Suboptimal physician adherence to quality indicators for the management of gout and asymptomatic hyperuricaemia: results from the UK General Practice Research Database (GPRD)

Quality Measures in Systemic Sclerosis

Quality improvement is an emerging field, that applies principles of improvement science and utilizes measurement methods with the aim of improving patient care. Systemic sclerosis (SSc) is a systemic autoimmune rheumatic disease associated with increased healthcare burden, cost, morbidity, and mortality. Gaps in delivering care to patients with SSc have been consistently observed. In this article, we introduce the discipline of quality improvement and its use of quality measures. We summarize and comparatively evaluate three sets of quality measures that have been proposed to evaluate the quality of care of patients with SSc. Finally, we highlight the areas of unmet needs and indicate future directions for quality improvement and quality measures in SSc.

Association between hyperuricemia and metabolic syndrome: A cross-sectional study in Tibetan adults on the Tibetan plateau

PURPOSE

This study aimed to assess the relationship of serum uric acid with metabolic syndrome and its components in Tibetan adults on the Tibetan plateau.

METHODS

A total of 307 participants were enrolled in this study and biochemical parameters including serum uric acid, fasting plasma glucose, white blood cell, lymphocyte count, mononuclear cells, alanine aminotransferase, aspartate aminotransferase, creatinine, and lipid profile were analyzed using standard methods. The IDF criteria were applied to define metabolic syndrome. The association of serum uric acid with metabolic syndrome and its components was evaluated by multivariable logistic regression models.

RESULTS

The overall prevalence of metabolic syndrome was 17.3% (53/307) with 19.6% (31/158) in females and 14.8% (22/149) in male participants. The prevalence of hyperuricemia was 40.7% (125/307) with significant differences between the male (53.7%,80/149) and female (28.5%,45/158) groups. In regression analysis, we observed that the risk of MetS was higher in participants in the hyperuricemia group (adjusted OR, 4.01; 95% CI, 2.02~7.99) compared with those in the normouricemia group. After adjusting for all confounding factors, a 9% higher risk of MetS could be shown in participants with SUA increased per 10umol/L (adjusted OR, 1.09; 95% CI, 1.04~1.14). These relationships were not affected by sex or age (p >0.05). After adjusting for the confounding factors, hyperuricemia is positively associated with abdominal obesity (adjusted OR, 2.53; 95% CI, 1.41~4.53), elevated blood pressure (adjusted OR, 2.61; 95% CI, 1.37~4.97), and elevated triglycerides(adjusted OR, 2.47; 95% CI, 1.09~5.57).

CONCLUSIONS

In our study, hyperuricemia is significantly associated with the prevalence of metabolic syndrome and part of its components, and these relationships are not affected by sex or age. Given the high prevalence of MetS and hyperuricemia among Tibetan adults, more studies are required to explore the role of SUA in the pathogenesis of MetS.

Incorporating gout guideline advice into urate reports is associated with reduced hospital admissions: results of an observational study

OBJECTIVES

To evaluate the impact of incorporating treatment guidance into reporting of urate test results.

METHODS

Urate targets for clinically confirmed gout were added to urate results above 0.36 mmol/l requested after September 2014 within NHS Lothian. Scotland-wide data on urate-lowering therapy prescriptions and hospital admissions with gout were analysed between 2009 and 2020. Local data on urate tests were analysed between 2014 and 2015.

RESULTS

Admissions with a primary diagnosis of gout in Lothian reduced modestly following the intervention from 111/year in 2010-2014-104/year in 2015-2019, a non-significant difference (p= 0.32). In contrast there was a significant increase in admissions to remaining NHS Scotland health boards (556/year vs 606/year, p< 0.01). For a secondary diagnosis of gout the number of admissions in NHS Lothian reduced significantly (58/year vs 39/year, p< 0.01) contrasting with a significant increase in remaining Scottish health boards (220/year vs 290/year, p< 0.01). The relative rate of admissions to NHS Lothian compared with remaining Scottish boards using a 2009 baseline were significantly reduced for both primary diagnosis of gout (1.06 vs 1.25, p< 0.001) and secondary diagnoses of gout (0.64 compared with 1.4, p< 0.001) after the intervention; however, there was no difference before the intervention. A relative increase in the prescription rates of allopurinol 300 mg tablets and febuxostat 120 mg tablets may have contributed to the improved outcomes seen.

CONCLUSION

Incorporation of clinical guideline advice into routine reporting of urate results was associated with reduced rates of admission with gout in NHS Lothian, in comparison to other Scottish health boards.

Assessing the sensitivity to change of the OMERACT ultrasound structural gout lesions during urate-lowering therapy

Objectives

To evaluate the sensitivity to change of ultrasound structural gout lesions, as defined by the Outcome Measures in Rheumatology (OMERACT) ultrasound group, in patients with gout during urate-lowering therapy (ULT).

Methods

Ultrasound (28 joints, 26 tendons) was performed in patients with microscopically verified gout initiating or increasing ULT and repeated after 3 and 6 months. Joints and tendons were evaluated by ultrasound for presence of the OMERACT structural gout lesions—double contour sign (DC), tophus, aggregates and erosion—scored binarily. A sum score was calculated at patient and lesion level. Changes at 3 and 6 months in patient sum scores and lesion scores at different locations were evaluated.

Results

50 patients (48 men), mean age 68.9 (range, 30–88) years, were included. Ultrasound showed a statistically significant decrease in DC and tophus sum scores from 0 months (3.16 and 2.68, respectively) to 3 months (2.33 and 2.43) and 6 months (1.34 and 1.83) (all p<0.002). The aggregate sum score only decreased significantly from 3 to 6 months (6.02 to 5.02, p=0.002), whereas erosion sum score remained almost unchanged. All four structural lesions were most commonly found in metatarsophalangeal (MTP) 1 joints (>1 lesions bilaterally), and furthermore MTP2–4 and knee joints were common sites especially for DC. Likewise, these regions were the locations with most pronounced changes in scores.

Conclusion

Ultrasound assessment of the OMERACT structural gout lesions scored binarily seems to be a useful tool for monitoring urate depositions during ULT. Particularly DC and tophus showed sensitivity to change after only 3 months of treatment.

Consensus-based semi-quantitative ultrasound scoring system for gout lesions: Results of an OMERACT Delphi process and web-reliability exercise

OBJECTIVE

This study aimed to develop (1) a new ultrasound definition for aggregates and (2) a semi-quantitative ultrasound scoring system (0-3) for tophus, double contour and aggregates. Furthermore, the intra- and inter-reader reliabilities of both the re-defined aggregates and the semi-quantitative scoring system were assessed using static image exercises.

METHODS

Thirty-seven rheumatologists were invited. A Delphi process was used for re-defining aggregates and for selecting a semi-quantitative scoring system with >75% agreement obligate for reaching consensus. Subsequently, a web-based exercise on static ultrasound images was conducted in order to assess the reliability of both the re-defined aggregates and the semi-quantitative scoring system.

RESULTS

Twenty rheumatologists contributed to all rounds of the Delphi and image exercises. A consensual re-definition of aggregates was obtained after three Delphi rounds but needed an overarching principle for scoring aggregates in patients. A consensus-based semi-quantitative ultrasound scoring system for gout lesions was developed after two Delphi rounds. The re-definition of aggregates showed good intra- and inter-reader reliability (κ-values 0.71 and 0.61). The reliabilities of the scoring system were good for all lesions with slightly higher intra-reader (κ-values 0.74-0.80) than inter-reader reliabilities (κ-values 0.61-0.67).

CONCLUSION

A re-definition of aggregates was obtained with a good reliability when assessing static images. The first consensus-based semi-quantitative ultrasound scoring system for gout-specific lesions was developed with good inter- and intra-reader reliability for all lesions when tested in static images. The next step is to assess the reliabilities when scoring lesions in patients.

Patient Perceptions of Gout Management Goals: A Cross-sectional Internet Survey

OBJECTIVE

To assess patient perceptions of gout management goals.

METHODS

We conducted a cross-sectional Internet survey of people who visited the Gout and Uric Acid Education Society's website to assess patient/respondent perception of gout management goals. We used chi-square test for categorical or t-test for continuous variables.

RESULTS

Among the 320 survey respondents with physician-diagnosed gout, mean age was 57 (SD, 13.4) years, 72% were male, 77% White; mean gout duration was 7.6 years (SD, 11), gout flares in the last year were 5.2 (SD, 6.1), and medical comorbidities were common, 2.7 (SD, 2.6). Two-thirds respondents each reported very severe or severe symptoms from gout and that gout ranked among the top two health conditions with a negative impact on quality of life. During a clinic visit, only one-third of respondents' physicians spent 50% of more of the time discussing gout treatment. Only 54% respondents were prescribed ULT by their healthcare provider. By patient preference, the best life-long gout treatment strategies were the lowering of the serum urate level and the control of gout symptoms (62%) followed by serum urate lowering (32%). Respondents considered the following as the most important things for making gout treatment satisfactory: (1) patient education; (2) effective physician-patient communication; (3) diet and lifestyle modification; (4) serum urate monitoring and target achievement; (5) pain management and flare prevention; and (6) medication management.

CONCLUSIONS

Patient identification of gout symptom control and serum urate level monitoring as the most important treatment goals is informative for clinicians and guideline developers.

Patient perspectives in gout: a review

PURPOSE OF REVIEW

Recent studies have produced evidence regarding the patient perspectives in gout including from disease experience to disease outcomes. Therefore, an overview on the topic can help improve our understanding of the patient experience.

RECENT FINDINGS

This article explores several aspects of the patient perspective including the impact of gout on a patient's life, patient knowledge and beliefs regarding gout and its treatments, patient-perceived barriers to optimal medication adherence in gout and patient's perception of their gout. This article also summarizes any evidence of the association of patient perceptions to patient outcomes in gout.

SUMMARY

A recognition of patient perspectives in gout has the potential to positively impact clinical care for gout. Discussion of disease impact, misperceptions about benefits/harms of urate-lowering therapy (ULT), and patient values/preferences regarding pharmacological and nonpharmacological treatments can lead to a better shared decision-making and improved outcomes in gout. These findings emphasize the importance of inclusion of patient perspective not only in clinical care and quality improvement and research initiatives but also in the design and implementation of the research agenda in gout. Inclusion of patient-reported outcomes in clinical research is likely to improve its relevance to patients with gout.

The prevalence of gout and hyperuricemia in middle-aged and elderly people in Tibet Autonomous Region, China: A preliminary study

OBJECTIVE

Gout and hyperuricemia are common public health problem. There has been no epidemiological survey of gout and hyperuricemia in Tibet Autonomous Region, the southwest of China. Therefore, we estimated the prevalence of gout and hyperuricemia in Luoma Town, Naqu City, Tibet Autonomous Region of China.

METHODS

A population-based cross-sectional survey was conducted among 1458 residents of Luoma Town, Tibet Autonomous Region, age ≥40 years. We used questionnaires in face-to-face interviews, anthropometric measurements and serum uric acid test. Hyperuricemia was defined as serum uric acid level ≥7 mg/dl in men and ≥6 mg/dl in women. The definition of gout in this study was on the basis of new 2015ACR/EULAR classification criteria.

RESULTS

Nine hundred eighty-nine participants completed all items of gout and 818 participants attended to be taken blood samples for serum UA levels test. The overall crude prevalence of gout and hyperuricemia was 0.30% and 1.83% respectively. It was more prevalent in men than in women (2.86% vs 0.75%, P = .034) in hyperuricemia group. Tibetan had a lower age-standardized prevalence of gout 0.26% (95% confidence interval (CI): 0%-0.60%) and hyperuricemia 2.05% (95% confidence interval (CI): 0.99%-3.44%) compared with the China Health and Retirement Longitudinal Study results.

CONCLUSION

This is the first large-scale population-based survey to demonstrate the prevalence of gout and hyperuricemia of the middle-aged and elderly population in Tibet Autonomous Region, China. The prevalence of gout and hyperuricemia is relatively lower than other places in China, and that might be influenced by ethnicity, genetic and environment factors. These findings will be useful for the future researches and health care strategies.

Variation in methods, results and reporting in electronic health record-based studies evaluating routine care in gout: A systematic review

OBJECTIVE

To perform a systematic review examining the variation in methods, results, reporting and risk of bias in electronic health record (EHR)-based studies evaluating management of a common musculoskeletal disease, gout.

METHODS

Two reviewers systematically searched MEDLINE, Scopus, Web of Science, CINAHL, PubMed, EMBASE and Google Scholar for all EHR-based studies published by February 2019 investigating gout pharmacological treatment. Information was extracted on study design, eligibility criteria, definitions, medication usage, effectiveness and safety data, comprehensiveness of reporting (RECORD), and Cochrane risk of bias (registered PROSPERO CRD42017065195).

RESULTS

We screened 5,603 titles/abstracts, 613 full-texts and selected 75 studies including 1.9M gout patients. Gout diagnosis was defined in 26 ways across the studies, most commonly using a single diagnostic code (n = 31, 41.3%). 48.4% did not specify a disease-free period before 'incident' diagnosis. Medication use was suboptimal and varied with disease definition while results regarding effectiveness and safety were broadly similar across studies despite variability in inclusion criteria. Comprehensiveness of reporting was variable, ranging from 73% (55/75) appropriately discussing the limitations of EHR data use, to 5% (4/75) reporting on key data cleaning steps. Risk of bias was generally low.

CONCLUSION

The wide variation in case definitions and medication-related analysis among EHR-based studies has implications for reported medication use. This is amplified by variable reporting comprehensiveness and the limited consideration of EHR-relevant biases (e.g. data adequacy) in study assessment tools. We recommend accounting for these biases and performing a sensitivity analysis on case definitions, and suggest changes to assessment tools to foster this.

Target genes, variants, tissues and transcriptional pathways influencing human serum urate levels

Elevated serum urate levels cause gout and correlate with cardiometabolic diseases via poorly understood mechanisms. We performed a trans-ancestry genome-wide association study of serum urate in 457,690 individuals, identifying 183 loci (147 previously unknown) that improve the prediction of gout in an independent cohort of 334,880 individuals. Serum urate showed significant genetic correlations with many cardiometabolic traits, with genetic causality analyses supporting a substantial role for pleiotropy. Enrichment analysis, fine-mapping of urate-associated loci and colocalization with gene expression in 47 tissues implicated the kidney and liver as the main target organs and prioritized potentially causal genes and variants, including the transcriptional master regulators in the liver and kidney, HNF1A and HNF4A. Experimental validation showed that HNF4A transactivated the promoter of ABCG2, encoding a major urate transporter, in kidney cells, and that HNF4A p.Thr139Ile is a functional variant. Transcriptional coregulation within and across organs may be a general mechanism underlying the observed pleiotropy between urate and cardiometabolic traits.

Factors Influencing the Effectiveness of Allopurinol in Achieving and Sustaining Target Serum Urate in a US Veterans Affairs Gout Cohort

OBJECTIVE

To assess factors associated with the ability to achieve and maintain target serum urate (SU) with allopurinol in patients with gout.

METHODS

We used US Veterans Affairs (VA) databases from 2002-2012. Eligible patients had ≥ 1 inpatient or ≥ 2 outpatient visits with a diagnostic code for gout, filled a new index allopurinol prescription, had at least 1 posttreatment SU level measured, and met the 12-month observability rule. Treatment successes were defined as the achievement of postindex SU < 6 mg/dl (success 1) and postindex SU < 6 mg/dl that was sustained (success 2).

RESULTS

Of the 198,839 unique patients with allopurinol use, 41,153 unique patients (with 47,072 episodes) and 17,402 unique patients (with 18,323 episodes) were eligible for analyses for success 1 and success 2; 42% each achieved (success 1) or achieved and maintained postindex SU < 6 mg/dl (success 2). In multivariable-adjusted models, factors associated with significantly higher odds of both outcomes were older age, normal body mass index, Deyo-Charlson index score of 0, rheumatologist as the main provider rather than non-rheumatologist, midwestern US location for the healthcare facility, a lower hospital bed size, military service connection for medical conditions of 50% or more (a measure of healthcare access priority), longer distance to the nearest VA facility, and lower preindex SU.

CONCLUSION

We identified novel factors associated with maintaining SU < 6 mg/dl based on a theoretical model. Several potentially modifiable factors can be targeted by individual/provider/systems interventions for improving successful achievement and maintenance of target SU in patients with gout.

Gout, flares, and allopurinol use: a population-based study

BACKGROUND

There is a paucity of community-based data regarding the prevalence and impact of gout flares as these may often be self-managed. The aim of this study was to determine the prevalence of self-reported gout and gout flares, the use of urate-lowering therapy (ULT), and the association of gout flares with health-related quality of life (HRQoL) in a large community sample. Covariate associations with flare frequency and allopurinol use were also examined.

METHODS

The South Australian Health Omnibus Survey is an annual, face-to-face population-based survey. Data collected in the 2017 survey included self-reported medically diagnosed gout, allopurinol use (first-line ULT in Australia), and gout attacks (flares) in the last 12 months, in addition to sociodemographic variables and health-related quality of life (HRQoL, SF-12). Data were weighted to the Australian Bureau of Statistics 2016 census data to reflect the South Australian population. Participants 25 years and over (n = 2778) were included in the analysis.

RESULTS

The prevalence of gout was 6.5% (95%CI 5.5, 7.5). Amongst participants with gout, 37.1% (95%CI 29.6, 45.3) reported currently using allopurinol, while 23.2% (95%CI 16.9, 21.0) reported prior use (38% discontinuation rate). Frequent flares (≥ 2 in the last year) were reported by 25% of participants with gout and were more likely with younger age, higher body mass index, and current allopurinol use (p < 0.05). The frequency of gout flares was associated with a lower physical HRQoL (p = 0.012). Current allopurinol use was reported by 51% of participants with frequent gout flares.

CONCLUSION

Flares were frequently reported by people with gout in the community. Gout flares were associated with reduced physical HRQoL. Almost one half of people with frequent gout flares were not receiving allopurinol, and current allopurinol use was associated with frequent gout flares, suggesting undertreated disease and suboptimal use of ULT. Determining covariate associations with flares and ineffective allopurinol use may identify means of improving treatment and reducing flares.

Knowledge and practice in the management of asymptomatic hyperuricemia among primary health care physicians in Jeddah, Western Region of Saudi Arabia

Objectives:

To assess knowledge and practice levels in asymptomatic hyperuricemia (AH) and investigate predictors of urate-lowering therapy (ULT) misprescribing among primary health care (PHC) physicians.

Methods:

A cross-sectional study was conducted among 201 PHC physicians from December 2017 to May 2018. A based clinical guidelines for hyperuricemia management from American Professional Organizations, a semi-structured questionnaire was administered to collect demographic and professional data; knowledge and practice levels in management of AH; and barriers to the management of hyperuricemia and gout, with focus of the misprescribing of ULT in AH. A 2-stage stratified sampling technique was used to select 4 PHC centers were from each of the 5 advisory sectors in Jeddah, Kingdom of Saudi Arabia; and to recruit a minimum of 10 eligible participants per primary health care center (PHCC). Binary logistic regression was used to analyze predictors of ULT misuse in AH.

Results:

Only 32.8% participating physicians had adequate knowledge about AH. Regarding practice, while majority (88.1%) correctly recommended a low-purine diet and lifestyle changes to patients, almost half misprescribed ULT and 10.9% misprescribed non-steroid anti-inflammatory drugs. Lack of knowledge and awareness about guidelines were the most frequently self-reported barriers to adequate practice. Predictors of ULT misuse included the percentage of patients having gout (1-10%: OR=5.40, p=0.047) or receiving ULT (>10-20%: OR=20.02, p=0.001)among patients seen in clinic, attendance of rheumatology conferences (OR=2.55, p=0.017), and having a close relative with hyperuricemia or gout (OR=2.45, p=0.026).

Conclusion:

There are inadequate levels of knowledge regarding AH among Saudi PHC physicians increasing risk of malpractice including misprescription of ULT and anti-inflammatory medications.

Incident gout and chronic Kidney Disease: healthcare utilization and survival

Background

Uncontrolled gout can cause significant joint and organ damage and has been associated with impairments in quality of life and high economic cost. Gout has also been associated with other comorbid diseases, such as chronic kidney disease. The current study explored if healthcare resource utilization (HRU) and survival differs between patients with incident gout in the presence or absence of chronic kidney disease (CKD).

Methods

Clalit Health Services (CHS) data were used to conduct a retrospective population-based cohort study of incident gout between 1/1/2006–31/12/2009. Incident cases of gout were identified and stratified by CKD status and by age group (< 55 and 55+ years). CKD status was defined as a pre-existing diagnosis of chronic kidney disease, chronic renal failure, kidney transplantation, or dialysis at index date. Demographic and clinical characteristics, as well as healthcare resource use, were reported.

Results

A total of 12,940 incident adult gout patients, with (n = 8286) and without (n = 4654) CKD, were followed for 55,206 person-years. Higher rates of HRU were observed for gout patients with CKD than without. Total annual hospital admissions for patients with gout and CKD were at least 3 times higher for adults < 55 (mean = 0.51 vs 0.13) and approximately 1.5 times higher for adults 55+ (mean = 0.46 vs 0.29) without CKD. Healthcare utilization rates from year 1 to year 5 remained similar for gout patients < 55 years irrespective of CKD status, however varied according to healthcare utilization by CKD status for gout patients 55+ years. The 5-year all-cause mortality was higher among those with CKD compared to those without CKD for both age groups (HR_{< 55 years} = 1.65; 95% CI 1.01–2.71; HR_{55+ years} = 1.50; 95% CI 1.37–1.65).

Conclusions

The current study suggests important differences exist in patient characteristics and outcomes among patients with gout and CKD. Healthcare utilization differed between sub-populations, age and comorbidities, over the study period and the 5-year mortality risk was higher for gout patients with CKD, regardless of age. Future work should explore factors associated with these outcomes and barriers to gout control in order to enhance patient management among this high-risk subgroup.

Expert opinion on emerging urate-lowering therapies

INTRODUCTION

There has been a resurgence in gout therapeutics in the last decade, not only for the management of gout flares, but also for the treatment of hyperuricemia. This editorial summarizes new, emerging therapies for people with gout. Areas covered: We review several new therapies for gout, including those that are focused on lowering serum urate (levotofisopam, ulodesine, verinurad, merbarone, KUX-1151, UR-1102, FYU-981, SEL-212), or treating gout flares (canakinumab, bucillamine) or both (arhalofenate, diacerein). Expert opinion: Among therapies with both urate lowering and anti-inflammatory action, arhalofenate seems promising, but more data are needed. Examining therapies aimed at treating gout flares [anti-inflammatory action], bucillamine has some potential, but more data and Phase III studies are needed, to better understand its efficacy and safety. Among the urate-lowering therapies (ULTs), verinurad seems to be the most promising, while levotofisopam and ulodesine require more data. A uricase-replacement therapy with improved immune reaction (SLE-212) is in a Phase II trial. A number of ULTs including KUX-1151, UR-1102 and FYU-981 are in early development and more will be known once initial data and studies are published.

Goals of gout treatment: a patient perspective

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.

Physiology of Hyperuricemia and Urate-Lowering Treatments

Gout is the most common form of inflammatory arthritis and is a multifactorial disease typically characterized by hyperuricemia and monosodium urate crystal deposition predominantly in, but not limited to, the joints and the urinary tract. The prevalence of gout and hyperuricemia has increased in developed countries over the past two decades and research into the area has become progressively more active. We review the current field of knowledge with emphasis on active areas of hyperuricemia research including the underlying physiology, genetics and epidemiology, with a focus on studies which suggest association of hyperuricemia with common comorbidities including cardiovascular disease, renal insufficiency, metabolic syndrome and diabetes. Finally, we discuss current therapies and emerging drug discovery efforts aimed at delivering an optimized clinical treatment strategy.

Budget impact of adding lesinurad for second-line treatment of gout: a US health plan perspective

Aim: To estimate budget impact of adopting lesinurad as add-on to allopurinol for urate-lowering therapy in gout. Methods: A budget impact model was developed for a US payer perspective, using a Markov model to estimate costs, survival and discontinuation in a one-million-member health plan. The population included patients failing first-line gout therapy, followed for 5 years. Results: Incremental costs of adding lesinurad versus no lesinurad were US$241,907 and US$1,098,220 in first and fifth years, respectively. Cumulative 5-year incremental cost was US$3,633,440. Estimated incremental mean cost per treated patient with gout per year was US$112. The mean per-member per-month cost increased by US$0.06. Conclusion: Initiating lesinurad would result in an incremental per-member per-month cost of US$0.06 over 5 years.

Improving adherence to gout therapy: an expert review

Gout is the most common form of inflammatory arthritis and is a considerable burden to patients and health care systems worldwide. Despite its clinical, economic, and social impact, patient persistence and adherence to prescribed urate-lowering therapies (ULT), ranging from 20% to 70%, is considered to be among the poorest of all chronic conditions. The majority of gout patients consequently receive suboptimal benefits of their prescribed pharmacotherapies. As gout is associated with several comorbidities along with an increased risk of premature mortality, achieving improved outcomes through adherence to ULT is crucial. Adherence to medication is complex and multidimensional and includes a combination of treatment-, patient-, and physician-related factors. This review explores the factors related to ULT adherence with the overall aim of helping health care providers better understand the barriers to adherence. Several interventions targeting pharmacists, nurses, and patients are being investigated to improve adherence. Furthermore, enhanced awareness and understanding of the need to treat-to-target in order to improve patient outcomes is needed among health care professionals. Greater understanding of the multidimensional nature of non-adherence can help physicians to treat gout more effectively and empower patients to improve self-management of this long-term disease.

Effects of Discontinuation of Urate-Lowering Therapy: A Systematic Review

BACKGROUND

Urate-lowering therapy (ULT) is associated with low rates of adherence, leading to a potential risk of relapse of gouty arthritis, tophi, or urolithiasis. Our main aim was to identify the recurrence of gouty arthritis, tophi, or urolithiasis after discontinuation of ULT. Secondary aims included an assessment of ULT reintroduction rates and factors associated with relapse.

METHODS

We conducted a systematic literature review of clinical studies investigating the effect of discontinuing any ULT (allopurinol, febuxostat, probenecid, sulfinpyrazone, benzbromarone) in adults on long-term therapy. We searched The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Science Citation Index, and ClinicalTrials.gov from inception to March 2016. Conference abstracts of the ACR/ARHP and EULAR annual conferences were hand-searched. Study quality was assessed using the first eight items of the methodological index for non-randomized studies (MINORS) tool. The review protocol is registered with PROSPERO (CRD42016042048).

RESULTS

A total of 4640 articles were identified, eight of which were ultimately included. Most of these studies predated 2000. MINORS scores ranged from 5 to 10 out of a possible 16. Mean follow-up duration after discontinuation ranged from 12 to 96 months. Five studies focused on discontinuation of ULT in gouty arthritis and tophi, two in urolithiasis, and one in asymptomatic hyperuricemia. Relapse rates were high in gout (36-81%) and lower in urolithiasis (15%). Relapses occurred 1-4.5 years after ULT discontinuation. In one study, a low serum urate level before and after ULT discontinuation was associated with lower gout recurrence.

DISCUSSION

Relapse of gout is common although delayed after discontinuation of ULT. Short-term prognosis after ULT discontinuation appears favorable if the serum urate level was low before ULT discontinuation. The results of this review are limited by the paucity of existing studies and their low quality. Further comparative studies should consider larger primary care populations and discontinuation of febuxostat.

Work disability in gout: a population-based case–control study

Objectives

To examine the extent and cost of work disability among patients with gout compared with matched population controls and to analyse predictors of work disability.

Methods

A regional cohort study using data from Swedish national and regional registries from January 2000 through December 2012, including 4571 patients with gout of working age, with a first recorded diagnosis of gout in the years 2003–2009 and 22 482 population controls, matched by age, sex and place of residence. Differences in baseline characteristics (educational level, income, previous employment and comorbidities) and the number of work-loss days (absenteeism) due to sick leave and disability pension for 3 years after identification were calculated. Predictors for new-onset work absenteeism (>90 days/year) in a subset were determined by conditional logistic regression.

Results

Patients with gout (median age 53 years) had significantly more comorbidities, lower income and lower level of education than matched controls. The average work absentee rate during the 3-year follow-up period was higher among patients with gout than controls, 22% and 14%, respectively (P<0.0001). New-onset absenteeism was in multivariate analyses significantly predicted by gout (OR 1.47; 95% CI 1.23 to 1.75). Other variables independently related to new-onset absenteeism were education ≤12 years, previous unemployment and history of sick leave, in addition to several comorbidities (renal disease, cardiovascular disease, alcohol abuse and obesity).

Conclusions

Gout is associated with substantially higher work absenteeism and costs for society due to productivity loss, after adjusting for associated comorbidities and socioeconomic differences. Whether more intensive treatment of gout is cost-effective needs to be addressed in future studies.

Calcium Pyrophosphate Deposition Disease and Associated Medical Comorbidities: A National Cross-Sectional Study of US Veterans

OBJECTIVE

Calcium pyrophosphate deposition disease (CPDD) is a common cause of acute and chronic arthritis, yet there are few large epidemiologic studies of CPDD. We sought to characterize CPDD in the national Veterans Affairs (VA) population.

METHODS

Using data from the Department of VA Corporate Data Warehouse, patients with International Classification of Diseases, Ninth Revision, codes for CPDD seen at any VA medical center from 2010 through 2014 were matched by age and sex with control patients without CPDD. We used multivariate analysis to compare the prevalence and odds ratios (ORs) of various comorbidities, substance use, medication exposures, and arthroplasties among patients with and without CPDD.

RESULTS

We identified 25,157 patients with CPDD, yielding a point prevalence of 5.2 per 1,000. The mean ± SD age was 68.1 ± 12.3 years, and 95% were male. The strongest positive associations with CPDD were hyperparathyroidism (OR 3.35 [95% confidence interval (95% CI) 2.96-3.79]), gout (OR 2.82 [95% CI 2.69-2.95]), osteoarthritis (OR 2.26 [95% CI 2.15-2.37]), rheumatoid arthritis (OR 1.88 [95% CI 1.74-2.03]), and hemochromatosis (OR 1.87 [95% CI 1.57-2.24]). Positive associations were also seen with higher odds for osteoporosis (OR 1.26 [95% CI 1.16-1.36]), hypomagnesemia (OR 1.23 [95% CI 1.16-1.30]), chronic kidney disease (OR 1.12 [95% CI 1.07-1.18]), and calcium supplementation (OR 1.15 [95% CI 1.06-1.24). Negative associations were seen with proton-pump inhibitors (OR 0.58 [95% CI 0.55-0.60]) and loop diuretics (OR 0.80 [95% CI 0.76-0.84]).

CONCLUSION

Using a large national data set, we confirmed known associations with CPDD, provided support for positive associations with rheumatoid arthritis, hypomagnesemia, and osteoporosis, and suggested potential novel negative associations with commonly used medications.

Camellia sinensis in asymptomatic hyperuricemia: A meta-analysis of tea or tea extract effects on uric acid levels

Flavanols of Camellia sinensis exhibit uric acid (UA) lowering effect, through the modulation of both xanthine oxidase and urate excretion. In order to investigate the potential benefit of Camellia Sinenis products in asymptomatic hyperuricemia, a meta-analysis of long-term Randomized Controlled Trials (RCT) with tea or tea extract has been conducted. From 20 human intervention studies selected only 5 RCT (13 interventions) were suitable for meta-analysis (n = 472). The current "normal" range set for hyperuricemia fails to identify patients with potential metabolic disorders. Therefore on the basis of the literature data, we fixed cut-off limits for UA baseline levels of 4.5 mg/dl for women, 6.1 mg/dl for men, and 5.5 mg/dl for studies involving mixed populations. Statistically significant effects were not found, but subgroup analysis revealed that the Pooled Estimate effect was different in subjects with baseline levels under [MD (95% CI): 0.1078 (-0.0528 to 0.2684)] and over the cut-off [MD (95% CI): -0.0239 (0.3311 to 0.2833)]. However, due to the low number of RCT and to the lack of data on bioavailability, it is difficult to draw any firm conclusion and more studies are needed to establish if tea flavanols could be useful in asymptomatic hyperuricemia treatment.

Rheumatologists' perception of systemic lupus erythematosus quality indicators: significant interest and perceived barriers

Differences in quality of care may contribute to health disparities in systemic lupus erythematosus (SLE). Studies show low physician adherence rates to the SLE quality indicators but do not assess physician perception of SLE quality indicators or quality improvement. Using a cross-sectional survey of rheumatologists in the southeastern USA, we assessed the perception and involvement of rheumatologists in quality improvement and the SLE quality indicators. Using electronic mail, an online survey of 32 questions was delivered to 568 rheumatologists. With a response rate of 19% (n = 106), the majority of participants were male, Caucasian, with over 20 years of experience, and seeing adult patients in an academic setting. Participants had a positive perception toward quality improvement (81%) with a majority responding that the SLE quality indicators would significantly impact quality of care (54%). While 66% of respondents were familiar with the SLE quality indicators, only 18% of respondents reported using them in everyday practice. The most commonly reported barrier to involvement in quality improvement and the SLE quality indicators was time. Rheumatologists had a positive perception of the SLE quality indicators and agreed that use of the quality indicators could improve quality of care in SLE; however, they identified time as a barrier to implementation. Future studies should investigate methods to increase use of the SLE quality indicators.

"It's complicated" - talking about gout medicines in primary care consultations: a qualitative study

Background

Gout is the most common form of inflammatory arthritis. It is associated with substantial co-morbidity and often managed in primary care. A greater understanding of the communication process between patients and healthcare professionals provides one way of improving the management of this condition. This paper describes communication about gout medicines and treatment between patients and primary care health professionals during routine consultations.

Methods

Video-recordings of 31 individual healthcare consultations between patients and a range of primary care practitioners (general practitioners, practice nurses, podiatrists, dietitians) from an archived database were reviewed. Consultations that encompassed any discussion about gout medicines and treatment were included (n = 27) and were not solely restricted to those where gout was the presenting complaint. Themes were derived from an inductive qualitative analysis, from clinical and linguistic perspectives, based on the conversation between patients and practitioners about medicines and visual observation of these interactions.

Results

A number of factors were identified that had the potential to impact on the optimal management of gout in primary care. These included level of patient knowledge, patient attitudes to medicines, and the attributes of practitioner communication with patients. The latter related to the style of delivery and content of the information provided, and the ability of practitioners to make use of opportunities that arose to discuss these issues.

Conclusions

Patients with gout communicate at varying levels of complexity with a diverse range of primary care healthcare professionals about the treatment of their condition. It is important that all practitioners engaging with gout patients in this setting are knowledgeable about the current management of gout, provide clear, consistent and accurate messages, remain aware that these messages may need repeating over time, and are supportive of patients’ medicine-taking preferences.

A joint effort over a period of time: factors affecting use of urate-lowering therapy for long-term treatment of gout

Background

Although international guidelines encourage urate lowering therapy (ULT) for people who have more than two attacks of gout, only 30 % of patients are prescribed it and only 40 % of those adhere to the treatment. The aim was to explore reasons for this through an exploration of patient experience and understanding of ULT treatment for gout.

Methods

A qualitative study was conducted throughout the United Kingdom. Narrative and semi-structured video-recorded interviews and thematic analysis were used.

Results

Participants talked about their views and experiences of treatment, and the factors that affected their use of ULT. The analysis revealed five main themes: 1) knowledge and understanding of gout and its treatment; 2) resistance to taking medication; 3) uncertainty about when to start ULT; 4) experiences of using ULT; and 5) desire for information and monitoring.

Conclusion

Patients’ understanding and experiences of gout and ULT are complex and it is important for clinicians to be aware of these when working with patients. It is also important for clinicians to know that patients’ perceptions and behaviour are not fixed, but can change over time, with changes to their condition, with dialogue and increased understanding. Patients want this interaction with their clinicians, through “a joint effort over a period of time”.

Understanding and improving the use of allopurinol in a teaching hospital

BACKGROUND

An emphasis on renal function in deciding maintenance doses of allopurinol to prevent allopurinol hypersensitivity has resulted in ineffective prevention of attacks of gout. New therapeutic guidelines for gout have shifted the focus back to titrating maintenance doses to reach a serum uric acid (SUA) concentration target of ≤ 0.36 mmol/L.

AIMS

To examine trends in the prescribing of allopurinol in a teaching hospital and their concordance with the new guidelines for gout management, and to explore prescribers' approaches and attitudes to the use of allopurinol.

METHODS

An audit was conducted of all inpatients prescribed allopurinol at a teaching hospital between January 2008 and December 2012. Allopurinol dose, SUA, serum creatinine concentrations and estimated glomerular filtration rates were extracted from the hospital databases. Doctors from medical units who regularly prescribed allopurinol were interviewed.

RESULTS

The allopurinol dose prescribed in gout patients most commonly was a continuation of the pre-admission dosage. Dosage change during admission was rarely observed. Dosages reflected a consideration of renal function. SUA concentrations were measured in only 21% (n = 269) of gout patients. Prescriber interviews (n = 12) reflected adequate knowledge regarding allopurinol use, but most maintained that the primary care setting was more suitable for the management of dose titration in gout.

CONCLUSIONS

SUA concentrations were not routinely measured in the majority of admitted gout patients taking allopurinol. Without SUA measurements and allopurinol dose titration, patients with SUA > 0.36 mmol/L are at increased risk for acute attacks of gout in hospital.

Hyperuricaemia with deposition: latest evidence and therapeutic approach

This article reviews recent evidence on urate deposition and the opportunity for a therapeutic approach. We reviewed Pubmed 2013-2015 literature using the search terms 'deposition' with 'hyperuricaemia', 'gout', 'ultrasonography', 'DECT' (dual-energy computed tomography), 'radiography', 'CT'(computed tomography), 'MRI' (magnetic resonance imaging), or 'cardiovascular', in addition to a digital bibliographic library compiled by the authors with 2072 papers on hyperuricaemia and gout. Relevant papers on the topic were selected. Recent evidence, mostly based on imaging studies, showed a continuum from hyperuricaemia to deposition and clinical manifestations. Chronic inflammation and structural damage may be present even in asymptomatic patients with crystal-proved deposition. The impact of early intervention in patients with asymptomatic deposition either on vascular outcomes or further structural joint damage has not been demonstrated yet. In conclusion, a worldwide definition of gout is still lacking, stages from hyperuricaemia to clinical gout not being definitively defined. Although there is increasing interest on the impact of early deposits on joint damage and cardiovascular outcomes, robust evidence is still lacking to fully support interventions.

Management of gout in the real world: current practice versus guideline recommendations

OBJECTIVES

Gout is a chronic, extremely painful disease that is potentially curable when treated effectively. Unfortunately approximately one-half of patients with gout are inadequately controlled.

METHODS

We surveyed 315 primary care physicians in the United States and Europe to investigate current practice in the real world, as distinct from recommendations in guidelines.

RESULTS

Our survey on 1657 patients found that regular testing of serum uric acid, in conformity with the guidelines, was conducted by approximately 50% of physicians. Advice to patients on diet and lifestyle was less well implemented, and identification of overweight/obese patients was inconsistent.

CONCLUSION

Improvements in practice by physicians would include comprehensive assessment of the patient, adoption of regular monitoring during treatment, and the provision of patient education on adherence and lifestyle.

Multimorbidity and Patient Safety Incidents in Primary Care: A Systematic Review and Meta-Analysis

BACKGROUND

Multimorbidity is increasingly prevalent and represents a major challenge in primary care. Patients with multimorbidity are potentially more likely to experience safety incidents due to the complexity of their needs and frequency of their interactions with health services. However, rigorous syntheses of the link between patient safety incidents and multimorbidity are not available. This review examined the relationship between multimorbidity and patient safety incidents in primary care.

METHODS

We followed our published protocol (PROSPERO registration number: CRD42014007434). Medline, Embase and CINAHL were searched up to May 2015. Study design and quality were assessed. Odds ratios (OR) and 95% confidence intervals (95% CIs) were calculated for the associations between multimorbidity and two categories of patient safety outcomes: 'active patient safety incidents' (such as adverse drug events and medical complications) and 'precursors of safety incidents' (such as prescription errors, medication non-adherence, poor quality of care and diagnostic errors). Meta-analyses using random effects models were undertaken.

RESULTS

Eighty six relevant comparisons from 75 studies were included in the analysis. Meta-analysis demonstrated that physical-mental multimorbidity was associated with an increased risk for 'active patient safety incidents' (OR = 2.39, 95% CI = 1.40 to 3.38) and 'precursors of safety incidents' (OR = 1.69, 95% CI = 1.36 to 2.03). Physical multimorbidity was associated with an increased risk for active safety incidents (OR = 1.63, 95% CI = 1.45 to 1.80) but was not associated with precursors of safety incidents (OR = 1.02, 95% CI = 0.90 to 1.13). Statistical heterogeneity was high and the methodological quality of the studies was generally low.

CONCLUSIONS

The association between multimorbidity and patient safety is complex, and varies by type of multimorbidity and type of safety incident. Our analyses suggest that multimorbidity involving mental health may be a key driver of safety incidents, which has important implication for the design and targeting of interventions to improve safety. High quality studies examining the mechanisms of patient safety incidents in patients with multimorbidity are needed, with the goal of promoting effective service delivery and ameliorating threats to safety in this group of patients.

Role of Community Pharmacies for the Detection of Potentially Inappropriate Xanthine Oxidase Inhibitor Prescriptions

Background

Xanthine oxidase (XO) inhibitors are largely the treatment of choice for gout, but allopurinol is often inappropriately used for asymptomatic hyperuricemia. There is little evidence that allopurinol is useful in preventing cardiovascular diseases and therapeutic decisions must the balance the expected benefit with the potential harm.

Objective

To investigate the appropriateness of XO inhibitor use in relation to evidence-based indications and examine the role of community pharmacies in the detection of inappropriate prescriptions of these drugs.

Methods

This is an observational study conducted in eight community pharmacies. Each pharmacist was asked to interview a sample of patients who had received prescriptions of XO inhibitors. Patients were asked to complete a structured minimum data set that collected information on drug indication, history of gout, and presence of cardiovascular diseases.

Results

The study sample included 74 patients receiving XO inhibitors. About one third of patients reported being treated for asymptomatic hyperuricemia and had never had a gout attack. About half of the patients treated for asymptomatic hyperuricemia had been receiving the drug treatment for more than 3 years. Four asymptomatic hyperuricemic patients received allopurinol to treat hypertension. Among the patients treated for asymptomatic hyperuricemia, there was a higher presence of diabetes mellitus, obesity, previous myocardial infarction, and heart failure than in patients treated for an appropriate indication.

Conclusions

Inappropriate use of XO inhibitors is principally related to the treatment of hyperuricemia in patients with cardiovascular diseases. Community pharmacists have a central role in pharmacovigilance, by contributing to the prevention and identification of potentially inappropriate drug prescriptions.

Electronic supplementary material

The online version of this article (doi:10.1007/s40801-015-0016-7) contains supplementary material, which is available to authorized users.

Epidemiology and management of gout in Taiwan: a nationwide population study

INTRODUCTION

Gout is the most common inflammatory arthritis worldwide and is the only type of chronic arthritis that potentially can be 'cured'. However, data on gout incidence, prevalence and management, assessed at multiple time points in the same population, are sparse, particularly in Asian populations. The aim of this study was to describe trends in the epidemiology of gout in the general population of Taiwan.

METHODS

The National Health Insurance Research Database was used to identify patients with gout and to estimate the prevalence and incidence of gout for each calendar year from 2005 to 2010. The pattern of gout management was also examined.

RESULTS

Of 23,371,362 beneficiaries in 2010, there were 1,458,569 prevalent and 56,595 incident cases of gout, giving a prevalence of 6.24% (95% confidence interval (CI), 6.23% to 6.25%) and an incidence of 2.74 (95% CI, 2.72 to 2.76) per 1,000 person-years. The annual percentage change (APC) of the standardised prevalence was -0.7% (95% CI, -1.7% to 0.3%; P=0.14), suggesting that the prevalence of gout was essentially the same throughout the study period. However, The APC of incidence was -13.4 (95% CI, -16.1 to -10.6) between 2005 and 2007 and -2.1 (95% CI, -10.4 to 7.1) between 2007 and 2010. Regions with the highest prevalence and incidence were eastern coastal counties and offshore islets, where indigenous people are clustered. Among prevalent gout cases in 2010, only 22.93% (95% CI, 22.87% to 23.00%) were prescribed urate-lowering treatment (ULT), which remained unchanged between 2005 and 2010 at an APC of 0.0 (95% CI, -3.8 to 4.0). Uricosuric agents were more commonly prescribed than xanthine oxidase inhibitors in Taiwan.

CONCLUSIONS

In Taiwan, 1 in 16 people have gout. Whereas the incidence has decreased recently, the prevalence remains unchanged. Management of gout in Taiwan is poor, with only one in five affected people being treated with ULT.

Modifiable factors associated with allopurinol adherence and outcomes among patients with gout in an integrated healthcare system

OBJECTIVE

To identify modifiable patient and provider factors associated with allopurinol adherence and the achievement of a serum urate acid (SUA) goal in gout.

METHODS

We identified a retrospective cohort of patients with gout, newly treated with allopurinol. All patient data came from administrative datasets at a large integrated health delivery system. Patients were ≥ 18 years old at time of initial allopurinol dispensing, and had 12 months or more of membership and drug eligibility prior to the index date. Allopurinol adherence was defined as a proportion of days covered ≥ 0.80, evaluated during the first 12 months of observation after the initial dispensing. Multivariable logistic regression was used to examine factors associated with allopurinol nonadherence and attaining an SUA concentration < 6.0 mg/dl.

RESULTS

We identified 13,341 patients with gout with incident allopurinol use (mean age 60 yrs, 78% men). Of these, 9581 patients (72%) had SUA measured both at baseline and during followup. Only 3078 patients (32%) attained an SUA target of < 6.0 mg/dl during followup. Potentially modifiable factors associated with treatment adherence and obtaining the SUA goal in the multivariable analysis included concomitant diuretic use, prescriber specialty, and allopurinol dosing practices. Adherent patients were 2.5-fold more likely than nonadherent patients to achieve an SUA < 6.0 mg/dl during observation.

CONCLUSION

Among patients with gout initiating allopurinol in our study, 68% did not reach the SUA goal and 57% of patients were nonadherent. Modifiable factors, including allopurinol dose escalation, treatment adherence, rheumatology referral, and concomitant medication use, could be important factors to consider in efforts aimed at optimizing gout treatment outcomes.

Health literacy in patients dealing with gout: a qualitative study

The objective of this study was to explore the health literacy of patients dealing with gout and to understand perceptions that might account for non-adherence to urate-lowering therapy (ULT). Semi-structured interviews involving patients with gout were conducted. The transcripts of the interviews were scored by two readers and a coding system to categorize the data was developed. Fifteen patients (14 men, mean age 63 years, mean disease duration 11 years) were interviewed; ten patients were recruited from secondary care and five from primary care. Six patients had gout tophi and 12 patients used ULT. Less than half of the patients were sufficiently aware of the pathophysiological processes that cause gout. Twelve patients indicated that treatment of gout only encompasses treatment of the acute attack. Patients were unaware of long-term treatment goals. Six patients admitted medication non-adherence at some point in time. Several reasons for non-adherence, such as healthcare professionals providing conflicting messages about medication, can be considered preventable. Half of the patients expressed that they, especially at the time of diagnosis, wanted to know more about the cause of gout, treatment goals and long-term consequences. In conclusion, the health literacy of patients dealing with gout was low in our study, especially with regard to medication. Yet, patients often recognized these knowledge gaps. Our data suggest that improving knowledge and addressing common misperceptions in training programmes, may ultimately contribute to adherence to ULT and an optimized outcome in patients with gout. This hypothesis needs to be confirmed in future research.

Gout: A clinical overview and its association with cardiovascular diseases

Gout is a common disease caused by the deposition of monosodium urate (MSU) crystals in patients with hyperuricemia, and characterized by very painful recurrent acute attacks of arthritis. The gold standard for diagnosing gout is the identification of MSU crystals in synovial fluid by polarization light microscopy. Arthritis attacks can be treated with anti-inflammatory medications, such as non-steroidal anti-inflammatory drugs, colchicine, oral prednisone, or intra-articular or intramuscular glucocorticoids. To prevent gout uric acid lowering therapy with for example allopurinol can be prescribed. When gout is adequately treated, the prognosis is good. Unfortunately, the management of gout patients is often insufficient. Gout is associated with dietary factors, the use of diuretics, and several genetic factors. Comorbidities as hypertension, chronic kidney disease, cardiovascular diseases, the metabolic syndrome, diabetes, obesity, hyperlipidemia, and early menopause are associated with a higher prevalence of gout. Xanthine oxidase and chronic systemic inflammation seem to play an important role in the pathophysiology of the association between gout and cardiovascular diseases. To prevent cardiovascular diseases gout patients must be early screened for cardiovascular risk factors.

Understanding adverse drug reactions in older adults through drug-drug interactions

AIMS

The aims of this study are to evaluate prevalence and characteristics of adverse drug reactions (ADRs) and to evaluate the potential contribution of specific medications, therapeutic categories and drug-drug interactions (DDIs) in older adults.

METHODS

All ADR reporting forms of persons aged 65+ years collected by the pharmacovigilance of one of the main hospitals in Italy during 2013 were evaluated. DDIs were analysed by a computerized prescription system (INTERCheck) and based on the interactions' database managed by the Istituto di Ricerche Farmacologiche Mario Negri. DDIs were classified according to their clinical relevance as contraindicated, major, and moderate.

RESULTS

Amongst all the ADR reporting forms (n=1014) collected during 2013, 343 affected older adults. The most frequent ADRs were: haemorrhages (n=122, 35.5%), allergic reactions (n=56, 16.3%), and elevated International Normalized Ratio (INR>6, n=54, 15.7%). The specific medications that contributed to ADRs were warfarin (42.5%), acenocumarol (9%), and allopurinol (8.5%); while the therapeutic categories were haematological agents (67%) and proton pump inhibitors (13%). A total of 912 DDIs were found; one third of them were contraindicated or major and 31.5% of them potentially contributed to ADRs; of these, the most frequent were: warfarin and heparin (contraindicated, n=5); warfarin and a statin (major, n=38); warfarin and a proton pump inhibitor (moderate, n=40). At least one DDI contributed to 66 haemorrhages out of 122 (54%) and to 41 elevated INR out of 54 (76%).

CONCLUSION

DDIs significantly contribute to the onset of ADRs in older adults and intervention programmes, e.g., the employment of a computerized system, may reduce the burden of iatrogenic illnesses in the elderly.

Increased risk of vascular disease associated with gout: a retrospective, matched cohort study in the UK clinical practice research datalink

Objectives

To determine whether gout increases risk of incident coronary heart disease (CHD), cerebrovascular (CVD) and peripheral vascular disease (PVD) in a large cohort of primary care patients with gout, since there have been no such large studies in primary care.

Methods

A retrospective cohort study was performed using data from the Clinical Practice Research Datalink (CPRD). Risk of incident CHD, CVD and PVD was compared in 8386 patients with an incident diagnosis of gout, and 39 766 age, sex and registered general practice-matched controls, all aged over 50 years and with no prior vascular history, in the 10 years following incidence of gout, or matched index date (baseline). Multivariable Cox Regression was used to estimate HRs and covariates included sex and baseline measures of age, Body Mass Index, smoking, alcohol consumption, Charlson comorbidity index, history of hypertension, hyperlipidaemia, chronic kidney disease, statin use and aspirin use.

Results

Multivariable analysis showed men were at increased risk of any vascular event (HRs (95% CIs)) HR 1.06 (1.01 to 1.12), any CHD HR 1.08 (1.01 to 1.15) and PVD HR 1.18 (1.01 to 1.38), while women were at increased risk of any vascular event, HR 1.25 (1.15 to 1.35), any CHD HR 1.25 (1.12 to 1.39), and PVD 1.89 (1.50 to 2.38)) but not any CVD.

Conclusions

In this cohort of over 50s with gout, female patients with gout were at greatest risk of incident vascular events, even after adjustment for vascular risk factors, despite a higher prevalence of both gout and vascular disease in men. Further research is required to establish the reason for this sex difference.

Measuring physician adherence with gout quality indicators: a role for natural language processing

OBJECTIVE

To evaluate physician adherence with gout quality indicators (QIs) for medication use and monitoring, and behavioral modification (BM).

METHODS

Gout patients were assessed for the QIs as follows: QI 1: initial allopurinol dosage <300 mg/day for patients with chronic kidney disease (CKD); QI 2: uric acid within 6 months of allopurinol start; and QI 3: complete blood count and creatinine phosphokinase within 6 months of colchicine initiation. Natural language processing (NLP) was used to analyze clinical narrative data from electronic medical records (EMRs) of overweight (body mass index ≥28 kg/m(2) ) gout patients for BM counseling on gout-specific dietary restrictions, weight loss, and alcohol consumption (QI 4). Additional data included sociodemographics, comorbidities, and number of rheumatology and primary care visits. QI compliance versus noncompliance was compared using chi-square analyses and independent-groups t-test.

RESULTS

In 2,280 gout patients, compliance with QI was as follows: QI 1: 92.1%, QI 2: 44.8%, and QI 3: 7.7%. Patients compliant with QI 2 had more rheumatology visits at 3.5 versus 2.6 visits (P < 0.001), while those compliant with QI 3 had more CKD (P < 0.01). Of 1,576 eligible patients, BM counseling for weight loss occurred in 1,008 patients (64.0%), low purine diet in 390 (24.8%), alcohol abstention in 137 (8.7%), and all 3 elements in 51 patients (3.2%). Regular rheumatology clinic visits correlated with frequent advice on weight loss and gout-specific diet (P < 0.0001).

CONCLUSION

Rheumatology clinic attendance was associated with greater QI compliance. NLP proved a valuable tool for measuring BM as documented in the clinical narrative of EMRs.

The impact of gout on patient's lives: a study of African-American and Caucasian men and women with gout

Introduction

The aim of this study was to examine the impact of gout on quality of life (QOL) and study differences by gender and race.

Methods

Ten race- and sex-stratified nominal groups were conducted, oversampling for African-Americans and women with gout. Patients presented, discussed, combined and rank-ordered their concerns.

Results

A total of 62 patients with mean age 65.1 years, 60% men, 64% African-American, participated in 10 nominal groups: African-American men (n = 23; 3 groups); African-American women (n = 18; 3 groups); Caucasian men (n = 15; 3 groups); and Caucasian women (n = 6; 1 group). The most frequently cited high-ranked concerns among the ten nominal groups were: (1) effect of gout flare on daily activities (n = 10 groups); (2) work disability (n = 8 groups); (3) severe pain (n = 8 groups); (4) joint swelling and tenderness (n = 6 groups); (5) food restrictions (n = 6 groups); (6) medication related issues (n = 6 groups); (7) dependency on family and others (n = 5 groups); (8) emotional Impact (n = 5 groups); (9) interference with sexual function (n = 4 groups); (10) difficulty with shoes (n = 4 groups); and (11) sleep disruption (n = 4 groups). Compared with men, women ranked the following concerns high more often: problems with shoes (n = 4 versus n = 0 groups); dependency (n = 3 versus n = 2 groups); and joint/limb deformity (n = 2 versus n = 0 group). Compared with Caucasians, African-Americans ranked the following concerns high more often: dietary restrictions (n = 6 versus n = 0 groups); severe pain (n = 6 versus n = 2 groups); gout bringing the day to a “halt” (n = 2 versus n = 0 group); effect on emotional health (n = 4 versus n = 1 groups); and the need for canes/crutches during flares (n = 2 versus n = 0 group).

Conclusions

Gout has a significant impact on a patient’s QOL. Important differences in the impact of gout by gender and race were noted.

[Diagnosis and management of gout in Austria. Survey of current practice considering the EULAR recommendations]

BACKGROUND AND OBJECTIVES

Gout shows an increasing incidence and has become a major health problem in the Western world. Despite effective treatment options, neither diagnosis nor therapeutic efforts can be regarded sufficient to date. It was of interest to investigate current handling of gout among Austrian rheumatologists.

MATERIAL AND METHODS

In 2012, a survey of Austrian rheumatologists concerning diagnosis and management of hyperuricemia and gout was performed. With the consent of the Austrian Society of Rheumatology, 574 society members (343 via electronic mail, 23 via mail) were sent a questionnaire consisting of 17 questions. This is the first survey assessing the management of gout among Austrian rheumatologists.

RESULTS

The overall response rate was 22.1 %. Of all the contacted members (email and mail), 19.9 % answered the questionnaire electronically and only 5.6 % by mail. The adherence to the EULAR recommendations for gout ranged between 69 and 95 % (median 84 %).

CONCLUSION

Among Austrian rheumatologists, the knowledge about gout, its diagnostic and imaging procedures, management and therapeutic goals is good and mainly in line with current international recommendations. To improve the management of patients with gout and hyperuricemia, a more frequent referral to rheumatologists could be beneficial.