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Helget LN, Davis-Karim A, O'Dell JR, Mikuls TR, Newcomb JA, Androsenko M, Brophy MT, England BR, Ferguson R, Pillinger MH, Neogi T, Wu H, Palevsky PM. Efficacy and Safety of Allopurinol and Febuxostat in Patients With Gout and CKD: Subgroup Analysis of the STOP Gout Trial. Am J Kidney Dis 2024:S0272-6386(24)00835-7. [PMID: 38906504 DOI: 10.1053/j.ajkd.2024.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 04/03/2024] [Accepted: 04/19/2024] [Indexed: 06/23/2024]
Abstract
RATIONALE & OBJECTIVE We conducted a prespecified examination of the efficacy and safety of allopurinol and febuxostat administered using a treat-to-target strategy in trial participants with chronic kidney disease (CKD). STUDY DESIGN Prespecified sub cohort analysis of a randomized controlled trial. SETTING & Participants: A sub study of the STOP Gout trial in participants with CKD. CKD was defined as an eGFR 30-59 mL/min/1.73 m2 at baseline. EXPOSURE Trial participants with CKD and gout and serum urate (sUA) concentration ≥6.8 mg/dL were randomized 1:1 to receive allopurinol or febuxostat. Urate lowering therapy (ULT) was titrated during weeks 0-24 to achieve a goal sUA of <6.0 mg/dl (<5.0 mg/dl with tophi) (Phase 1) and maintained during weeks 25-48 (Phase 2). Gout flare was assessed between weeks 49-72 (Phase 3). OUTCOME Gout flare between weeks 49-72 (Phase 3) was the primary outcome. Secondary outcomes included sUA goal achievement and ULT dosing at end of Phase 2, and serious adverse events (SAEs). ANALYTICAL APPROACH Outcomes between treatment groups were compared using logistic regression models for binary outcomes, and Poisson regression for flare rates. Multivariable models were subsequently used, adjusting for factors identified to be imbalanced by treatment arm. RESULTS 351 of 940 participants (37.3%) had CKD; 277 were assessed for the primary outcome. Fewer patients randomized to allopurinol had a flare during phase 3 (32% vs 45%; p=0.02) despite similar attainment of sUA goal (79% vs. 81%; p=0.6) by the end of Phase 2. Acute kidney injury (AKI) was more common in participants with stage 3 CKD randomized to allopurinol compared to febuxostat. LIMITATIONS Limited power to assess infrequent safety events, largely male, older population. CONCLUSIONS Allopurinol and febuxostat are similarly efficacious and well-tolerated in the treatment of gout in people with CKD when used in a treat-to-target regimen.
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Affiliation(s)
- Lindsay N Helget
- Veterans Affairs (VA) Nebraska-Western Iowa Health Care System, Omaha, Nebraska; Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska.
| | - Anne Davis-Karim
- VA Cooperative Studies Program Clinical Research Pharmacy Coordinating Center, Albuquerque, NM
| | - James R O'Dell
- Veterans Affairs (VA) Nebraska-Western Iowa Health Care System, Omaha, Nebraska; Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Ted R Mikuls
- Veterans Affairs (VA) Nebraska-Western Iowa Health Care System, Omaha, Nebraska; Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Jeff A Newcomb
- Veterans Affairs (VA) Nebraska-Western Iowa Health Care System, Omaha, Nebraska; Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Maria Androsenko
- VA Boston Cooperative Studies Program Coordinating Center, Boston
| | - Mary T Brophy
- VA Boston Cooperative Studies Program Coordinating Center, Boston; School of Medicine, VA Boston Health Care System, Boston University, Boston
| | - Bryant R England
- Veterans Affairs (VA) Nebraska-Western Iowa Health Care System, Omaha, Nebraska; Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Ryan Ferguson
- VA Boston Cooperative Studies Program Coordinating Center, Boston
| | - Michael H Pillinger
- VA New York Harbor Health Care System, New York; NYU Grossman School of Medicine, New York
| | | | - Hongsheng Wu
- VA Boston Cooperative Studies Program Coordinating Center, Boston; Babson College, Wellesley, MA
| | - Paul M Palevsky
- VA Pittsburgh Health Care System, Pittsburgh; University of Pittsburgh School of Medicine, Pittsburgh
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Wen H, Yongling Z, Shuying Z, Jiali W, Yanling Z. Effect of febuxostat on renal function in patients from South China with CKD3 diabetic nephropathy. J Bras Nefrol 2020; 42:393-399. [PMID: 32701116 PMCID: PMC7860659 DOI: 10.1590/2175-8239-jbn-2019-0091] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 04/08/2020] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To investigate the efficacy and safety of febuxostat on renal function in CKD stage 3 diabetic nephropathy patients. METHODS Patients in our hospital with chronic kidney disease (CKD) stage 3 diabetic nephropathy (DN) complicated by high serum uric acid (360 µmol/L) were recruited. Patients were then divided into treatment group and control group according to the random number table method. All the patients received low purine diet, renin-angiotensin-aldosterone system (RAAS) inhibitors, and adequate routine hypoglycemic treatment. Febuxostat was employed only in the treatment group. The levels of blood uric acid (sUA), serum creatinine (Scr), cystatin C (cys-c), eGFR, 24-hour urine protein quantification, albuminuria, and creatinine ratio (ACR) were evaluated in all patients before and after treatment at 4, 8, 12, and 24 week. RESULTS No difference was found before treatment between the two groups. After treatment at 4, 8, 12, and 24 week, the levels of sUA, SCr, cys-c, and eGFR between the two groups were significant different (P<0.05). There was no difference in 24-hour urine protein quantification, albuminuria, and creatinine ratio between two groups before treatment, and significant differences were observed after treatment. Fifty percent of patients from the treatment group achieved the treatment goal with 20 mg febuxostat at 4 weeks. Tubular markers were also decreased with the treatment. CONCLUSIONS Febuxostat can reduce uric acid and improve renal function effectively in patients with CKD stage 3 diabetic nephropathy, while being well tolerated. However, the conclusion is still uncertain due to the short term of the study.
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Affiliation(s)
- Huang Wen
- Wenzhou Medical University, Second Affiliated Hospital of Wenzhou Medical University, Department of Nephrology, Wenzhou, China
| | - Zhu Yongling
- Wenzhou City Second People's Hospital, Hematological Department, Wenzhou City, China
| | - Zheng Shuying
- Wenzhou Medical University, Second Affiliated Hospital of Wenzhou Medical University, Department of Nephrology, Wenzhou, China
| | - Wang Jiali
- Wenzhou Medical University, Second Affiliated Hospital of Wenzhou Medical University, Department of Nephrology, Wenzhou, China
| | - Zhao Yanling
- Wenzhou Medical University, Second Affiliated Hospital of Wenzhou Medical University, Department of Nephrology, Wenzhou, China
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Rezapour A, Alidoost S, Asgharzadeh A, Farhadi Z, Khodadadi N, Mohammadi Bakhsh R, Sepehrian R, Salemi M, Taheri Mirghaed M, Behzadifar M, Sohrabi R. Cost-effectiveness of allopurinol versus febuxostat in the treatment of gout patients: A systematic review. Med J Islam Repub Iran 2020; 34:41. [PMID: 32884916 PMCID: PMC7456432 DOI: 10.34171/mjiri.34.41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Indexed: 11/05/2022] Open
Abstract
Background: In recent years, increased longevity, poor dietary habits, and the rising prevalence of metabolic syndrome and hypertension have increased the prevalence of gout. Gout significantly increases direct and indirect costs and reduces the quality of life. Allopurinol and febuxostat are the most commonly used drugs for reducing uric acid levels and controlling this disease with different cost-effectiveness. The present systematic review compares the cost-effectiveness of these drugs. Methods: This was a systematic review of economic evaluations. Cochrane CENTRAL, Web of Science, PubMed, Embase, and the Cost-Effectiveness Analysis (CEA) Registry were searched up to April 30, 2018, based on the specific search strategy of each database. Keywords used in the search include gout, cost-effectiveness, allopurinol, and febuxostat in MeSH and free-text forms. Screening of identified studies, data extraction, and quality assessment were done independently by 2 reviewers. The quality of studies was assessed based on Drummond Checklist. Finally, a qualitative analysis was done to analyze the results. Results: A total of 94 studies were identified through database search and the review of references. After screening the titles, abstracts, and full-texts, 6 economic evaluations were included in the review. The majority of the studies had been conducted in the US using the Markov model, within a 5-year horizon, and from the payer's perspective, with the quality of life as a measure of effectiveness. In most studies, the incremental cost-effectiveness ratios (ICERs) of febuxostat per quality-adjusted life year (QALY) were below the threshold (10 000$/QALY and 30 000€/QALY). Conclusion: Febuxostat has been shown to be more cost-effective than allopurinol in all treatment sequences in studies that have used uric acid levels as the measure of effectiveness. Furthermore, in studies with the quality of life as the measure of effectiveness, febuxostat has been shown to be very cost-effective as the second-line treatment.
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Affiliation(s)
- Aziz Rezapour
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Saeide Alidoost
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Asra Asgharzadeh
- Health Technology Assessment Group (HTAG), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Zeynab Farhadi
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Najme Khodadadi
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
| | | | - Razieh Sepehrian
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Morteza Salemi
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Masood Taheri Mirghaed
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Masoud Behzadifar
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Rahim Sohrabi
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
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Lin LW, Teng GG, Lim AYN, Yoong JSY, Zethraeus N, Wee HL. Cost-effectiveness of an adherence-enhancing intervention for gout based on real-world data. Int J Rheum Dis 2018; 22:545-554. [PMID: 30556300 PMCID: PMC6590285 DOI: 10.1111/1756-185x.13446] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 10/08/2018] [Accepted: 10/23/2018] [Indexed: 12/28/2022]
Abstract
AIM Medication non-adherence influences outcomes of therapies for chronic diseases. Allopurinol is a cornerstone therapy for patients with gout; however, non-adherence to allopurinol is prevalent in Singapore and limits its effectiveness. Between 2008-2010, an adherence-enhancing program was implemented at the rheumatology division of a public tertiary hospital. The cost-effectiveness of this program has not been fully evaluated. With healthcare resources being finite, the value of investing in adherence-enhancing interventions should be ascertained. This study aims to evaluate the cost-effectiveness of this adherence-enhancing program to inform optimal resource allocation toward better gout management. METHOD Adopting a real-world data approach, we utilized patient clinical and financial records generated in their course of routine care. Intervention and control groups were identified in a standing database and matched on nine risk factors through propensity score matching. Cost and effect data were followed through 1-2 years. A decision tree was developed in TreeAge using a societal perspective. Deterministic and probabilistic sensitivity analyses were performed to assess parameter uncertainty. RESULTS At an assumed willingness-to-pay threshold of $50 000 USD ($70 000 SGD) per quality-adjusted life year (QALY), the intervention had an 85% probability of being cost-effective compared to routine care. The incremental cost-effectiveness ratio was $12 866 USD per QALY for the base case and ranged from $4 139 to $21 593 USD per QALY in sensitivity analyses. CONCLUSION The intervention is cost-effective in the short-term, although its long-term cost-effectiveness remains to be evaluated.
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Affiliation(s)
- Lydia Wenxin Lin
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore.,Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Gim Gee Teng
- Division of Rheumatology, University Medicine Cluster, National University Health System, Singapore, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Anita Yee Nah Lim
- Division of Rheumatology, University Medicine Cluster, National University Health System, Singapore, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Joanne Su-Yin Yoong
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Niklas Zethraeus
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Hwee-Lin Wee
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore.,Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore, Singapore
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Yu KH, Chen DY, Chen JH, Chen SY, Chen SM, Cheng TT, Hsieh SC, Hsieh TY, Hsu PF, Kuo CF, Kuo MC, Lam HC, Lee IT, Liang TH, Lin HY, Lin SC, Tsai WP, Tsay GJ, Wei JCC, Yang CH, Tsai WC. Management of gout and hyperuricemia: Multidisciplinary consensus in Taiwan. Int J Rheum Dis 2018; 21:772-787. [PMID: 29363262 DOI: 10.1111/1756-185x.13266] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Gout is an inflammatory disease manifested by the deposition of monosodium urate (MSU) crystals in joints, cartilage, synovial bursa, tendons or soft tissues. Gout is not a new disease, which was first documented nearly 5,000 years ago. The prevalence of gout has increased globally in recent years, imposing great disease burden worldwide. Moreover, gout or hyperuricemia is clearly associated with a variety of comorbidities, including cardiovascular diseases, chronic kidney disease, urolithiasis, metabolic syndrome, diabetes mellitus, thyroid dysfunction, and psoriasis. To prevent acute arthritis attacks and complications, earlier use of pharmacotherapeutic treatment should be considered, and patients with hyperuricemia and previous episodes of acute gouty arthritis should receive long-term urate-lowering treatment. Urate-lowering drugs should be used during the inter-critical and chronic stages to prevent recurrent gout attacks, which may elicit gradual resolution of tophi. The goal of urate-lowering therapy should aim to maintain serum uric acid (sUA) level <6.0 mg/dL. For patients with tophi, the initial goal can be set at lowering sUA to <5.0 mg/dL to promote tophi dissolution. The goal of this consensus paper was to improve gout and hyperuricemia management at a more comprehensive level. The content of this consensus paper was developed based on local epidemiology and current clinical practice, as well as consensuses from two multidisciplinary meetings and recommendations from Taiwan Guideline for the Management of Gout and Hyperuricemia.
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Affiliation(s)
- Kuang-Hui Yu
- Division of Rheumatology, Allergy, and Immunology, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Der-Yuan Chen
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,Ph.D. Program in Translational Medicine, Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Jiunn-Horng Chen
- Division of Immunology and Rheumatology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan.,School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | | | - Shyh-Ming Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung, Taiwan
| | - Tien-Tsai Cheng
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung, Taiwan
| | - Song-Chou Hsieh
- Division of Rheumatology, Immunology and Allergy, Department of Internal Medicine, National Taiwan University Hospital, Hsinchu, Taiwan
| | - Tsu-Yi Hsieh
- Division of Allergy, Immunology, and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,Ph.D. Program of Business, Institute of Business, Feng-Chia University, Taichung, Taiwan
| | - Pai-Feng Hsu
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Healthcare and Services Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chang-Fu Kuo
- Division of Rheumatology, Allergy, and Immunology, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Mei-Chuan Kuo
- Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Faculty of Renal Care, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hing-Chung Lam
- Division of Endocrinology and Metabolism, Department of Internal Medicine, E-Da Hospital/I-Shou University, Kaohsiung, Taiwan
| | - I-Te Lee
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Toong-Hua Liang
- Rheumatology Section, Renai Branch, Taipei City Hospital, Taipei, Taiwan
| | - Hsiao-Yi Lin
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Allergy, Immunology and Rheumatology, Department of Medicine, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Shih-Chang Lin
- Division of Rheumatology and Immunology, Cathay General Hospital, Taipei, Taiwan.,Department of Medicine, College of Medicine, Fu-Jen Catholic University, New Taipei, Taiwan
| | - Wen-Pin Tsai
- Department of Immunology and Rheumatology, Hsinchu MacKay Memorial Hospital, Hsinchu, Taiwan
| | - Gregory J Tsay
- Division of Immunology and Rheumatology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan.,School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - James Cheng-Chung Wei
- Division of Allergy, Immunology and Rheumatology, Chung Shan Medical University Hospital, Taichung, Taiwan.,Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan
| | - Chung-Han Yang
- Division of Rheumatology, Allergy, and Immunology, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan.,Department of Internal Medicine, Landseed Hospital, Taoyuan, Taiwan
| | - Wen-Chan Tsai
- Department of Allergy, Immunology, and Rheumatology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
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Vargas-Santos AB, Neogi T. Management of Gout and Hyperuricemia in CKD. Am J Kidney Dis 2017; 70:422-439. [PMID: 28456346 DOI: 10.1053/j.ajkd.2017.01.055] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 01/21/2017] [Indexed: 02/07/2023]
Abstract
Hyperuricemia and gout, the clinical manifestation of monosodium urate crystal deposition, are common in patients with chronic kidney disease (CKD). Although the presence of CKD poses additional challenges in gout management, effective urate lowering is possible for most patients with CKD. Initial doses of urate-lowering therapy are lower than in the non-CKD population, whereas incremental dose escalation is guided by regular monitoring of serum urate levels to reach the target level of <6mg/dL (or <5mg/dL for patients with tophi). Management of gout flares with presently available agents can be more challenging due to potential nephrotoxicity and/or contraindications in the setting of other common comorbid conditions. At present, asymptomatic hyperuricemia is not an indication for urate-lowering therapy, though emerging data may support a potential renoprotective effect.
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Affiliation(s)
| | - Tuhina Neogi
- Clinical Epidemiology Research and Training Unit, Boston University School of Medicine, Boston, MA.
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