Evaluation of febuxostat initiation during an acute gout attack: A prospective, randomized clinical trial

An updated systematic review and meta-analysis of randomised controlled trials on the effects of urate-lowering therapy initiation during a gout flare

BACKGROUND

There is uncertainty about the optimal time to start urate-lowering therapy (ULT) in the setting of a gout flare. The aim was to perform a systematic review and meta-analysis of randomised controlled trials (RCTs) assessing the effects of ULT initiation during a gout flare.

METHODS

This systematic review was conducted in accordance with PRISMA methodology. MEDLINE, EMBASE and The Cochrane Library were searched for studies published between database inception to 1 March 2023. RCTs published in English that examined ULT initiation during a gout flare in adults ≥18 years were included. The quality of included studies was assessed using the revised Cochrane Risk of Bias tool 2.0. Data were extracted for the following outcomes: patient-rated pain score, duration of gout flare, recurrent gout flares, time to achieve target serum urate, adherence to ULT, patient satisfaction with treatment and adverse events. Meta-analyses were performed using Review Manager v5.4. This study is registered on PROSPERO, number CRD42023404680.

RESULTS

A total of 972 studies were identified and of these, six RCTs met the criteria for inclusion in the analysis. Three studies were assessed as having high risk of bias, one study as having some concerns, and two studies as having low risk of bias. In total, there were 445 pooled participants; 226 participants randomised to early initiation of ULT and 219 to placebo or delayed initiation of ULT. Allopurinol was used in three studies, febuxostat in two studies and probenecid in one study. Few participants (n = 62, 13.9 %) had tophaceous gout. Participants with renal impairment were excluded from most studies. There were no differences in patient-rated pain scores at baseline, days 3-4, days 7-8, day 10 or days 14-15 (p ≥ 0.42). Additionally, there was no significant difference in time to resolution of gout flare (standardised mean difference 0.77 days; 95 % CI -0.26 to 1.79; p = 0.14) or the risk of recurrent gout flare in the subsequent 28 to 30 days (RR 1.06; 95 % CI 0.59 to 1.92; p = 0.84). Adverse events were similar between groups. The included studies did not report time to achieve target serum urate, long-term adherence to ULT, or patient satisfaction with treatment.

CONCLUSION

There appears to be no evidence for harm or for benefit to initiating ULT during a gout flare. These findings have limited applicability to patients with tophaceous gout, or those with renal impairment.

Efficacy of initiating urate-lowering therapy during an acute gout episode: a meta-analysis

OBJECTIVE

This study aimed to evaluate the effectiveness of initiating urate-lowering therapy (ULT) during acute gout episodes.

METHODS

We performed a literature search using MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (from inception to February 2023). We conducted a comprehensive review and meta-analysis of randomized controlled trials (RCTs) that examined the efficacy of ULT in individuals with acute gout flares.

RESULTS

This review included six RCTs with 479 patients (225 experimental participants and 254 controls). The experimental group had longer days to resolution than did the control group. There was no significant difference in the pain visual analogue scale score between the groups by day 10. Erythrocyte sedimentation rate and C‑reactive protein level did not significantly differ between the groups by days 7 to 14. Both groups had similar rates of recurrent gout attacks by 30 days. There was no significant between-group difference in the dropout rate.

CONCLUSION

Initiating ULT therapy during a gout attack does not appear to increase the duration of the flare or aggravate pain. Despite these findings, further studies with larger sample sizes are necessary to support these conclusions.

Korean guidelines for the management of gout

Gout is the most common form of arthritis, with the prevalence increasing worldwide. The present treatment guidelines provide recommendations for the appropriate treatment of acute gout, management during the inter-critical period, and prevention of chronic complications. The guidelines were developed based on evidence-based medicine and draft recommendations finalized after expert consensus. These guidelines are designed to provide clinicians with clinical evidence to enable efficient treatment of gout.

Korean guidelines for the management of gout

Gout is the most common form of arthritis, with the prevalence increasing worldwide. The present treatment guidelines provide recommendations for the appropriate treatment of acute gout, management during the inter-critical period, and prevention of chronic complications. The guidelines were developed based on evidence-based medicine and draft recommendations finalized after expert consensus. These guidelines are designed to provide clinicians with clinical evidence to enable efficient treatment of gout.

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

Aim

Shared decision-making improves patients’ experiences with care, satisfaction with management decisions and possibly health outcomes. This study describes the development of a decision aid (DA) that supports patients with gout and their physicians in a face-to-face clinical setting to (a) decide whether or not to (re)start urate-lowering therapy (ULT) and (b) agree on the preferred ULT.

Methods

Recommendations of the International Patient Decision Aid Standards group guided the development. A steering group of experts in gout and health services research specified the scope. Nominal group technique meetings were organised in which patients ranked the importance of preidentified potential characteristics/attributes of ULT and discussed further needs regarding the DA. A literature search was conducted to collect evidence on gout outcomes with and without ULT. Subsequently, the DA prototype was designed and adjusted using feedback from the steering group and results of cognitive debriefing interviews among five gout patients.

Results

The final DA consists of six pages. First, the DA clarifies the decision at stake and describes gout including its risk factors, the role of lifestyle and treatment of flares. Next, risk of future flares with and without ULT in relation to serum uric acid levels is described and visualised. Relevant attributes of ULT are presented in an option grid distinguishing first-line and second-line ULT. Finally, patients’ believes and preferences are explicitly addressed before making the shared decision.

Conclusion

This study provides initial support for usability of a DA for gout patients eligible for starting ULT.

The effect of initiation of urate-lowering treatment during a gout flare on the current episode: a meta-analysis of randomized controlled trials

OBJECTIVE

The objective was to evaluate whether initiation of urate-lowering treatment (ULT) during an acute gout flare prolonged the current episode.

METHODS

A comprehensive search of MEDLINE and Web of Science databases was conducted from their inception to 15 March 2021. Five randomized controlled trials (RCTs) with 381 patients met the inclusion criteria. Standardized mean difference (SMD), odds ratio (OR), and 95% confidence interval (CI) were used for estimating the clinical efficacy of ULT in acute gout.

RESULTS

There was no statistical difference in days to resolution (intent-to-treat analysis) (SMD, 0.68; 95% CI - 0.42 to 1.78; I², 49%; p = 0.22), the pain visual analogue score (VAS) by day 10 (SMD, - 0.07; 95% CI - 0.30 to 0.16; I², 0%; p = 0.53), C-reactive protein (CRP) from day 7 to 10 (SMD, - 1.14; 95% CI - 5.63 to 3.36; I², 55%; p = 0.62), erythrocyte sedimentation rate (ESR) from day 7 to 10 (SMD, - 2.51; 95% CI - 5.46 to 0.45; I², 0%; p = 0.10) and the recurrence of gout flares within 28-30 days (OR 0.78; 95% CI 0.29 to 2.09; I², 0%; p = 0.62).

CONCLUSION

Initiation of ULT during an acute gout flare did not prolong the duration of the flare. However, larger sample size studies are needed to confirm this finding. Trial registration number PROSPERO (CRD42021234581).

The Clinical Effects of Febuxostat Alone or Combined with Arthroscopic Surgery for Gout: A Single-Center Retrospective Study

Purpose

The purpose of the study was to retrospectively analyze the effects of febuxostat combined with arthroscopic debridement of monosodium urate crystal deposition and febuxostat treatment alone on uric acid levels and acute flares in gout patients.

Patients and Methods

We retrospectively analyzed gout patients who were treated from February 2016 to December 2020. Patients were divided into a control group (febuxostat treatment alone) or a combined group (febuxostat combined with arthroscopic surgery). We recorded and analyzed clinical data including age, sex, body mass index, comorbidities, lesion affected joints, acute flare times, medications history, febuxostat side effects, arthroscopic complications, and serum creatinine and uric acid levels changes.

Results

There were 80 patients in the control group and 93 patients in the combined group. At the beginning of treatment, the combined group had significantly higher disease severity (higher serum uric acid levels and more acute gout flare times). Arthroscopy was performed in 61 knees and 38 ankles, and 86 joints showed crystals deposition. Compared with baseline, follow-up results showed that serum creatinine significantly decreased in the combined group, and serum uric acid and acute gout flare times significantly decreased in both groups (all p < 0.05). In the comparison between the two groups at the follow-up endpoint, acute gout flare times did not differ significantly (p > 0.05), however, serum creatinine and uric acid levels were lower in the combined group compared with those in the control group (ps < 0.05).

Conclusion

Febuxostat combined with arthroscopic debridement of monosodium urate crystal deposition or tophi had a superior effect on lowering uric acid levels and acute flare times in gout patients than did febuxostat alone.

Improving outcomes for patients hospitalised with gout: a systematic review

Objectives

Hospital admissions for gout flares have increased dramatically in recent years, despite widely available, effective medications for the treatment and prevention of flares. We conducted a systematic review to evaluate the effectiveness and implementation of interventions in patients hospitalized for gout flares.

Methods

A search was conducted in MEDLINE, Embase and the Cochrane library, from database inception to 8 April 2021, using the terms ‘gout’ and ‘hospital’ and their synonyms. Studies were included if they evaluated the effectiveness and/or implementation of interventions during hospital admissions or emergency department attendances for gout flares. Risk of bias assessments were performed for included studies.

Results

Nineteen articles were included. Most studies were small, retrospective analyses performed in single centres, with concerns for bias. Eleven studies (including five randomized controlled trials) reported improved patient outcomes following pharmacological interventions with known efficacy in gout, including allopurinol, prednisolone, NSAIDs and anakinra. Eight studies reported improved outcomes associated with non-pharmacological interventions: inpatient rheumatology consultation and a hospital gout management protocol. No studies to date have prospectively evaluated strategies designed to prevent re-admissions of patients hospitalized for gout flares.

Conclusion

There is an urgent need for high-quality, prospective studies of strategies for improving uptake of urate-lowering therapies in hospitalized patients, incorporating prophylaxis against flares and treat-to-target optimization of serum urate levels. Such studies are essential if the epidemic of hospital admissions from this treatable condition is to be countered.

Why Does Hyperuricemia Not Necessarily Induce Gout?

Hyperuricemia is a risk factor for gout. It has been well observed that a large proportion of individuals with hyperuricemia have never had a gout flare(s), while some patients with gout can have a normuricemia. This raises a puzzle of the real role of serum uric acid (SUA) in the occurrence of gout flares. As the molecule of uric acid has its dual effects in vivo with antioxidant properties as well as being an inflammatory promoter, it has been placed in a delicate position in balancing metabolisms. Gout seems to be a multifactorial metabolic disease and its pathogenesis should not rely solely on hyperuricemia or monosodium urate (MSU) crystals. This critical review aims to unfold the mechanisms of the SUA role participating in gout development. It also discusses some key elements which are prerequisites for the formation of gout in association with the current therapeutic regime. The compilation should be helpful in precisely fighting for a cure of gout clinically and pharmaceutically.