence in gout is suboptimal, and the lack of effective interventions to address it presents a huge challenge. Medication adherence and gout outcomes are worse in racial/ethnic minorities. The objective of this paper was to provide the details of the study protocol for randomized, controlled trial (RCT) in African Americans (AAs) with gout that will test the effectiveness of a culturally appropriate gout storytelling intervention. Methods The SToRytelliing to Improve Disease outcomes in Gout (STRIDE-GO) study will be a 12-month, multicenter, open-label RCT that will assess the effect of a culturally appropriate gout storytelling in at least 300 AA veterans with gout. Participants will be randomized to gout-storytelling intervention vs. a stress reduction video in a 1:1 ratio. The primary outcome is urate-lowering therapy (ULT) adherence measured with MEMSCap™, an electronic monitoring system (efficacy, 6 months; sustenance of efficacy, 12 months). Secondary outcomes include gout flares, serum urate (SU), gout-specific health-related quality of life [HRQOL], self-reported ULT adherence, patient satisfaction with treatment, and patient understanding of the intervention. AA veterans with gout who met the 1977 Preliminary American College of Rheumatology (ACR) classification criteria for gout, currently prescribed an oral ULT medication (allopurinol or febuxostat) for at least 6 months, and not using a pillbox to redistribute their medications, will be invited to an in-person study visit. After the study coordinators obtain informed consent, and ensure that participants meet the inclusion criteria, the eligible participants will be provided with their current ULT in a MEMSCap™ bottle for the 1-month run-in period and asked to return to the clinic in 1 month. ULT adherence with MEMSCap™ will be recorded at a 1-month return visit. Interested participants will complete the baseline assessments, randomized using the computerized system to either gout-storytelling intervention or a stress reduction intervention video arm and watch the respective video in-clinic. Patients will be interviewed on the phone at 2 and 4 months regarding the viewing of the videos at home at each time. Participants will be assessed in-clinic at 3, 6, 9, and 12 months; MEMSCap™ data and patient surveys will be captured at each visit. For any missed visit, assessments will be completed on the phone and MEMSCap™ data captured at the next in-clinic visit. Discussion The study will assess the efficacy of a behavioral intervention to improve ULT adherence in minority populations with gout. Trial registration ClinicalTrials.gov NCT 02741700. Registered on 14 September 2018 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05847-9.
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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, 1720 Second Ave. South, Birmingham, AL, 35294-0022, USA. .,Division of Epidemiology at School of Public Health, University of Alabama at Birmingham, 1720 Second Ave. South, Birmingham, AL, 35294-0022, USA.
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17
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Morillon MB, Christensen R, Singh JA, Dalbeth N, Saag K, Taylor WJ, Neogi T, Kennedy MA, Pedersen BM, McCarthy GM, Shea B, Diaz-Torne C, Tedeschi SK, Grainger R, Abhishek A, Gaffo A, Nielsen SM, Noerup A, Simon LS, Lassere M, Tugwell P, Stamp LK, Gout Working Group FTO. Serum urate as a proposed surrogate outcome measure in gout trials: From the OMERACT working group. Semin Arthritis Rheum 2021; 51:1378-1385. [PMID: 34839932 PMCID: PMC10401605 DOI: 10.1016/j.semarthrit.2021.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/08/2021] [Accepted: 11/10/2021] [Indexed: 02/03/2023]
Abstract
Serum urate (SU) is the most common primary efficacy outcome in trials of urate-lowering therapies for gout. Despite this, it is not formally considered a validated surrogate outcome. In this paper we will outline the definitions of biomarkers and surrogate outcome measures, respectively as well as the available frameworks and challenges in the assessment of the validity of serum urate as a surrogate in gout (i.e. a reasonable replacement for gout symptoms).
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Affiliation(s)
- Melanie Birger Morillon
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark; Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark; Department of Medicine, Svendborg, Odense University Hospital, Denmark
| | - Robin Christensen
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark; Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Jasvinder A Singh
- Birmingham Veterans Affairs (VA) Medical Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Kenneth Saag
- Birmingham Veterans Affairs (VA) Medical Center, University of Alabama, Birmingham, AL, USA
| | | | | | | | | | - Geraldine M McCarthy
- Division of Rheumatology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Beverley Shea
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Cesar Diaz-Torne
- Rheumatology Department. Hospital de la Santa Creu i Sant Pau. Universitat Autònoma de Barcelona. Barcelona
| | - Sara K Tedeschi
- Brigham and Women's Hospital, Division of Rheumatology, Inflammation and Immunity, Boston, USA
| | - Rebecca Grainger
- Rehabilitation Teaching and Research Unit, Department of Medicine, University of Otago Wellington, Wellington, New Zealand
| | | | - Angelo Gaffo
- Birmingham Veterans Affairs (VA) Medical Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sabrina Mai Nielsen
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark; Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Alexander Noerup
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark; Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | | | - Marissa Lassere
- Department of Rheumatology, St George Hospital, University of NSW, Sydney, Australia
| | - Peter Tugwell
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Lisa K Stamp
- Department of Medicine, University of Otago, Christchurch, New Zealand.
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18
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Abstract
Gout flares are central to the patient experience of gout and are included in the Outcome Measures in Rheumatology (OMERACT) core outcome domain set for long-term gout studies. Although a valid definition for gout flare has been developed, there is no consensus around how flare outcomes are measured and reported in long-term clinical studies. Current methods of flare measurement, which are centered on measuring flares as a binary outcome (i.e., present vs absent), do not reflect the variable pattern of flares over time, nor the multidimensional patient experience of gout flares which include factors related to pain severity, functional disability, impact on family and social life, and psychological wellbeing. This review will discuss the importance and challenges of gout flare measurement.
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Affiliation(s)
- Sarah Stewart
- School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand.
| | - Nicola Dalbeth
- Department of Medicine, University of Auckland, Auckland, New Zealand.
| | - Angelo Gaffo
- Department of Medicine, University of Alabama and Birmingham, Alabama, United States.
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19
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Pouls BPH, Bekker CL, Gaffo AL, van den Bemt BJF, Flendrie M. Tele-monitoring flares using a smartphone app in patients with gout or suspected gout: a feasibility study. Rheumatol Adv Pract 2021; 5:rkab100. [PMID: 34988359 PMCID: PMC8713010 DOI: 10.1093/rap/rkab100] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 11/29/2021] [Indexed: 02/07/2023] Open
Abstract
Objectives Gout flares are painful and disabling. We developed a smartphone application (app) for patients to tele-monitor gout flares surveyed by clinicians. The aim of this study was to assess patient acceptability and technical and clinical feasibility. Methods Adult patients with either established gout or high suspicion thereof were recruited if they possessed a smartphone and reported a recent arthritis attack. A smartphone application was used to identify gout flares by asking during 90 consecutive days: (1) what is your pain score (0–10); (2) are your joints warm; (3) are your joints swollen; and (4) are you currently experiencing a gout flare? The clinician was alerted via email if a flare occurred. Patient acceptability was assessed using the technology acceptance model. Technical feasibility consisted of reported technical issues and clinical feasibility of actions taken by the clinician regarding gout flare alerts. Results Twenty-nine included patients completed the study. The mean age of participants was 57 years, and all but one were male. The adherence rate was 96% (110 of 2910 queries were missed). Patients had a positive attitude toward app use, found the app very easy to use (mean usability score 81 out of 100) and were neutral to positive on its usefulness. There were four minor technical issues. A total of 100 gout flare alerts were generated that led to 18 proactive contacts with patients. Conclusion A smartphone app to monitor gout flares was developed and tested, showing high adherence, good acceptability and clinical feasibility for established gout patients. Trial registration Netherlands Trial Register, https://www.trialregister.nl, NL6435.
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Affiliation(s)
- Bart P H Pouls
- Correspondence to: Bart P. H. Pouls, Department of Rheumatology Research, Sint Maartenskliniek, Hengstdal 3, 6500GM Nijmegen, The Netherlands. E-mail:
| | - Charlotte L Bekker
- Department of Pharmacy, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Angelo L Gaffo
- Division of Rheumatology, University of Alabama Medical Centre
- Division of Rheumatology, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
| | - Bart J F van den Bemt
- Department of Rheumatology Research, Sint Maartenskliniek
- Department of Pharmacy, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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20
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Bai XS, Wang M, Zhao XD, Cui LL, He YW, Wang C, Li XD, Qu XJ, Sun MS, Li CG. Treat-to-Target urate-lowering therapy in primary gout patients: A real-world retrospective study at a dedicated gout clinic in China. Technol Health Care 2021; 29:121-131. [PMID: 32444582 DOI: 10.3233/thc-191951] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Gout is the most common inflammatory arthritis affecting 1.1% of the population in mainland China with a higher prevalence in coastal areas. OBJECTIVE The purpose of the study was to investigate the clinical outcomes following urate-lowering therapy (ULT) in a real-world group study of primary gout patients in China. METHODS Electronic medical records of all the gout patients (n= 1588) that visited the Clinical Medical Center of Gout of the Affiliated Hospital of Qingdao University from September 2016 to February 2018 were analyzed in this study. The patients were treated with a standard treat-to-target (T2T) ULT strategy according to the 2016 EULAR Guidelines. Clinical data were collected in the first visit and one-month (defined as the baseline of ULT), 7-month, and 13-month follow-ups were completed. RESULTS Amongst the patients in the study, 92.70% accepted ULT and 82.93% completed ULT for 3 months, 63.54% for 6 months, and 40.49% (n= 643) for 12 months. Further analysis of the 643 patients included the following data: the sUA level reduced at month 7 and reduced further at month 13. The gout flares, patient global pain visual analogue score, and health assessment questionnaire score improved at month 7 but did not improve further at month 13, and the index tophus size did not.
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Affiliation(s)
- Xue-Shan Bai
- Department of Endocrinology, Zibo Central Hospital, Shandong, China.,The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China.,Department of Endocrinology, Zibo Central Hospital, Shandong, China
| | - Ming Wang
- The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China.,Department of Endocrinology, Zibo Central Hospital, Shandong, China
| | - Xiao-Dong Zhao
- Department of Endocrinology, Zibo Central Hospital, Shandong, China.,Department of Endocrinology, Zibo Central Hospital, Shandong, China
| | - Ling-Ling Cui
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Yu-Wei He
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Can Wang
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Xin-De Li
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Xiao-Jie Qu
- Department of Endocrinology, People's Hospital of Rongcheng, Weihai, Shandong, China
| | - Ming-Shu Sun
- Department of Rheumatology and Clinical Immunology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Chang-Gui Li
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China.,Department of Endocrinology and Metabolic Diseases, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
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21
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Jatuworapruk K, Grainger R, Dalbeth N, Lertnawapan R, Hanvivadhanakul P, Towiwat P, Shi L, Taylor WJ. The GOUT-36 prediction rule for inpatient gout flare in people with comorbid gout: derivation and external validation. Rheumatology (Oxford) 2021; 61:1658-1662. [PMID: 34297058 DOI: 10.1093/rheumatology/keab590] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/09/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To develop and validate a gout flare risk stratification tool for people with gout hospitalised for non-gout conditions. METHODS The prediction rule for inpatient gout flare was derived from a cohort of 625 hospitalised people with comorbid gout from New Zealand. The rule had four items: (1) no pre-admission GOut flare prophylaxis, (2) no pre-admission Urate-lowering therapy, (3) Tophus and (4) pre-admission serum urate >0.36 mmol/l within the previous year (GOUT-36 rule). Two or more items are required for the classification of high risk for developing inpatient gout flare. The GOUT-36 rule was validated in a prospective cohort of 284 hospitalised people with comorbid gout from Thailand and China. RESULTS The GOUT-36 rule had a sensitivity of 75%, specificity of 67% and AUC of 0.71 for classifying people at high risk for developing inpatient gout flare. Four risk groups were developed: low (no items), moderate (one item), high (two items) and very high risk (three or four items). In a population with frequent (overall 34%) in-hospital gout flare, 80% of people with very high risk people developed flare, while 11% of low-risk people had inpatient flare. CONCLUSION GOUT-36 rule is simple and sensitive for classifying people with high risk for inpatient gout flare. The rule may help inform clinical decision and future research on the prevention of inpatient gout flare.
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Affiliation(s)
- Kanon Jatuworapruk
- Department of Medicine, University of Otago, Wellington, New Zealand.,Department of Medicine, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Rebecca Grainger
- Department of Medicine, University of Otago, Wellington, New Zealand
| | - Nicola Dalbeth
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Ratchaya Lertnawapan
- Department of Medicine, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | | | - Patapong Towiwat
- Department of Medicine, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand
| | - Lianjie Shi
- Department of Rheumatology and Immunology, Peking University International Hospital, Beijing, China
| | - William J Taylor
- Department of Medicine, University of Otago, Wellington, New Zealand
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22
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Patient-Centered Outcomes and Key Study Procedure Finalization in the Pilot Feasibility Gout Randomized Trial: Comparative Feasibility Study in GOUt, CHerry Extract Versus Diet Modification (Mini-GOUCH). J Clin Rheumatol 2021; 26:181-191. [PMID: 30870252 DOI: 10.1097/rhu.0000000000001018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The aim of this study was to report patient-centered outcomes and finalization of key study procedures from a 9-month pilot internet randomized controlled trial of cherry extract versus diet modification. METHODS We randomized 84 people with physician-confirmed gout in an internet study to cherry extract (n = 41) or dietitian-assisted diet modification for gout (n = 43). All study outcomes were collected via internet and phone calls. We finalized key study procedures. We assessed acceptability and feasibility of the intervention and satisfaction with study website. RESULTS Study participant satisfaction with the intervention was high. The intervention was perceived as easy, enjoyable, understandable, and helpful (scores 65-88 for all; higher = better). The amount of time spent for the study was acceptable. Participant satisfaction with website interaction and content was very high; 85% or more were moderately to extremely satisfied. Significantly lower total calories, total carbohydrate, and saturated fat intake were noted at 6 months in the diet modification versus cherry extract group; differences were insignificant at 9 months. Six of the 8 Health Assessment Questionnaire sections/domains improved significantly from baseline to 9 months in cherry extract versus 2 Health Assessment Questionnaire sections/domains in the diet modification group. Key study procedures were finalized for a future trial, including an internet diet assessment tool, gout flare assessment, provider confirmation of gout diagnosis, patient reporting of classification criteria, and centralized laboratory-assisted serum urate testing. CONCLUSIONS High patient acceptability and feasibility of study/intervention and finalization of key study procedures indicate that hypothesis-testing internet gout trials of cherry extract and/or diet modification can be conducted in the future.
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23
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Abstract
Gout is a common and treatable disease caused by the deposition of monosodium urate crystals in articular and non-articular structures. Increased concentration of serum urate (hyperuricaemia) is the most important risk factor for the development of gout. Serum urate is regulated by urate transporters in the kidney and gut, particularly GLUT9 (SLC2A9), URAT1 (SLC22A12), and ABCG2. Activation of the NLRP3 inflammasome by monosodium urate crystals with release of IL-1β plays a major role in the initiation of the gout flare; aggregated neutrophil extracellular traps are important in the resolution phase. Although presenting as an intermittent flaring condition, gout is a chronic disease. Long-term urate lowering therapy (eg, allopurinol) leads to the dissolution of monosodium urate crystals, ultimately resulting in the prevention of gout flares and tophi and in improved quality of life. Strategies such as nurse-led care are effective in delivering high-quality gout care and lead to major improvements in patient outcomes.
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Affiliation(s)
- Nicola Dalbeth
- Department of Medicine, University of Auckland, Auckland, New Zealand.
| | - Anna L Gosling
- Department of Anatomy, University of Otago, Dunedin, New Zealand
| | - Angelo Gaffo
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; Birmingham VA Medical Center, Birmingham, AL, USA
| | - Abhishek Abhishek
- Academic Rheumatology, School of Medicine, University of Nottingham, Nottingham, UK; Nottingham National Institute for Health Research Biomedical Research Centre, Nottingham, UK
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24
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Jagpal A, Rahn EJ, Mudano AS, Dalbeth N, Taylor W, Saag KG, Singh JA, Cavagna L, Uhlig T, Perez-Ruiz F, McCarthy G, Gerritsen M, Stamp L, Vazquez Mellado J, Lin C, Vargas- Santos AB, Louthrenoo W, Neogi T, Chen YH, Castelar-Pinheiro GDR, Gaffo A. Which factors predict discordance between a patient and physician on a gout flare? Rheumatology (Oxford) 2021; 60:773-779. [PMID: 32793971 PMCID: PMC10687509 DOI: 10.1093/rheumatology/keaa413] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 06/13/2020] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To investigate the factors associated with discordance between patient and physician on the presence of a gout flare. METHODS Patients' self-reports of current gout flares were assessed with the question, 'Are you having a gout flare today?' which was then compared with a concurrent, blinded, physician's assessment. Based on agreement or disagreement with physicians on the presence of a gout flare, flares were divided into concordant and discordant groups, respectively. Within the discordant group, two subgroups-patient-reported flare but the physician disagreed and physician-reported flare but the patient disagreed-were identified. The factors associated with discordance were analysed with multivariable logistic regression analysis. RESULTS Of 268 gout flares, 81 (30.2%) flares were discordant, with either patient or physician disagreeing on the presence of a flare. Of the discordant flares, in 57 (70.4%) the patient reported a flare but the physician disagreed. In multivariable logistic regression analysis adjusted for demographics, disagreement among patients and physicians on the presence of a gout flare was associated with lower pain scores at rest [odds ratio (OR) for each point increase on 0-10 point pain scale 0.81 (95% Wald CI 0.73, 0.90), P < 0.0001] and less presence of joint swelling [OR 0.24 (95% CI 0.10, 0.61), P = 0.003] or joint warmth [OR 0.39 (95% CI 0.20, 0.75), P = 0.005]. CONCLUSION Although patients and physicians generally agree about the presence of gout flare, discordance may occur in the setting of low pain scores and in the absence of swollen or warm joints.
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Affiliation(s)
- Aprajita Jagpal
- Division of Rheumatology, University of Alabama, Birmingham, Birmingham, AL, USA
| | - Elizabeth J Rahn
- Division of Rheumatology, University of Alabama, Birmingham, Birmingham, AL, USA
| | - Amy S Mudano
- Division of Rheumatology, University of Alabama, Birmingham, Birmingham, AL, USA
| | - Nicola Dalbeth
- Department of Rheumatology, University of Auckland, Auckland, New Zealand
| | - William Taylor
- Department of Rheumatology, University of Otago, Wellington, New Zealand
| | - Kenneth G Saag
- Division of Rheumatology, University of Alabama, Birmingham, Birmingham, AL, USA
| | - Jasvinder A Singh
- Division of Rheumatology, University of Alabama, Birmingham, Birmingham, AL, USA
- Division of Rheumatology, Birmingham VA Medical Center, Birmingham, AL, USA
| | - Lorenzo Cavagna
- Department of Rheumatology, University and IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
| | - Till Uhlig
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Fernando Perez-Ruiz
- Division of Rheumatology, Osakidetza, OSI-EEC, Cruces University Hospital, Rheumatology Division, Biskay, Spain
| | - Geraldine McCarthy
- Department of Medicine, University College Dublin and Consultant Rheumatologist, Mater Misericordiae University Hospital Dublin, Ireland
| | | | - Lisa Stamp
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | | | - Chingtsai Lin
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung, Taiwan
| | | | | | - Tuhina Neogi
- Division of Rheumatology, Boston University School of Medicine, Boston, MA, USA
| | - Yi-Hsing Chen
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung, Taiwan
| | | | - Angelo Gaffo
- Division of Rheumatology, University of Alabama, Birmingham, Birmingham, AL, USA
- Division of Rheumatology, Birmingham VA Medical Center, Birmingham, AL, USA
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25
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Ebstein E, Forien M, Norkuviene E, Richette P, Mouterde G, Daien C, Ea HK, Brière C, Lioté F, Petraitis M, Bardin T, Ora J, Dieudé P, Ottaviani S. UltraSound evaluation in follow-up of urate-lowering therapy in gout phase 2 (USEFUL-2): Duration of flare prophylaxis. Joint Bone Spine 2020; 87:647-651. [PMID: 32979555 DOI: 10.1016/j.jbspin.2020.09.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2019] [Indexed: 01/22/2023]
Abstract
OBJECTIVES To determine whether changes in ultrasonography (US) features of monosodium urate crystal deposition is associated with the number of gouty flares after stopping gout flare prophylaxis. METHODS We performed a 1-year multicentre prospective study including patients with proven gout and US features of gout. The first phase of the study was a 6-month US follow-up after starting urate-lowering therapy (ULT) with gout flare prophylaxis. After 6 months of ULT, gout flare prophylaxis was stopped, followed by a clinical follow-up (M6 to 12) and ULT was maintained. Outcomes were the proportion of relapsing patients between M6 and M12 according to changes of US features of gout and determining a threshold decrease in tophus size according to the probability of relapse. RESULTS We included 79 gouty patients [mean (±SD) age 61.8±14 years, 91% males, median disease duration 4 (IQR 1.5;10) years]. Among the 49 completers at M12, 23 (47%) experienced relapse. Decrease in tophus size ≥50% at M6 was more frequent without than with relapse (54% vs. 26%, P=0.049). On ROC curve analysis, a threshold decrease of 50.8% in tophus size had the best sensitivity/specificity ratio to predict relapse [AUC 0.649 (95% confidence interval 0.488; 0.809)]. Probability of relapse was increased for patients with a decrease in tophus size <50% between M0 and M6 [OR 3.35 (95% confidence interval 0.98; 11.44)]. CONCLUSION A high reduction in US tophus size is associated with lower probability of relapse after stopping gout prophylaxis. US follow-up may be useful for managing ULT and gout flare prophylaxis.
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Affiliation(s)
- Esther Ebstein
- Rheumatology Department, DHU FIRE, Pôle infection immunité, Bichat Hospital (AP-HP), 75018 Paris, France
| | - Marine Forien
- Rheumatology Department, DHU FIRE, Pôle infection immunité, Bichat Hospital (AP-HP), 75018 Paris, France
| | - Eleonora Norkuviene
- Rheumatology Department, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Pascal Richette
- Rheumatology Department, centre Viggo Petersen, pole appareil locomoteur, Lariboisière Hospital (AP-HP); Inserm UMR 1132, USPC, 75010 Paris, France
| | - Gaël Mouterde
- Rheumatology Department, Lapeyronie hospital, EA 2415, Montpellier University, 34090 Montpellier, France
| | - Claire Daien
- Rheumatology Department, Lapeyronie hospital, EA 2415, Montpellier University, 34090 Montpellier, France
| | - Hang-Korng Ea
- Rheumatology Department, centre Viggo Petersen, pole appareil locomoteur, Lariboisière Hospital (AP-HP); Inserm UMR 1132, USPC, 75010 Paris, France
| | - Claire Brière
- Rheumatology Department, centre Viggo Petersen, pole appareil locomoteur, Lariboisière Hospital (AP-HP); Inserm UMR 1132, USPC, 75010 Paris, France
| | - Frédéric Lioté
- Rheumatology Department, centre Viggo Petersen, pole appareil locomoteur, Lariboisière Hospital (AP-HP); Inserm UMR 1132, USPC, 75010 Paris, France
| | - Mykolas Petraitis
- Rheumatology Department, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Thomas Bardin
- Rheumatology Department, centre Viggo Petersen, pole appareil locomoteur, Lariboisière Hospital (AP-HP); Inserm UMR 1132, USPC, 75010 Paris, France
| | - Jérémy Ora
- Rheumatology Department, centre Viggo Petersen, pole appareil locomoteur, Lariboisière Hospital (AP-HP); Inserm UMR 1132, USPC, 75010 Paris, France
| | - Philippe Dieudé
- Rheumatology Department, DHU FIRE, Pôle infection immunité, Bichat Hospital (AP-HP), 75018 Paris, France
| | - Sébastien Ottaviani
- Rheumatology Department, DHU FIRE, Pôle infection immunité, Bichat Hospital (AP-HP), 75018 Paris, France.
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Botson JK, Tesser JRP, Bennett R, Kenney HM, Peloso PM, Obermeyer K, LaMoreaux B, Weinblatt ME, Peterson J. Pegloticase in Combination With Methotrexate in Patients With Uncontrolled Gout: A Multicenter, Open-label Study (MIRROR). J Rheumatol 2020; 48:767-774. [PMID: 32934137 DOI: 10.3899/jrheum.200460] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To examine the efficacy and safety of pegloticase in combination with methotrexate (MTX) in patients with uncontrolled gout in an exploratory, open-label clinical trial (ClinicalTrials.gov: NCT03635957) prior to a randomized, controlled trial. METHODS A multicenter, open-label efficacy and safety study of pegloticase with MTX co-treatment was conducted in patients with uncontrolled gout. Patients were administered oral MTX (15 mg/week) and folic acid (1 mg/day) 4 weeks prior to and throughout pegloticase treatment. The primary study outcome was the proportion of responders, defined as serum uric acid (sUA) < 6 mg/dL for ≥ 80% of the time during Month 6 (Weeks 20, 22, and 24). All analyses were performed on a modified intent-to-treat population, defined as patients who received ≥ 1 pegloticase infusion. RESULTS Seventeen patients were screened and 14 patients (all men, average age 49.3 ± 8.7 years) were enrolled. On Day 1, mean sUA was 9.2 ± 2.5 mg/dL, and 12 of the 14 patients had visible tophi. At the 6-month timepoint, 11/14 (78.6%, 95% CI 49.2-95.3%) met the responder definition, with 3 patients discontinuing after meeting protocol-defined treatment discontinuation rules (preinfusion sUA values > 6 mg/dL at 2 consecutive scheduled visits). All patients tolerated MTX. No new safety concerns were identified. CONCLUSION In this study, an increased proportion of patients maintained therapeutic response at 6 months when treated concomitantly with MTX and pegloticase as compared to the previously reported 42% using pegloticase alone. These results support the need for a randomized study of MTX or placebo with pegloticase to validate these open-label findings.
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Affiliation(s)
- John K Botson
- J.K. Botson, MD, RPh, Orthopedic Physicians Alaska, Anchorage, Alaska;
| | - John R P Tesser
- J.R. Tesser, MD, R. Bennett, MD, Arizona Arthritis & Rheumatology Associates, P.C., Phoenix, Arizona
| | - Ralph Bennett
- J.R. Tesser, MD, R. Bennett, MD, Arizona Arthritis & Rheumatology Associates, P.C., Phoenix, Arizona
| | - Howard M Kenney
- H.M. Kenney, MD, Arthritis Northwest, PLLC, Spokane, Washington
| | - Paul M Peloso
- P.M. Peloso, MD, MSc, K. Obermeyer, MS, B. LaMoreaux, MD, MS, Horizon Therapeutics, Lake Forest, Illinois
| | - Katie Obermeyer
- P.M. Peloso, MD, MSc, K. Obermeyer, MS, B. LaMoreaux, MD, MS, Horizon Therapeutics, Lake Forest, Illinois
| | - Brian LaMoreaux
- P.M. Peloso, MD, MSc, K. Obermeyer, MS, B. LaMoreaux, MD, MS, Horizon Therapeutics, Lake Forest, Illinois
| | | | - Jeff Peterson
- J. Peterson, MD, Western Washington Arthritis Clinic, Bothell, Washington, USA
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Singh JA, Green C, Morgan S, Willig AL, Darnell B, Saag KG, Weiss R, Cutter G, McGwin G. A Randomized Internet-Based Pilot Feasibility and Planning Study of Cherry Extract and Diet Modification in Gout. J Clin Rheumatol 2020; 26:147-156. [PMID: 32453288 PMCID: PMC8664374 DOI: 10.1097/rhu.0000000000001004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE The aim of this study was to conduct a 9-month pilot Internet randomized controlled trial (RCT) of cherry extract and diet modification in gout to assess the feasibility of an Internet study and obtain effect estimates. METHODS After providing online informed consent in response to Internet advertisements and social media or clinic flyers, 84 people with physician-confirmed gout were randomized to either cherry extract 3,600 mg/d (n = 41) or dietitian-assisted diet modification for gout (n = 43). All study outcomes were collected via Internet and phone calls. The primary objective was the feasibility of an Internet study, and secondary objectives were to obtain effect estimates for gout flares, functional ability assessed with the Health Assessment Questionnaire (HAQ), and adverse events (AEs) for future trials. RESULTS Of the 84 people randomized, overall completion rates were more than 80% for most study procedures up to 6 months and similar for the 2 active comparators. Improvements were seen in gout flares and HAQ scores in cherry extract and diet modification groups at 9 months compared with baseline: gout flares per month, 0.22 versus 0.36 (p = 0.049) and 0.28 versus 0.31 (p = 0.76); proportion with any gout flare, 56% versus 98% (p < 0.0001) and 65% versus 98% (p = 0.0002); and mean ± standard deviation HAQ score, 0.28 ± 0.54 versus 0.55 ± 0.68 (p = 0.001) and 0.23 ± 0.40 versus 0.48 ± 0.61 (p = 0.06), respectively. Any AEs and gastrointestinal symptoms/AEs at 9 months in cherry extract and diet modification groups were 3% versus 0% and 28% versus 27%, respectively. CONCLUSIONS An Internet gout RCT is feasible for nonpharmacological gout treatments. A hypothesis-testing, large Internet RCT of cherry extract versus placebo is needed.
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Affiliation(s)
- Jasvinder A Singh
- From the Medicine Service, VA Medical Center, Birmingham, AL
- Division of Clinical Immunology and Rheumatology
- Department of Epidemiology, School of Public Health
| | | | - Sarah Morgan
- Division of Clinical Immunology and Rheumatology
| | - Amanda L Willig
- Division of Infectious Diseases, Department of Medicine at School of Medicine
| | | | | | | | - Gary Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL
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How flare prevention outcomes are reported in gout studies: A systematic review and content analysis of randomized controlled trials. Semin Arthritis Rheum 2020; 50:303-313. [DOI: 10.1016/j.semarthrit.2019.11.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 11/01/2019] [Indexed: 01/09/2023]
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Pei L, Xie L, Wu J, Zhang H, Zhang X. Study on the relationship between FFA and gout flare. Clin Rheumatol 2020; 39:1251-1255. [DOI: 10.1007/s10067-019-04903-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 12/10/2019] [Accepted: 12/19/2019] [Indexed: 11/29/2022]
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Sharma E, Pedersen B, Terkeltaub R. Patients Prescribed Anakinra for Acute Gout Have Baseline Increased Burden of Hyperuricemia, Tophi, and Comorbidities, and Ultimate All-Cause Mortality. CLINICAL MEDICINE INSIGHTS-ARTHRITIS AND MUSCULOSKELETAL DISORDERS 2019; 12:1179544119890853. [PMID: 31839715 PMCID: PMC6902385 DOI: 10.1177/1179544119890853] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 11/01/2019] [Indexed: 12/22/2022]
Abstract
Objective: The interleukin-1 (IL-1) receptor antagonist anakinra is an effective, off-label option in acute gout flares, when conventional therapy options are narrowed. We performed a retrospective, randomized, case-controlled study to gain clinical insight on baseline factors for gout patients most likely to receive anakinra, and ultimate mortality of those who received anakinra. Methods: Of 1451 gout patients seen between January 2003 and January 2015 in a Veterans Affairs (VA) rheumatology group practice, under stringent managed care principles, 13 (100% male), who received anakinra at least once for flares, were compared with 1:4 age- and sex-matched gout controls. Each patient’s first rheumatology encounter was studied by factor analysis for variables associated with later anakinra. Results: At baseline, patients that received anakinra had higher urate burden (palpable tophi [10/13] vs controls [16/52], P = .003), serum urate ([10.6 mg/dL] vs controls [7.6 mg/dL], P < .0001), and East Asian descent ([7/13] vs [16/52], P = .041). The anakinra group had higher ultimate all-cause mortality ([6/13] vs controls [7/52], relative risk [RR] = 3.43, 95% confidence interval [CI] = 1.39-8.48, P = .0076). Factor analysis showed baseline visit palpable tophus and statin use to be most strongly associated with later anakinra use. Increased mortality of anakinra users, as per a factorial analysis, was linked more strongly to comorbidities than to anakinra. Conclusions: At baseline rheumatology gout encounter, higher urate, palpable tophi, statin prescription, and East Asian descent were associated with later anakinra use for flares. Mortality was more closely associated to the presence of comorbidities at baseline rheumatology visit than to anakinra prescription.
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Affiliation(s)
- Ena Sharma
- Department of Medicine, San Diego Veterans Affairs Healthcare System, San Diego, CA, USA.,Division of Rheumatology, Allergy & Immunology, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Brian Pedersen
- Department of Medicine, San Diego Veterans Affairs Healthcare System, San Diego, CA, USA.,Division of Rheumatology, Allergy & Immunology, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Robert Terkeltaub
- Department of Medicine, San Diego Veterans Affairs Healthcare System, San Diego, CA, USA.,Division of Rheumatology, Allergy & Immunology, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
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Howren A, Tsao NW, Choi HK, Shojania K, Kydd A, Friesen R, Avina-Zubieta JA, De Vera MA. eHealth-supported decentralized multi-disciplinary care for gout involving rheumatology, pharmacy, and dietetics: proof-of-concept study. Clin Rheumatol 2019; 39:1241-1249. [PMID: 31720913 DOI: 10.1007/s10067-019-04809-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 09/09/2019] [Accepted: 10/07/2019] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To conduct quantitative and qualitative evaluation of an electronic health (eHealth)-supported decentralized multi-disciplinary care model for gout involving rheumatologists, pharmacist, and dietitian. METHODS We conducted a 12-month proof-of-concept study. Gout patients with ≥ 1 flare in the past year and serum urate (SUA) ≥ 360 μmol/L within the previous 2 months were followed by participating community rheumatologists on an as-needed basis, received monthly telephone consults with a pharmacist, and one telephone consult with a dietitian. Healthcare professionals were not co-located but had shared access to the rheumatologists' electronic medical records (EMR) for remote communication and collaboration. In quantitative evaluation, the primary outcome was the proportion of patients with SUA < 360 μmol/L at 12 months. In qualitative evaluation, we conducted semi-structured interviews with a subset of patients and applied constructivist grounded theory to gather patients' perspectives. RESULTS Overall, 35 gout patients (86% males, mean age 60.9 ± 14.9 years) participated. At 12 months, 72% of patients achieved target SUA < 360 μmol/L. Qualitative analysis of interviews with a subset of 12 patients resulted in two themes: (1) experiences with receiving care, including categories of improved knowledge about gout, receiving personalized support, and knowing someone cares, and (2) practical considerations, including categories of optimizing timing of care and coordination and accessibility. CONCLUSION Our multi-method study shows that a decentralized, multi-disciplinary care for gout involving rheumatology, pharmacy, and dietetics with shared EMR access led to gout patients achieving target SUA. It was well-received by patients who perceived better education about gout and personalized care.Key Points• We demonstrated the feasibility and impact of an eHealth-supported, decentralized collaborative care model for gout involving rheumatology, pharmacy, and dietetics• Although prior multi-disciplinary models of care for gout have been reported, the novelty of our model is that healthcare providers are not co-located, lending to potential efficiencies and outreach to patients in rural areas.
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Affiliation(s)
- Alyssa Howren
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada.,Arthritis Research Canada, Richmond, BC, Canada.,Collaboration for Outcomes Research and Evaluation, Vancouver, BC, Canada
| | - Nicole W Tsao
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada.,Arthritis Research Canada, Richmond, BC, Canada.,Collaboration for Outcomes Research and Evaluation, Vancouver, BC, Canada
| | - Hyon K Choi
- Arthritis Research Canada, Richmond, BC, Canada.,Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kam Shojania
- Arthritis Research Canada, Richmond, BC, Canada.,Faculty of Medicine, Department of Medicine, Division of Rheumatology, University of British Columbia, Vancouver, BC, Canada
| | - Alison Kydd
- Faculty of Medicine, Department of Medicine, Division of Rheumatology, University of British Columbia, Vancouver, BC, Canada
| | | | - J Antonio Avina-Zubieta
- Arthritis Research Canada, Richmond, BC, Canada.,Faculty of Medicine, Department of Medicine, Division of Rheumatology, University of British Columbia, Vancouver, BC, Canada
| | - Mary A De Vera
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada. .,Arthritis Research Canada, Richmond, BC, Canada. .,Collaboration for Outcomes Research and Evaluation, Vancouver, BC, Canada.
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Teoh N, Gamble GD, Horne A, Taylor WJ, Palmano K, Dalbeth N. The challenges of gout flare reporting: mapping flares during a randomized controlled trial. BMC Rheumatol 2019; 3:27. [PMID: 31334482 PMCID: PMC6615178 DOI: 10.1186/s41927-019-0075-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 06/24/2019] [Indexed: 12/27/2022] Open
Abstract
Background Methods of gout flare reporting in research settings are inconsistent and poorly defined. The aim of this study was to describe patterns of gout flare and assess the concurrent validity of different methods of flare reporting in a gout clinical trial. Methods Daily flare diary entries including self-report of flare and pain scale from a randomised controlled trial of 120 patients with gout were analysed. Detailed pain-by-time plots for each participant were inspected and analysed for different methods of flare reporting for both self-report and the classification tree (CART)-defined flare developed by Gaffo in 2012. Concurrent validity for different methods of flare reporting were analysed. Results Although the single gout flare had a 'typical' average pattern (peak on day 1 and resolution over 14 days), individual pain-by-time plots showed wide variation in pain intensity, duration and frequency of flares. Over the four-month study period, there were 84/120 (70%) participants who experienced at least one self-reported flare that was not a 'typical' flare. The time to first self-reported flare correlated poorly with other measures of gout activity and other methods of flare reporting. The number of days with flare (either self-reported or Gaffo-defined) and the area under the pain-by-time curve correlated most strongly with other measures of disease severity. Conclusion There is wide variation in the patterns of flare over time in individuals with gout, leading to challenges for flare reporting in clinical trials. Time-dependent reporting strategies such as number of days with flare or area under the pain-by-time curve correlate well with other measures of gout disease severity and may provide a more accurate measure of flare burden. Trial registration Clinical trial number: ACTRN12609000479202, registered 17/06/2009.
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Affiliation(s)
- Novell Teoh
- 1Faculty of Medical and Health Sciences, University of Auckland, 85 Park Rd, Grafton, Auckland, New Zealand
| | - Gregory D Gamble
- 2Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Rd, Grafton, Auckland, New Zealand
| | - Anne Horne
- 2Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Rd, Grafton, Auckland, New Zealand
| | - William J Taylor
- 3Department of Medicine, University of Otago Wellington, Wellington, New Zealand
| | | | - Nicola Dalbeth
- 2Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Rd, Grafton, Auckland, New Zealand
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Costa N, Ferreira ML, Setchell J, Makovey J, Dekroo T, Downie A, Diwan A, Koes B, Natvig B, Vicenzino B, Hunter D, Roseen EJ, Rasmussen-Barr E, Guillemin F, Hartvigsen J, Bennell K, Costa L, Macedo L, Pinheiro M, Underwood M, Van Tulder M, Johansson M, Enthoven P, Kent P, O'Sullivan P, Suri P, Genevay S, Hodges PW. A Definition of "Flare" in Low Back Pain: A Multiphase Process Involving Perspectives of Individuals With Low Back Pain and Expert Consensus. THE JOURNAL OF PAIN 2019; 20:1267-1275. [PMID: 30904517 DOI: 10.1016/j.jpain.2019.03.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 02/25/2019] [Accepted: 03/16/2019] [Indexed: 11/19/2022]
Abstract
Low back pain (LBP) varies over time. Consumers, clinicians, and researchers use various terms to describe LBP fluctuations, such as episodes, recurrences and flares. Although "flare" is use commonly, there is no consensus on how it is defined. This study aimed to obtain consensus for a LBP flare definition using a mixed-method approach. Step 1 involved the derivation of a preliminary candidate flare definition based on thematic analysis of views of 130 consumers in consultation with an expert consumer writer. In step 2, a workshop was conducted to incorporate perspectives of 19 LBP experts into the preliminary flare definition, which resulted in 2 alternative LBP flare definitions. Step 3 refined the definition using a 2-round Delphi consensus with 50 experts in musculoskeletal conditions. The definition favored by experts was further tested with 16 individuals with LBP in step 4, using the definition in three scenarios. This multiphase study produced a definition of LBP flare that distinguishes it from other LBP fluctuations, represents consumers' views, involves expert consensus, and is understandable by consumers in clinical and research contexts: "A flare-up is a worsening of your condition that lasts from hours to weeks that is difficult to tolerate and generally impacts your usual activities and/or emotions." Perspective: A multiphase process, incorporating consumers' views and expert consensus, produced a definition of LBP flare that distinguishes it from other LBP fluctuations.
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Affiliation(s)
- Nathalia Costa
- The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Queensland, Australia
| | - Manuela L Ferreira
- The University of Sydney, Institute of Bone and Joint Research, The Kolling Institute, Sydney Medical School, Sydney, Australia
| | - Jenny Setchell
- The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Queensland, Australia
| | - Joanna Makovey
- The University of Sydney, Institute of Bone and Joint Research, The Kolling Institute, Sydney Medical School, Sydney, Australia
| | - Tanya Dekroo
- The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Queensland, Australia
| | - Aron Downie
- Musculoskeletal Health Sydney, University of Sydney, Sydney, Australia; Department of Chiropractic, Macquarie University, Sydney, Australia
| | - Ashish Diwan
- Spine Service, Department of Orthopaedic Surgery, St. George & Sutherland Clinical School, University of New South Wales Australia, Kogarah, Sydney, Australia
| | - Bart Koes
- Department of General Practice, Erasmus MC, Rotterdam, the Netherlands; Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark
| | - Bard Natvig
- Institute for Health and Society, Department of General Practice, University of Oslo, Oslo, Norway
| | - Bill Vicenzino
- The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Queensland, Australia
| | - David Hunter
- The University of Sydney, Institute of Bone and Joint Research, The Kolling Institute, Sydney Medical School, Sydney, Australia; Department of Rheumatology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Eric J Roseen
- Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Eva Rasmussen-Barr
- Karolinska Institute, Department of Neurobiology, Care Sciences and Society, Division of Physiotherapy, Stockholm, Sweden
| | - Francis Guillemin
- Universite de Lorraine, CHRU Nancy, Inserm, CIC1433-Epidemiologie Clinique, Nancy, France
| | - Jan Hartvigsen
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark; Nordic Institute of Chiropractic and Clinical Biomechanics, Odense, Denmark
| | - Kim Bennell
- Centre for Health, Exercise and Sports Medicine, Department of Physiotherapy, School of Health Sciences, Melbourne, The University of Melbourne, Victoria, Australia
| | - Leonardo Costa
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, São Paulo, Brazil
| | - Luciana Macedo
- McMaster University School of Rehabilitation Science Hamilton, Ontario, Canada
| | - Marina Pinheiro
- Faculty of Health Sciences, The University of Sydney, Sydney, Australia
| | - Martin Underwood
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Mauritus Van Tulder
- Department of Health Sciences, Faculty of Science, Vrije Universiteit, Amsterdam Movement Science research institute, Amsterdam, the Netherlands
| | - Melker Johansson
- Warwick Medical School, University of Warwick, Coventry, United Kingdom; Musculoskeletal Disorders and Physical Workload, National Research Centre for the Working Environment, Copenhagen, Denmark
| | - Paul Enthoven
- Department of Medical and Health Sciences, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | - Peter Kent
- Department of Physiotherapy and Exercise Science, Curtin University, Perth, Australia
| | - Peter O'Sullivan
- Department of Physiotherapy and Exercise Science, Curtin University, Perth, Australia
| | - Pradeep Suri
- Seattle Epidemiologic Research and Information Center (ERIC) and Division of Rehabilitation Care Services, VA Puget Sound Health Care System, Seattle, Washington; Department of Rehabilitation Medicine, University of Washington, Seattle, Washington; New England Baptist Hospital, Boston, Massachusetts; Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
| | - Stephane Genevay
- Division of Rheumatology, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Paul W Hodges
- The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Queensland, Australia.
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Dalbeth N, Choi HK, Terkeltaub R. Review: Gout: A Roadmap to Approaches for Improving Global Outcomes. Arthritis Rheumatol 2019; 69:22-34. [PMID: 27389665 DOI: 10.1002/art.39799] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 06/21/2016] [Indexed: 12/30/2022]
Affiliation(s)
| | - Hyon K Choi
- Massachusetts General Hospital and Harvard Medical School, Boston
| | - Robert Terkeltaub
- VA San Diego Healthcare System and University of California, San Diego
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35
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Costa N, Ferreira ML, Cross M, Makovey J, Hodges PW. How is symptom flare defined in musculoskeletal conditions: A systematic review. Semin Arthritis Rheum 2018; 48:302-317. [DOI: 10.1016/j.semarthrit.2018.01.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Revised: 01/19/2018] [Accepted: 01/24/2018] [Indexed: 01/10/2023]
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Stamp L, Morillon MB, Taylor WJ, Dalbeth N, Singh JA, Lassere M, Christensen R. Serum urate as surrogate endpoint for flares in people with gout: A systematic review and meta-regression analysis. Semin Arthritis Rheum 2018; 48:293-301. [PMID: 29566967 DOI: 10.1016/j.semarthrit.2018.02.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Revised: 01/17/2018] [Accepted: 02/16/2018] [Indexed: 01/22/2023]
Abstract
OBJECTIVES The primary efficacy outcome in trials of urate lowering therapy (ULT) for gout is serum urate (SU). The aim of this study was to examine the strength of the relationship between SU and patient-important outcomes to determine whether SU is an adequate surrogate endpoint for clinical trials. METHODS Multiple databases through October 2017 were searched. Randomized controlled trials comparing any ULT in people with gout with any control or placebo, ≥three months duration were included. Open label extension (OLE) trial data were included in secondary analyses. Standardized data elements were extracted independently by two reviewers. RESULTS Ten RCTs and 3 OLE studies were identified. From the RCTs (maximum duration 24 months) meta-regression did not reveal an association between the relative risk of a gout flare and the difference in proportions of individuals with SU < 6mg/dL (P = 0.47; R2 = 8%). In a post hoc analysis, the ratio of the time in months at which the proportion of individuals having a flare was reported/time in months at which the proportion of individuals with SU < 6mg/dL was reported was calculated and studies where the ratio was <2 were excluded. Using the remaining 6 studies there was an association between proportion of individuals achieving SU < 6mg/dL and gout flares (over patient years). Duration of ULT was inversely associated with the proportion of patients experiencing a flare. Study duration and variability in reporting of outcomes limited the analysis. Observational studies supported the trend of fewer flares in those with lower SU. CONCLUSIONS Based on aggregate clinical trial-level data an association between SU and gout flare could not be confirmed. However, based on observational ecological study design data-including longer duration extension studies-SU < 6mg/dL was associated with reduced gout flares.
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Affiliation(s)
- Lisa Stamp
- Department of Medicine, University of Otago, Christchurch, P.O. Box 4345, Christchurch, New Zealand.
| | - Melanie B Morillon
- Musculoskeletal Statistics Unit, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark; Department of Rheumatology, Odense University Hospital, Denmark; Department of Medicine, Vejle Hospital, Denmark
| | - William J Taylor
- Department of Medicine, University of Otago, Wellington, New Zealand
| | - Nicola Dalbeth
- Department of Medicine, University of Auckland, New Zealand
| | - Jasvinder A Singh
- Department of Medicine, University of Alabama at Birmingham & Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
| | - Marissa Lassere
- Department of Rheumatology, St George Hospital, University of NSW, Sydney, Australia
| | - Robin Christensen
- Musculoskeletal Statistics Unit, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
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Fatima T, McKinney C, Major TJ, Stamp LK, Dalbeth N, Iverson C, Merriman TR, Miner JN. The relationship between ferritin and urate levels and risk of gout. Arthritis Res Ther 2018; 20:179. [PMID: 30111358 PMCID: PMC6094576 DOI: 10.1186/s13075-018-1668-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Accepted: 07/12/2018] [Indexed: 01/11/2023] Open
Abstract
Background Ferritin positively associates with serum urate and an interventional study suggests that iron has a role in triggering gout flares. The objective of this study was to further explore the relationship between iron/ferritin and urate/gout. Methods European (100 cases, 60 controls) and Polynesian (100 cases, 60 controls) New Zealand (NZ) males and 189 US male cases and 60 male controls participated. The 10,727 participants without gout were from the Jackson Heart (JHS; African American = 1260) and NHANES III (European = 5112; African American = 4355) studies. Regression analyses were adjusted for age, sex, body mass index and C-reactive protein. To test for a causal relationship between ferritin and urate, bidirectional two-sample Mendelian randomization analysis was performed. Results Serum ferritin positively associated with gout in NZ Polynesian (OR (per 10 ng ml− 1 increase) = 1.03, p = 1.8E–03) and US (OR = 1.11, p = 7.4E–06) data sets but not in NZ European (OR = 1.00, p = 0.84) data sets. Ferritin positively associated with urate in NZ Polynesian (β (mg dl− 1) = 0.014, p = 2.5E–04), JHS (β = 0.009, p = 3.2E–05) and NHANES III (European β = 0.007, p = 5.1E–11; African American β = 0.011, p = 2.1E–16) data sets but not in NZ European (β = 0.009, p = 0.31) or US (β = 0.041, p = 0.15) gout data sets. Ferritin positively associated with the frequency of gout flares in two of the gout data sets. By Mendelian randomization analysis a one standard deviation unit increase in iron and ferritin was, respectively, associated with 0.11 (p = 8E–04) and 0.19 mg dl− 1 (p = 2E–04) increases in serum urate. There was no evidence for a causal effect of urate on iron/ferritin. Conclusions These data replicate the association of ferritin with serum urate. Increased ferritin levels associated with gout and flare frequency. There was evidence of a causal effect of iron and ferritin on urate. Electronic supplementary material The online version of this article (10.1186/s13075-018-1668-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tahzeeb Fatima
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
| | - Cushla McKinney
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
| | - Tanya J Major
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
| | - Lisa K Stamp
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Nicola Dalbeth
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Cory Iverson
- Medical Scientific Affairs, Ironwood Pharmaceuticals, Cambridge, MA, USA
| | - Tony R Merriman
- Department of Biochemistry, University of Otago, Dunedin, New Zealand.
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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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Timilsina S, Brittan K, O'Dell JR, Brophy M, Davis-Karim A, Henrie AM, Neogi T, Newcomb J, Palevsky PM, Pillinger MH, Pittman D, Taylor TH, Wu H, Mikuls TR. Design and Rationale for the Veterans Affairs "Cooperative Study Program 594 Comparative Effectiveness in Gout: Allopurinol vs. Febuxostat" Trial. Contemp Clin Trials 2018; 68:102-108. [PMID: 29597007 DOI: 10.1016/j.cct.2018.03.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 03/21/2018] [Accepted: 03/22/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Gout patients do not routinely achieve optimal outcomes related in part to suboptimal administration of urate lowering therapy (ULT) including first-line xanthine oxidase inhibitors allopurinol or febuxostat. Studies leading to the approval of febuxostat compared this agent to allopurinol in inappropriately low, fixed doses. We will compare allopurinol with febuxostat in gout using appropriately titrated doses of both agents and a "treat-to-target" strategy congruent with specialty guidelines. METHODS We have planned and initiated the Veterans Affairs (VA) Cooperative Study Program (CSP) 594, Comparative Effectiveness in Gout: Allopurinol vs Febuxostat study. This large double-blind, non-inferiority trial will enroll 950 gout patients randomized to receive allopurinol or febuxostat. Patients will be followed for a total of 72 weeks encompassing 3 distinct 24-week study phases. During Phase I (0-24 weeks), participants will undergo gradual dose titration of ULT until achievement of serum uric acid (sUA) <6.0 mg/dL or <5.0 mg/dL if tophi are present. Dose escalation will not be allowed during final three study visits of Phase 2 (24-48 weeks) and during Phase 3 (48-72 weeks). The primary study outcome is the proportion of participants experiencing at least one gout flare during Phase 3. Subsequent to the 72-week study, participants will be followed passively for up to 10 years after the study to assess long-term health outcomes. CONCLUSION With its completion, the VA Comparative Effectiveness in Gout: Allopurinol vs Febuxostat study will demonstrate the central role of gradual ULT dose escalation and a treat-to-target strategy in gout management.
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Affiliation(s)
- S Timilsina
- VA Nebraska-Western Iowa Health Care System, Omaha, NE, United States; University of Nebraska Medical Center, Omaha, NE, United States
| | - K Brittan
- VA Nebraska-Western Iowa Health Care System, Omaha, NE, United States; University of Nebraska Medical Center, Omaha, NE, United States
| | - J R O'Dell
- VA Nebraska-Western Iowa Health Care System, Omaha, NE, United States; University of Nebraska Medical Center, Omaha, NE, United States
| | - M Brophy
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), Cooperative Study Program Coordinating Center, Boston, MA, United States
| | - A Davis-Karim
- VA Cooperative Study Program, Clinical Research Pharmacy Coordinating Center, Albuquerque, NM, United States
| | - A M Henrie
- VA Cooperative Study Program, Clinical Research Pharmacy Coordinating Center, Albuquerque, NM, United States
| | - T Neogi
- Boston University School of Medicine, Boston, MA, United States
| | - J Newcomb
- VA Nebraska-Western Iowa Health Care System, Omaha, NE, United States; University of Nebraska Medical Center, Omaha, NE, United States
| | - P M Palevsky
- VA Pittsburgh Healthcare System, Pittsburgh, PA, United States
| | - M H Pillinger
- New York University Langone Medical Center, New York, NY, United States
| | - D Pittman
- VA Cooperative Study Program, Clinical Research Pharmacy Coordinating Center, Albuquerque, NM, United States
| | - T H Taylor
- White River Junction VA Hospital, White River Junction, VT, United States
| | - H Wu
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), Cooperative Study Program Coordinating Center, Boston, MA, United States
| | - T R Mikuls
- VA Nebraska-Western Iowa Health Care System, Omaha, NE, United States; University of Nebraska Medical Center, Omaha, NE, United States.
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Gaffo AL, Dalbeth N, Saag KG, Singh JA, Rahn EJ, Mudano AS, Chen YH, Lin CT, Bourke S, Louthrenoo W, Vazquez-Mellado J, Hernández-Llinas H, Neogi T, Vargas-Santos AB, da Rocha Castelar-Pinheiro G, Amorim RBC, Uhlig T, Hammer HB, Eliseev M, Perez-Ruiz F, Cavagna L, McCarthy GM, Stamp LK, Gerritsen M, Fana V, Sivera F, Taylor W. Brief Report: Validation of a Definition of Flare in Patients With Established Gout. Arthritis Rheumatol 2018; 70:462-467. [DOI: 10.1002/art.40381] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 11/14/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Angelo L. Gaffo
- University of Alabama at Birmingham and Birmingham VA Medical Center; Birmingham Alabama
| | | | | | - Jasvinder A. Singh
- University of Alabama at Birmingham and Birmingham VA Medical Center; Birmingham Alabama
| | | | | | | | | | | | | | | | | | - Tuhina Neogi
- Boston University School of Medicine; Boston Massachusetts
| | - Ana Beatriz Vargas-Santos
- Boston University School of Medicine, Boston, Massachusetts; and Universidade do Estado do Rio de Janeiro; Rio de Janeiro Brazil
| | | | | | | | | | - Maxim Eliseev
- Research Institute of Rheumatology of Russia; Moscow Russia
| | - Fernando Perez-Ruiz
- University of the Basque Country; Cruces University Hospital, and Biocruces Health Research Institute; Vizcaya Spain
| | - Lorenzo Cavagna
- University and IRCCS Policlinico S. Matteo Foundation; Pavia Italy
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Stamp LK, Morillon MB, Taylor WJ, Dalbeth N, Singh JA, Lassere M, Christensen R. Variability in the Reporting of Serum Urate and Flares in Gout Clinical Trials: Need for Minimum Reporting Requirements. J Rheumatol 2017; 45:419-424. [DOI: 10.3899/jrheum.170911] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2017] [Indexed: 01/18/2023]
Abstract
Objective.To describe the ways in which serum urate (SU) and gout flares are reported in clinical trials, and to propose minimum reporting requirements.Methods.This analysis was done as part of a systematic review aiming to validate SU as a biomarker for gout. The ways in which SU and flares were reported were extracted from each study by 2 reviewers.Results.A total of 22 studies (10 randomized controlled trials, 3 open-label extension studies, and 9 observational studies) were identified. There were 3 broad categories of SU reporting: percentage at target SU, mean SU, and change in SU. A median of 2 (range 1–3) categories were reported across all studies. The most common method of reporting SU was percentage at target in 17/22 (77.3%) studies, with all studies reporting a target of SU < 6 mg/dl. There were 12/22 (54.5%) studies reporting mean SU at some time after study entry, with 7 (58.3%) of these reporting at more than just the final study visit. Two ways of reporting gout flares were identified: mean flare rate and percentage of participants with flares. There was variability in time periods over which flares rates were reported.Conclusion.There is inconsistent reporting of SU and flares in gout studies. Reporting the percentage of participants who achieve a target SU reflects international treatment guidelines. SU should also be reported as a continuous variable with a relevant central and dispersion estimate. Gout flares should be reported as both percentage of participants and mean flare rates at each timepoint.
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Yamanaka H, Tamaki S, Ide Y, Kim H, Inoue K, Sugimoto M, Hidaka Y, Taniguchi A, Fujimori S, Yamamoto T. Stepwise dose increase of febuxostat is comparable with colchicine prophylaxis for the prevention of gout flares during the initial phase of urate-lowering therapy: results from FORTUNE-1, a prospective, multicentre randomised study. Ann Rheum Dis 2017; 77:270-276. [PMID: 29102957 PMCID: PMC5867413 DOI: 10.1136/annrheumdis-2017-211574] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 10/02/2017] [Accepted: 10/22/2017] [Indexed: 11/05/2022]
Abstract
Objectives To determine whether febuxostat with stepwise dose increase is as useful as colchicine prophylaxis in reducing gout flares during the initial introduction of urate-lowering therapy in patients with gout in comparison with febuxostat with no dose titration. Methods In this prospective, multicentre, randomised open-label comparative study, patients were randomised to group A (stepwise dose increase of febuxostat from 10 to 40 mg/day), group B (fixed-dose febuxostat 40 mg/day plus colchicine 0.5 mg/day) or group C (fixed-dose febuxostat 40 mg/day) and observed for 12 weeks. Gout flare was defined as non-steroidal anti-inflammatory drug use for gout symptoms. Results A total of 255 patients were randomised, and 241 patients were treated. Among the treated patients, gout flares were experienced by 20/96 (20.8%) in group A, 18/95 (18.9%) in group B and 18/50 (36.0%) in group C. The incidence of flare was significantly lower in groups A and B than that in group C (P=0.047 and P=0.024, respectively), although the differences were not significant after correction for multiple comparisons. No significant difference was noted between the incidence of gout flare in groups A and B. Conclusions Our data suggested that stepwise dose increase of febuxostat and low-dose colchicine prophylaxis effectively reduced gout flares in comparison with fixed-dose febuxostat alone. Stepwise dose increase of febuxostat may be an effective alternative to low-dose colchicine prophylaxis during the introduction of urate-lowering therapy. Trial registration number UMIN 000008414.
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Affiliation(s)
- Hisashi Yamanaka
- Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | | | | | | | | | - Masayuki Sugimoto
- Shoi-kai Medical Association, Koganeibashi Sakura Clinic, Tokyo, Japan
| | - Yuji Hidaka
- Taizan-kai Medical Association, Akasaka Central Clinic, Tokyo, Japan
| | - Atsuo Taniguchi
- Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | | | - Tetsuya Yamamoto
- Department of Diabetes, Endocrinology and Metabolism, Hyogo College of Medicine, Hyogo, Japan
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Setchell J, Costa N, Ferreira M, Makovey J, Nielsen M, Hodges PW. What constitutes back pain flare? A cross sectional survey of individuals with low back pain. Scand J Pain 2017; 17:294-301. [PMID: 28866119 DOI: 10.1016/j.sjpain.2017.08.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 07/27/2017] [Accepted: 08/01/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND PURPOSE Low back pain (LBP) is a lifelong problem for many. In acute episodes, or as a persistent condition, LBP is fluctuating in nature, with pain and other features of the condition varying in intensity and duration over time. Symptom flares (also known as flare ups) contribute to this variation and can have a great impact on the lives of those who have LBP. An important goal of treatments for, and research on, LBP is arguably to decrease symptom flare in both frequency and severity. However, this goal is problematic with little research, and no consensus, on how to define LBP flare. In particular, patients' understandings of LBP flare have received limited attention in the literature. To appropriately address this issue, we sought to understand how flares are conceptualized by individuals with LBP. METHODS We used an inductive, predominantly qualitative methodology, conducting an online survey with 130 individuals who self-reported experiencing LBP. The survey investigated participants' views on LBP flare including its meaning, features and symptoms, and whether 'flare' and 'pain increase' were synonymous. Qualitative analysis of responses involved thematic and content analysis with descriptive statistics used for the quantitative component. RESULTS Our data analysis found that participants identified many aspects of a flare to be important. Qualitative analyses highlighted a number of themes including that LBP flare was conceptualized as: (1) an increase in pain and other uncomfortable sensations such as paraesthesia or muscle tension, (2) an increase in the area, quality and/or duration of symptoms, (3) a reduction in physical, cognitive and/or social functioning, and (4) negative psychological and/or emotional factors. Flare was also discussed as a change that was difficult to settle. When participants considered whether 'flare' and 'pain increase' were synonymous, responses were evenly divided between 'no' (47%) and 'yes' (46%) with remaining participants 'unsure'. CONCLUSIONS The key finding was that many people with LBP do not consider their condition to be flared simply on the basis of a pain increase. In general, other features were required to also change. Results highlighted that a narrow focus on pain is unlikely to differentiate minor pain events from a flare. These findings are important as they contrast with most commonly used definitions of a flare that focus predominantly on pain increase. IMPLICATIONS Our findings have implications for understanding the trajectory of LBP over time. Understandings derived from perspectives of individuals with LBP highlight that defining flare in LBP is complex. In order to provide person-centred care, individual context and experiences should be taken into account. Therefore, understandings of LBP flare require consideration of factors beyond simply an increase in pain. A comprehensive, person-centred understanding of flare that includes a number of features beyond simply an increase in pain intensity is likely to be useful to better identify flares in research settings, assisting endeavours to understand and reduce LBP. Similarly, in clinical settings a nuanced conceptualisation of flare is likely to help health professionals communicate understandings of flare when working with individuals to manage their LBP.
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Affiliation(s)
- Jenny Setchell
- The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Australia.
| | - Nathalia Costa
- The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Australia
| | - Manuela Ferreira
- The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Australia; Institute of Bone and Joint Research/The Kolling Institute, Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Joanna Makovey
- The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Australia; Institute of Bone and Joint Research/The Kolling Institute, Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Mandy Nielsen
- The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Australia
| | - Paul W Hodges
- The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Australia
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Poiley J, Steinberg AS, Choi YJ, Davis CS, Martin RL, McWherter CA, Boudes PF. A Randomized, Double-Blind, Active- and Placebo-Controlled Efficacy and Safety Study of Arhalofenate for Reducing Flare in Patients With Gout. Arthritis Rheumatol 2017; 68:2027-34. [PMID: 26989892 PMCID: PMC5129473 DOI: 10.1002/art.39684] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Accepted: 03/15/2016] [Indexed: 01/28/2023]
Abstract
Objective Arhalofenate is a novel antiinflammatory uricosuric agent. The objective of this study was to evaluate its antiflare activity in patients with gout. Methods This was a 12‐week, randomized, double‐blind, controlled phase IIb study. Eligible patients had had ≥3 flares of gout during the previous year, had discontinued urate‐lowering therapy and colchicine, and had a serum uric acid (UA) level of 7.5–12 mg/dl. Patients were randomly assigned at a 2:2:2:2:1 ratio to receive 600 mg arhalofenate, 800 mg arhalofenate, 300 mg allopurinol, 300 mg allopurinol plus 0.6 mg colchicine, or placebo once a day. The primary outcome measure was the flare incidence (number of flares divided by time of exposure). The serum UA level was a secondary outcome measure. Results A total of 239 gout patients were randomized and took at least 1 dose of study medication. The primary outcome measure comparing flare incidence between 800 mg arhalofenate and 300 mg allopurinol was achieved, with a 46% decrease in the 800 mg arhalofenate group (0.66 versus 1.24; P = 0.0056). Treatment with 800 mg arhalofenate was also significantly better than placebo (P = 0.049) and not significantly different from treatment with 300 mg allopurinol plus 0.6 mg colchicine (P = 0.091). Mean changes in serum UA level were −12.5% with 600 mg arhalofenate and −16.5% with 800 mg arhalofenate (P = 0.001 and P = 0.0001, respectively, versus −0.9% with placebo). There were no meaningful differences in adverse events (AEs) between groups, and there were no serious AEs related to arhalofenate. Urinary calculus occurred in 1 patient receiving 300 mg allopurinol. No abnormal serum creatinine values >1.5‐fold the baseline value were observed in the arhalofenate‐treated groups. Conclusion Arhalofenate at a dosage of 800 mg decreased gout flares significantly compared to allopurinol at a dosage of 300 mg. Arhalofenate was well tolerated and appeared safe. Arhalofenate is the first urate‐lowering antiflare therapy.
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Yu J, Qiu Q, Liang L, Yang X, Xu H. Prophylaxis of acute flares when initiating febuxostat for chronic gouty arthritis in a real-world clinical setting. Mod Rheumatol 2017; 28:339-344. [PMID: 28485997 DOI: 10.1080/14397595.2017.1318467] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Flare prophylaxis is recommended during urate-lowering therapy (ULT) despite lack of proven benefit especially when initiating febuxostat. We investigated if colchicine or steroids administration during initiation of febuxostat for chronic gouty arthritis reduces the frequency and/or severity of acute gout flares. METHODS Patients with confirmed diagnosis of gout starting febuxostat were retrospectively studied. Frequency, severity, and length of flares were analyzed. Assessment of severity based on a visual analog scale (VAS). RESULTS Two hundred and seventy-three patients were studied. The mean dose of colchicine and steroids was 0.53 ± 0.15 mg PO QD and 7.55 ± 1.30 mg prednisone equivalent PO QD; while the duration was 6.13 ± 1.14 and 6.20 ± 1.36 months, respectively. Subjects treated with colchicine and steroids suffered fewer total flares (0.30, 0.96 vs 2.47, p = .000), fewer flares from 0 to 3 months (0.26, 0.71 vs 1.72, p = .000), less severe flares assessed by VAS than those without prophylactic therapy (3.65, 3.49 vs 5.54, p = .000). Both total flares (p = .003) and flares from 0 to 3 months (p = .008) of the colchicine group were fewer than the steroids group. There were no significant differences in length of flares among groups (p = .815). Both colchicine and steroids were well tolerated. CONCLUSION The use of colchicine or steroids prophylaxis reduces the frequency and severity of acute gout flares during initiation of febuxostat for chronic gouty arthritis. Colchicine is superior to steroids in flares prophylaxis. Prophylactic therapy with colchicine 0.5 mg PO QD or steroids 7.5 mg prednisone equivalent PO QD for 6 months is suggested.
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Affiliation(s)
- Jinquan Yu
- a Department of Rheumatology , The University of Hong Kong-Shenzhen Hospital , Shenzhen , P.R. China.,b Department of Internal Medicine , Distinct HealthCare , Shenzhen , P.R. China
| | - Qian Qiu
- c Department of Rheumatology , The first Affiliated Hospital of Sun Yat-sen University , Guangzhou , P.R. China
| | - Liuqin Liang
- c Department of Rheumatology , The first Affiliated Hospital of Sun Yat-sen University , Guangzhou , P.R. China
| | - Xiuyan Yang
- c Department of Rheumatology , The first Affiliated Hospital of Sun Yat-sen University , Guangzhou , P.R. China
| | - Hanshi Xu
- c Department of Rheumatology , The first Affiliated Hospital of Sun Yat-sen University , Guangzhou , P.R. China
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Abstract
Gout is the most prevalent inflammatory arthritis and affects 2.5% of the general population in the UK. It is also the only arthritis that has the potential to be cured with safe, inexpensive and well tolerated urate-lowering treatments, which reduce serum uric acid by either inhibiting xanthine oxidase - eg allopurinol, febuxostat - or by increasing the renal excretion of uric acid. Of these, xanthine oxidase inhibitors are used first line and are effective in 'curing' gout in the vast majority of patients. Gout can be diagnosed on clinical grounds in those with typical podagra. However, in those with involvement of other joints, joint aspiration is recommended to demonstrate monosodium urate crystals and exclude other causes of acute arthritis, such as septic arthritis. However, a clinical diagnosis of gout can be made if joint aspiration is not feasible. This review summarises the current understanding of the pathophysiology, clinical presentation, investigations and treatment of gout.
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Affiliation(s)
| | - Edward Roddy
- Arthritis Research UK Primary Care Centre, Keele University, Staffordshire, UK
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MacFarlane LA, Liu CC, Solomon DH, Kim SC. Validation of claims-based algorithms for gout flares. Pharmacoepidemiol Drug Saf 2016; 25:820-6. [PMID: 27230083 DOI: 10.1002/pds.4044] [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: 01/12/2016] [Revised: 04/28/2016] [Accepted: 05/09/2016] [Indexed: 12/27/2022]
Abstract
PURPOSE Gout is a common inflammatory arthritis characterized by repeated acute flares. The ability to accurately identify gout flares is critical for comparative effectiveness studies of gout treatments. We developed and examined the accuracy of a claims-based algorithm to identify gout flares. METHODS Patients receiving care at an academic medical center between 2006 and 2010 with a diagnosis of gout or hyperuricemia were selected using an electronic medical record-Medicare claims linked dataset. Gout flares were identified by several claims-based algorithms using a diagnosis of gout combined with gout-related medication claims and/or procedure codes for arthrocentesis or joint injection. We calculated positive predictive value of these algorithms based on physician documentation of gout flare in medical record as the gold standard. Negative predictive value of the gout flare algorithm was calculated in a randomly selected subgroup of 200 patients with gout. RESULTS Among 3952 subjects with gout or hyperuricemia, 503 flares were identified using the medication-based algorithm, and 290 were identified using the procedure-based algorithm. The positive predictive value for gout flares ranged from 50-54% for the medication-based algorithms and 59-68% for the procedure-based algorithms. The negative predictive value of the algorithm combining both medication and procedure claims was high (85.2%). CONCLUSION Use of gout diagnosis codes in combination with medication dispensing or procedure codes did not appear to accurately capture gout flares in patients with gout in a claims database. However, the claims-based flare algorithm could be useful in identifying a cohort of gout patients with no flares. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Lindsey A MacFarlane
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA
| | - Chih-Chin Liu
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA
| | - Daniel H Solomon
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA.,Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, MA, USA
| | - Seoyoung C Kim
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA.,Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, MA, USA
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Significance of the initiation time of urate-lowering therapy in gout patients: A retrospective research. Joint Bone Spine 2015; 82:428-31. [PMID: 26456042 DOI: 10.1016/j.jbspin.2015.02.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Accepted: 02/21/2015] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To evaluate the efficacy and safety of the initiation time of urate-lowering treatments (ULT) in gout patients. METHOD We retrospectively reviewed patients who were diagnosed with gout and were treated with ULT for at least 3 years. They were divided into two groups: group 1: 123 patients initiating ULT during an acute attack of gout; group 2: 457 patients prescribed ULT after an acute attack. Both demographic and clinical characteristics associated with gout were analyzed. RESULTS Comparing patients in group 1 versus group 2: the former exhibited a shorter duration of gout (6.3±2.1 vs. 8.9±3.3 years). At the baseline, there was no significant difference in mean serum urate (SU; 7.8±1.4mg/dL vs. 7.9±1.9mg/dL, respectively). SU target levels (<6.0mg/dL) were achieved by 66.7 and 65.6% of the patients, respectively. The duration from initiation of ULT until the SU target was attained was lower in group 1 than in group 2. During the first 12 weeks, patients on ULT in group 1 had higher attack rates than those in group 2. The incidence of chronic kidney disease increased in percentage in group 1 was lower than in group 2. CONCLUSIONS Our survey revealed that in patients experiencing acute gout, initiation of ULT decreased the time required to reach the target SU and the incidence of CKD, but the attack rate was greater in the first 12 weeks.
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van Tuyl LHD, Boers M. Patient-reported outcomes in core domain sets for rheumatic diseases. Nat Rev Rheumatol 2015; 11:705-12. [PMID: 26324860 DOI: 10.1038/nrrheum.2015.116] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Patient-reported outcomes (PROs) are abundant in rheumatology and their numbers continue to increase. But which of the available measures are most important? Core outcome sets-including groups of domains and instruments for measuring them-have been defined for many rheumatic diseases, with the aim that all these outcomes should be measured in every clinical trial. The subgroup of PROs included in these core sets is, therefore, undoubtedly important. This Review summarizes the PROs included in core outcome sets developed for use in clinical trials across a wide range of rheumatic diseases. Three PROs are commonly utilized across the majority of rheumatic conditions: pain, physical functioning and the patient global assessment of disease activity. However, additional research is needed to fully understand the role of the patient global assessment of disease activity, to distinguish specific domains within the broad concept of health-related quality of life, and to work towards consensus on the choice between generic and disease-specific instruments in various contexts.
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Affiliation(s)
- Lilian H D van Tuyl
- Amsterdam Rheumatology and Immunology Center, VU University Medical Centre, PO Box 7057, Amsterdam, 1007 MB, Netherlands
| | - Maarten Boers
- Amsterdam Rheumatology and Immunology Center, VU University Medical Centre, PO Box 7057, Amsterdam, 1007 MB, Netherlands.,Department of Clinical Epidemiology and Biostatistics, VU University Medical Center, PO Box 7057, Amsterdam, 1007 MB, Netherlands
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Rashid N, Levy GD, Wu YL, Zheng C, Koblick R, Cheetham TC. Patient and clinical characteristics associated with gout flares in an integrated healthcare system. Rheumatol Int 2015; 35:1799-807. [PMID: 25991397 PMCID: PMC4611012 DOI: 10.1007/s00296-015-3284-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 05/07/2015] [Indexed: 11/02/2022]
Abstract
Gout flares have been challenging to identify in retrospective databases due to gout flares not being well documented by diagnosis codes, making it difficult to conduct accurate database studies. Previous studies have used different algorithms, and in this study, we used a computer-based method to identify gout flares. The objectives of this study were to identify gout flares in gout patients newly initiated on urate-lowering therapy and evaluate factors associated with a patient experiencing gout flares after starting drug treatment. This was a retrospective cohort study identifying gout patients newly initiated on a urate-lowering therapy (ULT) during the study time period of January 1, 2007-December 31, 2010. The index date was the first dispensed ULT prescription during the study time period. Patients had to be ≥18 years of age on index date, have no history of prior ULT prescription during 12 months before index date, and were required to have 12 months of continuous membership with drug benefit during pre-/post-index. Electronic chart notes were reviewed to identify gout flares; these reviews helped create a validated computer-based method to further identify patients with gout flares and were categorized into 0 gout flares, 1-2 gout flares, and ≥3 gout flares during the 12 months post-index period. Multivariable logistic regression was used to examine patient and clinical factors associated with gout flares during the 12-month follow-up period. There were 8905 patients identified as the final cohort and 68 % of these patients had one or more gout flares during the 12-month follow-up: 2797 patients (31 %) had 0 gout flares, 4836 (54 %) had 1-2 gout flares, and 1272 patients (14 %) had ≥3 gout flares. Using a multivariate regression analyses, factors independently associated with 1-2 gout flares and ≥3 gout flares versus no gout flares were similar, however, with slight differences, such as younger patients were more likely to have 1-2 gout flares and patients ≥65 years of age had ≥3 gout flares. Factors such as male gender, not attaining sUA goal, having ≥3 comorbidities, diuretics use, no changes in initial ULT dose, and not adhering to ULT all were associated with gout flares versus no gout flares. Using a new method to identify gout flares, we had the opportunity to compare our findings with the previous studies. Our study findings echo other previous studies where older patients, male, diuretics, having a greater number of comorbidities, and non-adherence are more likely to have more gout flares during the first year of newly initiating ULT. There is an unmet need for patients with gout to be educated and managed more closely, especially during the first year.
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Affiliation(s)
- Nazia Rashid
- Drug Information Services, Kaiser Permanente SCAL Region, 12254 Bellflower Blvd, Room 106, 1st Floor, Downey, CA, 90242, USA.
| | - Gerald D Levy
- Southern California Permanente Medical Group, Kaiser Permanente Southern California, Downey, CA, USA
| | - Yi-Lin Wu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Chengyi Zheng
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - River Koblick
- Drug Information Services, Kaiser Permanente SCAL Region, 12254 Bellflower Blvd, Room 106, 1st Floor, Downey, CA, 90242, USA
| | - T Craig Cheetham
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
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