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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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Maher D, Reeve E, Hopkins A, Tan JM, Tantiongco M, Ailabouni N, Woodman R, Stamp L, Bursill D, Proudman S, Wiese M. Comparative Risk of Gout Flares When Initiating or Escalating Various Urate-Lowering Therapy: A Systematic Review With Network Meta-Analysis. Arthritis Care Res (Hoboken) 2024; 76:871-881. [PMID: 38303574 DOI: 10.1002/acr.25309] [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: 08/17/2023] [Revised: 12/07/2023] [Accepted: 01/29/2024] [Indexed: 02/03/2024]
Abstract
OBJECTIVE We systematically examined comparative gout flare risk after initiation or escalation of different urate-lowering therapies (ULTs), comparative flare risk with and without concomitant flare prophylaxis, adverse event rates associated with flare prophylaxis, and optimal duration of flare prophylaxis. METHODS We searched the Medline, Embase, Web of Science, and Cochrane databases and clinical trial registries from inception to November 2021 for trials investigating adults with gout initiating or escalating ULT. We performed random effects network meta-analyses and calculated risk ratios (RRs) between treatments. Bias was assessed using the revised Cochrane risk-of-bias tool. RESULTS We identified 3,775 records, of which 29 publications (27 trials) were included. When compared to placebo plus prophylaxis, the RR of flares ranged from 1.08 (95% confidence interval [CI] 0.87-1.33) for febuxostat 40 mg plus prophylaxis to RR 2.65 [95% CI 1.58-4.45] for febuxostat 80 mg plus lesinurad 400 mg plus prophylaxis. Compared to ULT alone, the RR of flares was lower for ULT plus rilonacept 160 mg (RR 0.35 [95% CI 0.25-0.50]), ULT plus rilonacept 80 mg (RR 0.43 [95% CI 0.31-0.60]) and ULT plus colchicine (RR 0.50 [95% CI 0.35-0.72]). There was limited evidence for other flare prophylaxis and on prophylaxis harms and optimal duration. Primarily because of missing outcome data and bias in the selection of reported results, 71.4% and 63.4% of studies were assessed as high risk of bias for flares and adverse events, respectively. CONCLUSION The RR of flares when introducing ULT varies depending on ULT drug and dosing strategies. There were limited data on ULT escalation. Flare prophylaxis with colchicine and rilonacept reduces flare incidence. More research is required on the harms and optimal duration of prophylaxis.
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Affiliation(s)
- Dorsa Maher
- University of South Australia and Southern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Emily Reeve
- University of South Australia, Adelaide, South Australia, and Monash University, Melbourne, Victoria, Australia
| | - Ashley Hopkins
- Flinders University, Adelaide, South Australia, Australia
| | - Jiun Ming Tan
- University of South Australia, Adelaide, South Australia, Australia
| | - Mahsa Tantiongco
- Southern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | | | | | - Lisa Stamp
- University of Otago, Christchurch, Christchurch, New Zealand
| | - David Bursill
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | | | - Michael Wiese
- University of South Australia, Adelaide, South Australia, Australia
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Stamp L, Horne A, Mihov B, Drake J, Haslett J, Chapman PT, Frampton C, Dalbeth N. Is colchicine prophylaxis required with start-low go-slow allopurinol dose escalation in gout? A non-inferiority randomised double-blind placebo-controlled trial. Ann Rheum Dis 2023; 82:1626-1634. [PMID: 37652661 DOI: 10.1136/ard-2023-224731] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 08/18/2023] [Indexed: 09/02/2023]
Abstract
OBJECTIVES To determine whether placebo is non-inferior to low-dose colchicine for reducing gout flares during the first 6 months of allopurinol using the 'start-low go-slow' dose approach. METHODS A 12-month double-blind, placebo-controlled non-inferiority trial was undertaken. Adults with at least one gout flare in the preceding 6 months, fulfilling the American College of Rheumatology (ACR) recommendations for starting urate-lowering therapy and serum urate ≥0.36 mmol/L were recruited. Participants were randomised 1:1 to colchicine 0.5 mg daily or placebo for the first 6 months. All participants commenced allopurinol, increasing monthly to achieve target urate <0.36 mmol/L. The primary efficacy outcome was the mean number of gout flares/month between 0 and 6 months, with a prespecified non-inferiority margin of 0.12 gout flares/month. The primary safety outcome was adverse events over the first 6 months. RESULTS Two hundred participants were randomised. The mean (95% CI) number of gout flares/month between baseline and month 6 was 0.61 (0.47 to 0.74) in the placebo group compared with 0.35 (0.22 to 0.49) in the colchicine group, mean difference 0.25 (0.07 to 0.44), non-inferiority p=0.92. There was no difference in the mean number of gout flares/month between randomised groups over the 12-month period (p=0.68). There were 11 serious adverse events in 7 participants receiving colchicine and 3 in 2 receiving placebo. CONCLUSIONS Placebo is not non-inferior to colchicine in prevention of gout flares in the first 6 months of starting allopurinol using the 'start-low go-slow' strategy. After stopping colchicine, gout flares rise with no difference in the mean number of gout flares/month between groups over a 12-month period. TRIAL REGISTRATION NUMBER ACTRN 12618001179224.
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Affiliation(s)
- Lisa Stamp
- Department of Medicine, University of Otago, Christchurch, Christchurch, New Zealand
| | - Anne Horne
- Department of Medicine, The Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Borislav Mihov
- Department of Medicine, The Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Jill Drake
- Department of Rheumatology, Immunology and Allergy, Te Whatu Ora Health New Zealand Waitaha Canterbury, Christchurch, New Zealand
| | - Janine Haslett
- Department of Medicine, University of Otago, Christchurch, Christchurch, New Zealand
| | - Peter T Chapman
- Department of Rheumatology, Immunology and Allergy, Te Whatu Ora Health New Zealand Waitaha Canterbury, Christchurch, New Zealand
| | - Christopher Frampton
- Department of Medicine, University of Otago, Christchurch, Christchurch, New Zealand
| | - Nicola Dalbeth
- Department of Medicine, The Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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Kannuthurai V, Gaffo A. Management of Patients with Gout and Kidney Disease: A Review of Available Therapies and Common Missteps. KIDNEY360 2023; 4:e1332-e1340. [PMID: 37526648 PMCID: PMC10550007 DOI: 10.34067/kid.0000000000000221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 07/13/2023] [Indexed: 08/02/2023]
Abstract
Gout, a common form of inflammatory arthritis, is characterized by deposition of monosodium urate crystals in articular and periarticular tissues. Repeated flares of gout cause joint damage as well as significant health care utilization and decreased quality of life. Patients with CKD have a higher prevalence of gout. Treating Patients with CKD and gout is challenging because of the lack of quality data to guide management in this specific population. This often leads to suboptimal treatment of patients with gout and impaired renal function because concerns regarding the efficacy and safety of available gout therapies in this population often result in significant interphysician variability in treatment regimens and dosages. Acute gout flares are treated with various agents, including nonsteroidal anti-inflammatory drugs, colchicine, glucocorticoids, and-more recently-IL-1 inhibitors. These medications can also be used as prophylaxis if urate-lowering therapy (ULT) is initiated. While these drugs can be used in patients with gout and CKD, there are often factors that complicate treatment, such as the numerous medication interactions involving colchicine and the effect of glucocorticoids on common comorbidities, such as diabetes and hypertension. ULT is recommended to treat recurrent flares, tophaceous deposits, and patients with moderate-to-severe CKD with a serum urate goal of <6 mg/dl recommended to prevent flares. While many misconceptions exist around the risks of using urate-lowering agents in patients with CKD, there is some evidence that these medications can be used safely in Patients with renal impairment. Additional questions exist as to whether gout treatment is indicated for Patients on RRT. Furthermore, there are conflicting data on whether ULT can affect renal function and cardiovascular disease in patients. All of these factors contribute to the unique challenges physicians face when treating patients with gout and CKD.
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Affiliation(s)
- Vijay Kannuthurai
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Angelo Gaffo
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
- Birmingham VA Medical Center, Birmingham, Alabama
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Anders HJ, Li Q, Steiger S. Asymptomatic hyperuricaemia in chronic kidney disease: mechanisms and clinical implications. Clin Kidney J 2023; 16:928-938. [PMID: 37261000 PMCID: PMC10229286 DOI: 10.1093/ckj/sfad006] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Indexed: 10/19/2023] Open
Abstract
Asymptomatic hyperuricaemia (HU) is considered a pathogenic factor in multiple disease contexts, but a causative role is only proven for the crystalline form of uric acid in gouty arthritis and urate nephropathy. Epidemiological studies document a robust association of HU with hypertension, cardiovascular disease (CVD) and CKD progression, but CKD-related impaired uric acid (UA) clearance and the use of diuretics that further impair UA clearance likely accounts for these associations. Interpreting the available trial evidence is further complicated by referring to xanthine oxidase inhibitors as urate-lowering treatment, although these drugs inhibit other substrates, so attributing their effects only to HU is problematic. In this review we provide new mechanistic insights into the biological effects of soluble and crystalline UA and discuss clinical evidence on the role of asymptomatic HU in CKD, CVD and sterile inflammation. We identify research areas with gaps in experimental and clinical evidence, specifically on infectious complications that represent the second common cause of death in CKD patients, referred to as secondary immunodeficiency related to kidney disease. In addition, we address potential therapeutic approaches on how and when to treat asymptomatic HU in patients with kidney disease and where further interventional studies are required.
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Affiliation(s)
- Hans-Joachim Anders
- Division of Nephrology, Department of Medicine IV, Hospital of the Ludwig-Maximilians University, Munich, Germany
| | - Qiubo Li
- Division of Nephrology, Department of Medicine IV, Hospital of the Ludwig-Maximilians University, Munich, Germany
| | - Stefanie Steiger
- Division of Nephrology, Department of Medicine IV, Hospital of the Ludwig-Maximilians University, Munich, Germany
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Morillon MB, Nørup A, Singh JA, Dalbeth N, Taylor WJ, Kennedy MA, Pedersen BM, Grainger R, Tugwell P, Perez-Ruiz F, Diaz-Torne C, Edwards NL, Shea B, Ellingsen TJ, Christensen R, Stamp LK. Outcome reporting in randomized trials in gout: A systematic scoping review from the OMERACT gout working group assessing the uptake of the core outcome set. Semin Arthritis Rheum 2023; 60:152191. [PMID: 36963128 DOI: 10.1016/j.semarthrit.2023.152191] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 02/21/2023] [Accepted: 02/27/2023] [Indexed: 03/17/2023]
Abstract
OBJECTIVE The selection and reporting of core outcome measures in clinical trials is essential for patients, researchers, and healthcare providers for clinical research to have an impact on healthcare. In this systematic scoping review, we aimed to quantify the extent to which gout clinical trials are collecting and reporting data in accordance with the core outcome domains from Outcome Measures in Rheumatology (OMERACT) published in 2009 applicable for both acute and chronic trials and evaluate the reporting according to the core domains before and after the 2009 OMERACT endorsement. METHODS We searched multiple databases PubMed, EMBASE, the Cochrane Library including the Cochrane Central Register of Controlled Trials (CENTRAL), and Cochrane Database of Systematic Reviews (CDSR) and www. CLINICALTRIALS gov for randomized controlled trials (RCTs) allocating people with gout versus an active pharmacological gout treatment or a control comparator (no date limitation). We extracted the data in accordance with the core outcome sets, focusing individually on core outcome domains and the core outcome measurements for acute and chronic trials, respectively. In this study 'Acute trials' reflect studies that describe interventions for short term management of gout flares, and 'chronic trials' describe interventions for long-term urate lowering therapy in the management of gout. RESULTS From 8,522 records identified in the database search, 134 full text papers were reviewed, and 71 trials were included, of which 36 were acute and 35 were chronic. Only 3 of 36 (8%) acute trials reported all five core domains and none of the 35 included chronic trials reported all 7 core domains. In the acute trials, twenty-seven unique measurement instruments across the 5 core domains were identified. For chronic trials there were 31 unique measurement instruments used across the 7 core domains. Serum urate was reported in 100% of the chronic trials and gout flares in 80%. However, other core domains were reported in <30% of chronic trials. In particular the patient-important domains such as HR-QOL, patient global assessment and activity limitations were rarely reported. A broad variety of different measurement instruments were used to assess each endorsed core domain, a minority of trials used the OMERACT endorsed instruments. For acute trials, the number reporting on all core domains was consistently low and no change was detected before and after the endorsement of the core domains in 2009. None of the included chronic trials reported on all 7 endorsed core domains at any time. CONCLUSION In this study we found a low adherence with the intended endorsed (i.e., core) outcome domains for acute and chronic gout studies which represents a poor uptake of the global OMERACT efforts for the minimum of what should be measured in clinical trials. In addition, there is a significant variation in how the OMERACT endorsed outcome domains have been measured. This systematic review demonstrates the need for continuous encouragement among gout researchers to adhere to OMERACT core domains as well as further guidance on outcome measurements reporting. REGISTRATION Prospero: CRD42019151316.
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Affiliation(s)
- Melanie B Morillon
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Denmark & Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Denmark; Department of Internal Medicine, Odense University Hospital, Svendborg, Denmark
| | - Alexander Nørup
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Denmark & Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Denmark
| | - Jasvinder A Singh
- Birmingham Veterans Affairs (VA) Medical Center and University of Alabama, Birmingham, AL, United States
| | | | | | - Martin A Kennedy
- Department of Pathology and Biomedical Science, University of Otago, Christchurch, Christchurch, New Zealand
| | | | - Rebecca Grainger
- Department of Medicine, University of Otago, Wellington, New Zealand
| | - Peter Tugwell
- Division of Rheumatology, Department of Medicine, and School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, and Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Fernando Perez-Ruiz
- Rheumatology Division, Osakidetza, OSI-EE Cruces, Cruces University Hospital, Barakaldo, Spain
| | - Cesar Diaz-Torne
- Rheumatology Department. Hospital de la Sant Pau. Universitat Autonoma de Barcelona, Barcelona, Spain
| | | | - Beverley Shea
- Clinical Epidemiology program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Torkell J Ellingsen
- Department of Clinical Research, University of Southern Denmark; the Department of Rheumatology, Odense University Hospital, the Faculty of Health Sciences, Denmark
| | - Robin Christensen
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Denmark & Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Denmark
| | - Lisa K Stamp
- Department of Medicine, University of Otago, Christchurch, Christchurch, New Zealand.
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Andrés M, Sivera F, Buchbinder R, Pardo Pardo J, Carmona L. Dietary supplements for chronic gout. Cochrane Database Syst Rev 2021; 11:CD010156. [PMID: 34767649 PMCID: PMC8589461 DOI: 10.1002/14651858.cd010156.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Dietary supplements are frequently used for the treatment of several medical conditions, both prescribed by physicians or self administered. However, evidence of benefit and safety of these supplements is usually limited or absent. OBJECTIVES To assess the efficacy and safety of dietary supplementation for people with chronic gout. SEARCH METHODS We updated the original search by searching CENTRAL, MEDLINE, Embase, CINAHL, and four trials registers (August 2020). We applied no date or language restrictions. We also handsearched the abstracts from the 2010 to 2019 American College of Rheumatology and European League against Rheumatism conferences, and checked the references of all included studies. SELECTION CRITERIA We considered all published randomised controlled trials (RCTs) or quasi-RCTs that compared dietary supplements with no supplements, placebo, another supplement, or pharmacological agents for adults with chronic gout for inclusion. Dietary supplements included, but were not limited to, amino acids, antioxidants, essential minerals, polyunsaturated fatty acids, prebiotic agents, probiotic agents, and vitamins. The major outcomes were acute gout flares, study withdrawal due to adverse events (AEs), serum uric acid (sUA) reduction, joint pain reduction, participant global assessment, total number of AEs, and tophus regression. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS Two previously included RCTs (160 participants) met our inclusion criteria; we did not identify any new trials for this update. As these two trials evaluated different diet supplements (enriched skim milk powder (SMP) and vitamin C) with different outcomes (gout flare prevention for enriched SMP, and sUA reduction for vitamin C), we reported the results separately. One trial (120 participants), at unclear risk of selection and detection bias, compared SMP enriched with glycomacropeptides (GMP) with un-enriched SMP, and with lactose, over three months. Participants were predominantly men, aged in their 50s, who had severe gout. The results for all major outcomes were imprecise, except for pain. None of the results were clinically significant. The frequency of acute gout attacks, measured as the number of flares per month, decreased in all three groups over the three-month study period. The effects of enriched SMP (SMP/GMP/G600) compared with the combined control groups (SMP and lactose powder) at three months in terms of mean number of gout flares per month were not clinically significant (mean (standard deviation (SD)) flares per month: 0.49 (1.52) in SMP/GMP/G60 group versus 0.70 (1.28) in the control groups; absolute risk difference: mean difference (MD) -0.21 flares per month, 95% confidence interval (CI) -0.76 to 0.34; low-quality evidence). The number of withdrawals due to adverse effects was similar between groups (7/40 in SMP/GMP/G600 group versus 11/80 in control groups; (risk ratio (RR) 1.27, 95% CI 0.53 to 3.03); there were 4% more withdrawals in the SMP/lactose groups (10% fewer to 18% more; low-quality evidence). Serum uric acid reduction was similar across groups (mean (SD) -0.025 (0.067) mmol/L in SMP/GMP/G60 group versus -0.010 (0.069) in control groups; MD -0.01, 95% CI -0.04 to 0.01; low-quality evidence). Pain from self-reported gout flares (measured on a 10-point Likert scale) improved slightly more in the GMP/G600 SMP group compared with controls (mean (SD) -1.97 (2.28) in SMP/GMP/G600 group versus -0.94 (2.25) in control groups; MD -1.03, 95% CI -1.89 to -0.17). This was an absolute reduction of 10% (95% CI 20% to 1% reduction; low-quality evidence), which may not be of clinical relevance. The risk of adverse events was similar between groups (19/40 in SMP/GMP/G600 group versus 39/80 in control groups; RR 0.97, 95% CI 0.66 to 1.45); the absolute risk difference was 1% fewer adverse events (1% fewer to 2% more), low-quality evidence). Gastrointestinal events such as nausea, flatulence and diarrhoea were the most commonly reported adverse effects. Data for participant global assessment were not available for analysis; the study did not report tophus regression. One trial (40 participants), at high risk of selection, performance, and detection bias, compared vitamin C alone with allopurinol, and with allopurinol plus vitamin C, in a three-arm study. We only included data from the vitamin C versus allopurinol comparison in this review. Participants were predominantly middle-aged men, and their severity of gout was representative of gout in general. Allopurinol reduced sUA levels more than vitamin C (MD 0.10 mmol/L, 95% CI 0.06 to 0.15), low-quality evidence. The study reported no adverse events; none of the participants withdrew due to adverse events. The study did not assess the rate of gout attacks, joint pain reduction, participant global assessment, or tophus regression. AUTHORS' CONCLUSIONS While dietary supplements may be widely used for gout, this review found no high-quality that supported or refuted the use of glycomacropeptide-enriched skim milk powder or vitamin C for adults with chronic gout.
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Affiliation(s)
- Mariano Andrés
- Sección de Reumatología, Hospital General Universitario de Alicante, Alicante, Spain
- Departamento de Medicina Clínica, Universidad Miguel Hernández, Elche, Spain
| | - Francisca Sivera
- Departamento de Medicina Clínica, Universidad Miguel Hernández, Elche, Spain
- Servicio de Reumatologia, Hospital de Elda, Elda (Alicante), Spain
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Melbourne, Australia
| | - Jordi Pardo Pardo
- Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus, Ottawa, Canada
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Holyer J, Taylor WJ, Gaffo A, Hosie G, Horne A, Mihov B, Su I, Gamble GD, Dalbeth N, Stewart S. Which Attributes Are Most and Least Important to Patients When Considering Gout Flare Burden Over Time? A Best-worst Scaling Choice Study. J Rheumatol 2021; 49:213-218. [PMID: 34725178 DOI: 10.3899/jrheum.210605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Several factors contribute to the patient experience of gout flares, including pain intensity, duration, frequency, and disability. It is unknown which of these factors are most important to patients when considering flare burden over time, including those related to the cumulative experience of all flares, or the experience of a single worst flare. This study aimed to determine which flare attributes are the most and least important to the patient experience of flare burden over time. METHODS Participants with gout completed an anonymous online survey. Questions were aimed at identifying which attributes of gout flares, representing both individual and cumulative flare burden, were the most and least important over a hypothetical 6-month period. A best-worst scaling method was used to determine the importance hierarchy of the included attributes. RESULTS Fifty participants were included. Difficulty doing usual activities during the worst flare and pain of the worst flare were ranked as the most important, whereas average pain of all flares was considered the least important. Overall, attributes related to the single worst gout flare were considered more important than attributes related to the cumulative impact of all flares. CONCLUSION When thinking about the burden of gout flares over time, patients rank activity limitation and pain experienced during their worst gout flare as the most important contributing factors, whereas factors related to the cumulative impact of all flares over time are relatively less important.
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Affiliation(s)
- Jeremy Holyer
- JH was supported by a University of Auckland summer student scholarship. J. Holyer, medical student, G. Hosie, NZ Dip. in Policing, A. Horne, MBChB, B. Mihov, BPHty, I. Su, BSc, G.D. Gamble, MSc, N. Dalbeth, MBChB, MD, FRACP, S. Stewart, PhD, Deparment of Medicine, University of Auckland, Auckland, New Zealand; W.J. Taylor, MBChB, PhD, FRACP, FAFRM, Department of Medicine, University of Otago, Wellington, New Zealand; A. Gaffo, MD, MsPH, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA. ND reports grants and personal fees from AstraZeneca, personal fees from Horizon, AbbVie, AstraZeneca, Jansen, Hengrui, Dyve Biosciences, Selecta, and Arthrosi; and grants from Amgen and AstraZeneca outside the submitted work. The remaining authors declare no conflicts of interest relevant to this article. Address correspondence to Dr. S. Stewart, Department of Medicine, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand. . Accepted for publication October 13, 2021
| | - William J Taylor
- JH was supported by a University of Auckland summer student scholarship. J. Holyer, medical student, G. Hosie, NZ Dip. in Policing, A. Horne, MBChB, B. Mihov, BPHty, I. Su, BSc, G.D. Gamble, MSc, N. Dalbeth, MBChB, MD, FRACP, S. Stewart, PhD, Deparment of Medicine, University of Auckland, Auckland, New Zealand; W.J. Taylor, MBChB, PhD, FRACP, FAFRM, Department of Medicine, University of Otago, Wellington, New Zealand; A. Gaffo, MD, MsPH, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA. ND reports grants and personal fees from AstraZeneca, personal fees from Horizon, AbbVie, AstraZeneca, Jansen, Hengrui, Dyve Biosciences, Selecta, and Arthrosi; and grants from Amgen and AstraZeneca outside the submitted work. The remaining authors declare no conflicts of interest relevant to this article. Address correspondence to Dr. S. Stewart, Department of Medicine, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand. . Accepted for publication October 13, 2021
| | - Angelo Gaffo
- JH was supported by a University of Auckland summer student scholarship. J. Holyer, medical student, G. Hosie, NZ Dip. in Policing, A. Horne, MBChB, B. Mihov, BPHty, I. Su, BSc, G.D. Gamble, MSc, N. Dalbeth, MBChB, MD, FRACP, S. Stewart, PhD, Deparment of Medicine, University of Auckland, Auckland, New Zealand; W.J. Taylor, MBChB, PhD, FRACP, FAFRM, Department of Medicine, University of Otago, Wellington, New Zealand; A. Gaffo, MD, MsPH, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA. ND reports grants and personal fees from AstraZeneca, personal fees from Horizon, AbbVie, AstraZeneca, Jansen, Hengrui, Dyve Biosciences, Selecta, and Arthrosi; and grants from Amgen and AstraZeneca outside the submitted work. The remaining authors declare no conflicts of interest relevant to this article. Address correspondence to Dr. S. Stewart, Department of Medicine, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand. . Accepted for publication October 13, 2021
| | - Graham Hosie
- JH was supported by a University of Auckland summer student scholarship. J. Holyer, medical student, G. Hosie, NZ Dip. in Policing, A. Horne, MBChB, B. Mihov, BPHty, I. Su, BSc, G.D. Gamble, MSc, N. Dalbeth, MBChB, MD, FRACP, S. Stewart, PhD, Deparment of Medicine, University of Auckland, Auckland, New Zealand; W.J. Taylor, MBChB, PhD, FRACP, FAFRM, Department of Medicine, University of Otago, Wellington, New Zealand; A. Gaffo, MD, MsPH, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA. ND reports grants and personal fees from AstraZeneca, personal fees from Horizon, AbbVie, AstraZeneca, Jansen, Hengrui, Dyve Biosciences, Selecta, and Arthrosi; and grants from Amgen and AstraZeneca outside the submitted work. The remaining authors declare no conflicts of interest relevant to this article. Address correspondence to Dr. S. Stewart, Department of Medicine, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand. . Accepted for publication October 13, 2021
| | - Anne Horne
- JH was supported by a University of Auckland summer student scholarship. J. Holyer, medical student, G. Hosie, NZ Dip. in Policing, A. Horne, MBChB, B. Mihov, BPHty, I. Su, BSc, G.D. Gamble, MSc, N. Dalbeth, MBChB, MD, FRACP, S. Stewart, PhD, Deparment of Medicine, University of Auckland, Auckland, New Zealand; W.J. Taylor, MBChB, PhD, FRACP, FAFRM, Department of Medicine, University of Otago, Wellington, New Zealand; A. Gaffo, MD, MsPH, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA. ND reports grants and personal fees from AstraZeneca, personal fees from Horizon, AbbVie, AstraZeneca, Jansen, Hengrui, Dyve Biosciences, Selecta, and Arthrosi; and grants from Amgen and AstraZeneca outside the submitted work. The remaining authors declare no conflicts of interest relevant to this article. Address correspondence to Dr. S. Stewart, Department of Medicine, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand. . Accepted for publication October 13, 2021
| | - Borislav Mihov
- JH was supported by a University of Auckland summer student scholarship. J. Holyer, medical student, G. Hosie, NZ Dip. in Policing, A. Horne, MBChB, B. Mihov, BPHty, I. Su, BSc, G.D. Gamble, MSc, N. Dalbeth, MBChB, MD, FRACP, S. Stewart, PhD, Deparment of Medicine, University of Auckland, Auckland, New Zealand; W.J. Taylor, MBChB, PhD, FRACP, FAFRM, Department of Medicine, University of Otago, Wellington, New Zealand; A. Gaffo, MD, MsPH, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA. ND reports grants and personal fees from AstraZeneca, personal fees from Horizon, AbbVie, AstraZeneca, Jansen, Hengrui, Dyve Biosciences, Selecta, and Arthrosi; and grants from Amgen and AstraZeneca outside the submitted work. The remaining authors declare no conflicts of interest relevant to this article. Address correspondence to Dr. S. Stewart, Department of Medicine, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand. . Accepted for publication October 13, 2021
| | - Isabel Su
- JH was supported by a University of Auckland summer student scholarship. J. Holyer, medical student, G. Hosie, NZ Dip. in Policing, A. Horne, MBChB, B. Mihov, BPHty, I. Su, BSc, G.D. Gamble, MSc, N. Dalbeth, MBChB, MD, FRACP, S. Stewart, PhD, Deparment of Medicine, University of Auckland, Auckland, New Zealand; W.J. Taylor, MBChB, PhD, FRACP, FAFRM, Department of Medicine, University of Otago, Wellington, New Zealand; A. Gaffo, MD, MsPH, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA. ND reports grants and personal fees from AstraZeneca, personal fees from Horizon, AbbVie, AstraZeneca, Jansen, Hengrui, Dyve Biosciences, Selecta, and Arthrosi; and grants from Amgen and AstraZeneca outside the submitted work. The remaining authors declare no conflicts of interest relevant to this article. Address correspondence to Dr. S. Stewart, Department of Medicine, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand. . Accepted for publication October 13, 2021
| | - Gregory D Gamble
- JH was supported by a University of Auckland summer student scholarship. J. Holyer, medical student, G. Hosie, NZ Dip. in Policing, A. Horne, MBChB, B. Mihov, BPHty, I. Su, BSc, G.D. Gamble, MSc, N. Dalbeth, MBChB, MD, FRACP, S. Stewart, PhD, Deparment of Medicine, University of Auckland, Auckland, New Zealand; W.J. Taylor, MBChB, PhD, FRACP, FAFRM, Department of Medicine, University of Otago, Wellington, New Zealand; A. Gaffo, MD, MsPH, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA. ND reports grants and personal fees from AstraZeneca, personal fees from Horizon, AbbVie, AstraZeneca, Jansen, Hengrui, Dyve Biosciences, Selecta, and Arthrosi; and grants from Amgen and AstraZeneca outside the submitted work. The remaining authors declare no conflicts of interest relevant to this article. Address correspondence to Dr. S. Stewart, Department of Medicine, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand. . Accepted for publication October 13, 2021
| | - Nicola Dalbeth
- JH was supported by a University of Auckland summer student scholarship. J. Holyer, medical student, G. Hosie, NZ Dip. in Policing, A. Horne, MBChB, B. Mihov, BPHty, I. Su, BSc, G.D. Gamble, MSc, N. Dalbeth, MBChB, MD, FRACP, S. Stewart, PhD, Deparment of Medicine, University of Auckland, Auckland, New Zealand; W.J. Taylor, MBChB, PhD, FRACP, FAFRM, Department of Medicine, University of Otago, Wellington, New Zealand; A. Gaffo, MD, MsPH, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA. ND reports grants and personal fees from AstraZeneca, personal fees from Horizon, AbbVie, AstraZeneca, Jansen, Hengrui, Dyve Biosciences, Selecta, and Arthrosi; and grants from Amgen and AstraZeneca outside the submitted work. The remaining authors declare no conflicts of interest relevant to this article. Address correspondence to Dr. S. Stewart, Department of Medicine, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand. . Accepted for publication October 13, 2021
| | - Sarah Stewart
- JH was supported by a University of Auckland summer student scholarship. J. Holyer, medical student, G. Hosie, NZ Dip. in Policing, A. Horne, MBChB, B. Mihov, BPHty, I. Su, BSc, G.D. Gamble, MSc, N. Dalbeth, MBChB, MD, FRACP, S. Stewart, PhD, Deparment of Medicine, University of Auckland, Auckland, New Zealand; W.J. Taylor, MBChB, PhD, FRACP, FAFRM, Department of Medicine, University of Otago, Wellington, New Zealand; A. Gaffo, MD, MsPH, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA. ND reports grants and personal fees from AstraZeneca, personal fees from Horizon, AbbVie, AstraZeneca, Jansen, Hengrui, Dyve Biosciences, Selecta, and Arthrosi; and grants from Amgen and AstraZeneca outside the submitted work. The remaining authors declare no conflicts of interest relevant to this article. Address correspondence to Dr. S. Stewart, Department of Medicine, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand. . Accepted for publication October 13, 2021
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9
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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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10
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Stamp LK, Farquhar H, Pisaniello HL, Vargas-Santos AB, Fisher M, Mount DB, Choi HK, Terkeltaub R, Hill CL, Gaffo AL. Management of gout in chronic kidney disease: a G-CAN Consensus Statement on the research priorities. Nat Rev Rheumatol 2021; 17:633-641. [PMID: 34331037 PMCID: PMC8458096 DOI: 10.1038/s41584-021-00657-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2021] [Indexed: 11/08/2022]
Abstract
Gout and chronic kidney disease (CKD) frequently coexist, but quality evidence to guide gout management in people with CKD is lacking. Use of urate-lowering therapy (ULT) in the context of advanced CKD varies greatly, and professional bodies have issued conflicting recommendations regarding the treatment of gout in people with concomitant CKD. As a result, confusion exists among medical professionals about the appropriate management of people with gout and CKD. This Consensus Statement from the Gout, Hyperuricemia and Crystal-Associated Disease Network (G-CAN) discusses the evidence and/or lack thereof for the management of gout in people with CKD and identifies key areas for research to address the challenges faced in the management of gout and CKD. These discussions, which address areas for research both in general as well as related to specific medications used to treat gout flares or as ULT, are supported by separately published G-CAN systematic literature reviews. This Consensus Statement is not intended as a guideline for the management of gout in CKD; rather, it analyses the available literature on the safety and efficacy of drugs used in gout management to identify important gaps in knowledge and associated areas for research.
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Affiliation(s)
| | | | - Huai Leng Pisaniello
- Discipline of Medicine, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Ana B Vargas-Santos
- Department of Internal Medicine, Rio de Janeiro State University, Rio de Janeiro, Brazil
| | - Mark Fisher
- Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA
- Prima CARE, Fall River, MA, USA
| | - David B Mount
- Renal Divisions, Brigham and Women's Hospital, Boston, MA, USA
- VA Boston Healthcare System, Boston, MA, USA
| | - Hyon K Choi
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Robert Terkeltaub
- VA San Diego Healthcare System, San Diego, CA, USA
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Catherine L Hill
- Discipline of Medicine, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Rheumatology Unit, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
| | - Angelo L Gaffo
- University of Alabama at Birmingham, Birmingham, AL, USA
- Birmingham VA Medical Center, Birmingham, AL, USA
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11
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Holyer J, Garcia-Guillen A, Taylor WJ, Gaffo AL, Gott M, Slark J, Horne A, Su I, Dalbeth N, Stewart S. What Represents Treatment Efficacy in Long-term Studies of Gout Flare Prevention? An Interview Study of People With Gout. J Rheumatol 2021; 48:1871-1875. [PMID: 34470799 DOI: 10.3899/jrheum.210476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The patient experience of gout flares is multidimensional, with several contributing factors including pain intensity, duration, and frequency. There is currently no consistent method for reporting gout flare burden in long-term studies. This study aimed to determine which factors contribute to patient perceptions of treatment efficacy in long-term studies of gout flare prevention. METHODS This study involved face-to-face interviews with people with gout using visual representations of gout flare patterns. Participants were shown different flare scenarios over a hypothetical 6-month treatment period that portrayed varying flare frequency, pain intensity, and flare duration. The participants were asked to indicate and discuss which scenario they believed was most indicative of successful treatment over time. Quantitative data relating to the proportion of participants selecting each scenario were reported using descriptive statistics. A qualitative descriptive approach was used to code and categorize the data from the interview transcripts. RESULTS Twenty-two people with gout participated in the semistructured interviews. All 3 factors of pain intensity, flare duration, and flare frequency influenced participants' perception of treatment efficacy. However, a shorter flare duration was the most common indicator of successful treatment, with half of participants (n = 11, 50%) selecting the scenario with a shorter flare duration over those with less painful flares. CONCLUSION Flare duration, flare frequency, and pain severity are all taken into account by patients with gout when considering treatment efficacy over time. Long-term studies of gout should ideally capture all these factors to better represent patients' experience of treatment success.
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Affiliation(s)
- Jeremy Holyer
- J. Holyer, medical student, A. Garcia-Guillen, MD, M. Gott, PhD, J. Slark, PhD, A. Horne, MBChB, I. Su, BSc, N. Dalbeth, MBChB, MD, FRACP, S. Stewart, PhD, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Andrea Garcia-Guillen
- J. Holyer, medical student, A. Garcia-Guillen, MD, M. Gott, PhD, J. Slark, PhD, A. Horne, MBChB, I. Su, BSc, N. Dalbeth, MBChB, MD, FRACP, S. Stewart, PhD, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - William J Taylor
- W.J. Taylor, MBChB, PhD, FRACP, FAFRM, Department of Medicine, University of Otago, Wellington, New Zealand
| | - Angelo L Gaffo
- A.L. Gaffo, MD, MSPH, FACP, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Merryn Gott
- J. Holyer, medical student, A. Garcia-Guillen, MD, M. Gott, PhD, J. Slark, PhD, A. Horne, MBChB, I. Su, BSc, N. Dalbeth, MBChB, MD, FRACP, S. Stewart, PhD, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Julia Slark
- J. Holyer, medical student, A. Garcia-Guillen, MD, M. Gott, PhD, J. Slark, PhD, A. Horne, MBChB, I. Su, BSc, N. Dalbeth, MBChB, MD, FRACP, S. Stewart, PhD, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Anne Horne
- J. Holyer, medical student, A. Garcia-Guillen, MD, M. Gott, PhD, J. Slark, PhD, A. Horne, MBChB, I. Su, BSc, N. Dalbeth, MBChB, MD, FRACP, S. Stewart, PhD, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Isabel Su
- J. Holyer, medical student, A. Garcia-Guillen, MD, M. Gott, PhD, J. Slark, PhD, A. Horne, MBChB, I. Su, BSc, N. Dalbeth, MBChB, MD, FRACP, S. Stewart, PhD, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Nicola Dalbeth
- J. Holyer, medical student, A. Garcia-Guillen, MD, M. Gott, PhD, J. Slark, PhD, A. Horne, MBChB, I. Su, BSc, N. Dalbeth, MBChB, MD, FRACP, S. Stewart, PhD, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Sarah Stewart
- J. Holyer, medical student, A. Garcia-Guillen, MD, M. Gott, PhD, J. Slark, PhD, A. Horne, MBChB, I. Su, BSc, N. Dalbeth, MBChB, MD, FRACP, S. Stewart, PhD, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand;
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12
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Pisaniello HL, Fisher MC, Farquhar H, Vargas-Santos AB, Hill CL, Stamp LK, Gaffo AL. Efficacy and safety of gout flare prophylaxis and therapy use in people with chronic kidney disease: a Gout, Hyperuricemia and Crystal-Associated Disease Network (G-CAN)-initiated literature review. Arthritis Res Ther 2021; 23:130. [PMID: 33910619 PMCID: PMC8080370 DOI: 10.1186/s13075-021-02416-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 01/04/2021] [Indexed: 12/27/2022] Open
Abstract
Gout flare prophylaxis and therapy use in people with underlying chronic kidney disease (CKD) is challenging, given limited treatment options and risk of worsening renal function with inappropriate treatment dosing. This literature review aimed to describe the current literature on the efficacy and safety of gout flare prophylaxis and therapy use in people with CKD stages 3-5. A literature search via PubMed, the Cochrane Library, and EMBASE was performed from 1 January 1959 to 31 January 2018. Inclusion criteria were studies with people with gout and renal impairment (i.e. estimated glomerular filtration rate (eGFR) or creatinine clearance (CrCl) < 60 ml/min/1.73 m2), and with exposure to colchicine, interleukin-1 inhibitors, non-steroidal anti-inflammatory drugs (NSAIDs), and glucocorticoids. All study designs were included. A total of 33 studies with efficacy and/or safety analysis stratified by renal function were reviewed-colchicine (n = 20), anakinra (n = 7), canakinumab (n = 1), NSAIDs (n = 3), and glucocorticoids (n = 2). A total of 58 studies reported these primary outcomes without renal function stratification-colchicine (n = 29), anakinra (n = 10), canakinumab (n = 6), rilonacept (n = 2), NSAIDs (n = 1), and glucocorticoids (n = 10). Most clinical trials excluded study participants with severe CKD (i.e. eGFR or CrCl of < 30 mL/min/1.73 m2). Information on the efficacy and safety outcomes of gout flare prophylaxis and therapy use stratified by renal function is lacking. Clinical trial results cannot be extrapolated for those with advanced CKD. Where possible, current and future gout flare studies should include patients with CKD and with study outcomes reported based on renal function and using standardised gout flare definition.
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Affiliation(s)
- Huai Leng Pisaniello
- Discipline of Medicine, Faculty of Health and Medical Sciences, the University of Adelaide, Adelaide, South Australia, Australia
| | - Mark C Fisher
- Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA.,Prima CARE, Fall River, MA, USA
| | - Hamish Farquhar
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | | | - Catherine L Hill
- Discipline of Medicine, Faculty of Health and Medical Sciences, the University of Adelaide, Adelaide, South Australia, Australia.,Rheumatology Unit, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - Lisa K Stamp
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Angelo L Gaffo
- Division of Rheumatology and Clinical Immunology, University of Alabama, 1720 2nd Avenue South, Birmingham, AL, 35294, USA. .,Birmingham VA Medical Center, Birmingham, USA.
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13
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Autoinflammatory Features in Gouty Arthritis. J Clin Med 2021; 10:jcm10091880. [PMID: 33926105 PMCID: PMC8123608 DOI: 10.3390/jcm10091880] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/16/2021] [Accepted: 04/22/2021] [Indexed: 12/16/2022] Open
Abstract
In the panorama of inflammatory arthritis, gout is the most common and studied disease. It is known that hyperuricemia and monosodium urate (MSU) crystal-induced inflammation provoke crystal deposits in joints. However, since hyperuricemia alone is not sufficient to develop gout, molecular-genetic contributions are necessary to better clinically frame the disease. Herein, we review the autoinflammatory features of gout, from clinical challenges and differential diagnosis, to the autoinflammatory mechanisms, providing also emerging therapeutic options available for targeting the main inflammatory pathways involved in gout pathogenesis. This has important implication as treating the autoinflammatory aspects and not only the dysmetabolic side of gout may provide an effective and safer alternative for patients even in the prevention of possible gouty attacks.
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14
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Garcia-Guillen A, Stewart S, Su I, Taylor WJ, Gaffo AL, Gott M, Slark J, Horne A, Dalbeth N. Gout flare severity from the patient perspective: a qualitative interview study. Arthritis Care Res (Hoboken) 2020; 74:317-323. [PMID: 33026692 DOI: 10.1002/acr.24475] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/15/2020] [Accepted: 09/29/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVE The patient experience of a gout flare is multi-dimensional. To establish the most appropriate methods of flare measurement, there is a need to understand the complete experience of a flare. This qualitative study aimed to examine what factors contribute to the severity of a flare from the patient perspective. METHODS Face-to-face interviews were conducted with people with gout. Participants were asked to share their experience with their worst gout flare and contrast it to their experience of a less severe or mild flare. Interviews were audio-recorded and transcribed verbatim. Data was analysed using a reflexive thematic approach. RESULTS Twenty-two participants with gout (17 males, mean age 66.5 years) were interviewed at an academic centre in Auckland, New Zealand. Four key themes were identified as contributing to the severity of a flare: flare characteristics (pain intensity, joint swelling, redness and warmth, duration, and location), impact on function (including walking, activities of daily living, wearing footwear, and sleep), impact on family and social life (dependency on others, social connection, and work) and psychological impact (depression, anxiety, irritability, and sense of control). CONCLUSION A wide range of interconnecting factors contribute to the severity of a gout flare from the patient perspective. Capturing these domains in long-term gout studies would provide more meaningful and accurate representation of cumulative flare burden.
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Affiliation(s)
- Andrea Garcia-Guillen
- The University of Auckland Faculty of Medical and Health Sciences, Medicine, Auckland, New Zealand
| | - Sarah Stewart
- The University of Auckland Faculty of Medical and Health Sciences, Medicine, Auckland, New Zealand
| | - Isabel Su
- The University of Auckland Faculty of Medical and Health Sciences, Medicine, Auckland, New Zealand
| | - William J Taylor
- University of Otago, Department of Medicine, Wellington, New Zealand
| | - Angelo L Gaffo
- UAB Health System, Rheumatology, Birmingham, United States
| | - Merryn Gott
- The University of Auckland Faculty of Medical and Health Sciences, Medicine, Auckland, New Zealand
| | - Julia Slark
- The University of Auckland Faculty of Medical and Health Sciences, Medicine, Auckland, New Zealand
| | - Anne Horne
- The University of Auckland Faculty of Medical and Health Sciences, Medicine, Auckland, New Zealand
| | - Nicola Dalbeth
- The University of Auckland Faculty of Medical and Health Sciences, Medicine, Auckland, New Zealand
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15
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Stewart S, Guillen AG, Taylor WJ, Gaffo A, Slark J, Gott M, Dalbeth N. The experience of a gout flare: a meta-synthesis of qualitative studies. Semin Arthritis Rheum 2020; 50:805-811. [PMID: 32554059 DOI: 10.1016/j.semarthrit.2020.06.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/03/2020] [Accepted: 06/02/2020] [Indexed: 11/19/2022]
Abstract
AIMS Gout flares are an important concern for people with gout and an understanding of patients' experiences with gout flares is central in developing meaningful outcome measures for clinical trials. This study aimed to systematically review and thematically synthesize the qualitative literature reporting the patient experience of gout flares, to inform the development of flare-specific outcome measures. METHODS MEDLINE, EMBASE, CINAHL Plus and PsycINFO electronic databases were searched in October 2019 to identify original qualitative research articles reporting on the patient experience of gout flares. Methodological quality of all included papers was assessed using the Critical Appraisal Skills Program (CASP) tool. Following data extraction, coding and synthesis was undertaken using reflexive thematic analysis. RESULTS Sixteen papers reporting the patient experience of gout flares were included. The majority of CASP criteria were met by most studies, indicating good methodological quality. Four predominant and overlapping themes were identified from the thematic analysis: gout flare characteristics (pain, swelling, location, duration and frequency); impact on function and activities of daily living (walking, housework and yard work, self-care, exercise and sports, driving, sleep); effects on social and family life (social participation, inability to plan, employment, dependency, relationships, intimacy); and psychological impact (boredom, irritability, fear, shame and embarrassment, isolation, financial worry, depression and anxiety). CONCLUSIONS Gout flares impact many aspects of patients' lives, including physical and psychological and social and family life. The patient experience of gout flares goes beyond what is routinely measured in research settings. Measurement and reporting methods that capture these aspects of patients' experiences with gout flares would provide more meaningful outcome measures in clinical trials of flare prevention.
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Affiliation(s)
- Sarah Stewart
- Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand.
| | - Andrea Garcia Guillen
- Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand.
| | - William J Taylor
- Department of Medicine, University of Otago, PO Box 7343, Wellington South 6242, New Zealand.
| | - Angelo Gaffo
- School of Medicine, University of Alabama at Birmingham, 1720 2nd Ave South, Birmingham, AL 35294, USA.
| | - Julia Slark
- Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand.
| | - Merryn Gott
- Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand.
| | - Nicola Dalbeth
- Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand.
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