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Gerritsen M, Nurmohamed MT. The Effects of Pharmacological Urate-Lowering Therapy on Cardiovascular Disease in Older Adults with Gout. Drugs Aging 2024; 41:319-328. [PMID: 38416394 DOI: 10.1007/s40266-024-01098-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2024] [Indexed: 02/29/2024]
Abstract
Cardiovascular disease is an important cause of mortality in older patients. In addition to the traditional risk factors for cardiovascular disease, hyperuricemia has been increasingly associated with an elevated risk of cardiovascular disease. Uric acid itself has several unfavorable effects on the cardiovascular system, and hyperuricemia can lead to the development of gout. Gout is the most prevalent inflammatory rheumatic disease. Older patients with gout have an increased risk of cardiovascular morbidity and mortality due to an increased prevalence of traditional risk factors, as well as the inflammatory burden of gout activity. As the prevalence of traditional risk factors and the prevalence of both hyperuricemia and gout are increasing in older adults, cardiovascular risk management in these patients is very important. This risk management consists of, on the one hand, treatment of individual traditional risk factors and, on the other hand, of urate lowering, thereby decreasing inflammatory burden of gout. However, there is insufficient evidence to conclude that urate-lowering therapy reduces the risk of cardiovascular events. Moreover, from a cardiovascular point of view, there is no preference for one urate lowering drug over another in patients with gout, nor is there enough evidence to support a preference in patients with gout with increased cardiovascular risk. Personalized treatment in older patients with gout should be aimed at optimizing serum uric acid levels, as well as targeting traditional cardiovascular risk factors. Further prospective randomized trials are needed to support the hypothesis that urate lowering reduces cardiovascular risk in older patients with gout.
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Affiliation(s)
- Martijn Gerritsen
- Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Reade, Admiraal Helfrichstraat 1, 1056 AA, Amsterdam, The Netherlands.
- Amsterdam University Medical Centers, Amsterdam, The Netherlands.
| | - Mike T Nurmohamed
- Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Reade, Admiraal Helfrichstraat 1, 1056 AA, Amsterdam, The Netherlands
- Amsterdam University Medical Centers, Amsterdam, The Netherlands
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Yuan J, Xie Z, Pan B, Zhang J. Impact of gout on cardiovascular disease mortality: a meta-analysis. Z Rheumatol 2024:10.1007/s00393-024-01479-x. [PMID: 38302663 DOI: 10.1007/s00393-024-01479-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2023] [Indexed: 02/03/2024]
Abstract
BACKGROUND Several epidemiological studies have suggested that gout patients have a higher risk of cardiovascular disease mortality than healthy people. In contrast, the association between gout and cardiovascular disease (CVD) mortality was not obvious in other studies. In the present study, we aimed to investigate the relative risk for CVD mortality in gout patients in comparison to healthy controls. METHODS Literature published before March 2023 was searched in Google Scholar, PubMed, and the Web of Science. We summarized the impact of gout on CVD mortality with a meta-analysis. Hazard ratios (HRs) and 95% confidence intervals (CIs) regarding the impact of gout on CVD mortality were summarized with STATA 12.0 software. RESULTS Compared to individuals without gout, those with gout had higher mortality risks for CVD during follow-up, with a random effects model showing a risk of 1.30 (95% CI 1.15 to 1.48, p < 0.001; p-value for Cochran Q test < 0.001, I2 = 95.9%). Similarly, subjects with gout had a mortality risk of 1.28 (95% CI 1.12 to 1.46, p < 0.001; p-value for Cochran Q test = 0.050, I2 = 50.2%) for coronary heart disease (CHD) mortality during follow-up using the same statistical model. Furthermore, using a fixed effects model, individuals with gout had a mortality risk of 1.13 (95% CI 1.00 to 1.27, p = 0.049; p-value for Cochran Q test = 0.494, I2 = 0.0%) for myocardial infarction (MI) mortality during follow-up. CONCLUSION In conclusion, this meta-analysis provides evidence supporting a markedly increased mortality risk from CVD and CHD as well as MI in patients with gout relative to reference subjects without gout.
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Affiliation(s)
- Jielin Yuan
- The Second Nanning People's Hospital, The Third Affiliated Hospital of Guangxi Medical University, No.13 Dancun Road, Jiangnan District, 530031, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Zhitao Xie
- The Second Nanning People's Hospital, The Third Affiliated Hospital of Guangxi Medical University, No.13 Dancun Road, Jiangnan District, 530031, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Bo Pan
- The Second Nanning People's Hospital, The Third Affiliated Hospital of Guangxi Medical University, No.13 Dancun Road, Jiangnan District, 530031, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Jingchang Zhang
- The Second Nanning People's Hospital, The Third Affiliated Hospital of Guangxi Medical University, No.13 Dancun Road, Jiangnan District, 530031, Nanning, Guangxi Zhuang Autonomous Region, China.
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Timsans J, Kauppi JE, Kerola AM, Lehto TM, Kautiainen H, Kauppi MJ. Hyperuricaemia: prevalence and association with mortality in an elderly Finnish population. BMJ Open 2023; 13:e072110. [PMID: 37137562 PMCID: PMC10163549 DOI: 10.1136/bmjopen-2023-072110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2023] Open
Abstract
OBJECTIVE To establish the prevalence of hyperuricaemia in an elderly Finnish cohort and to assess its association with comorbidities and mortality. DESIGN Prospective cohort study. SETTING Good Ageing in Lahti Region study, Finland 2002-2012 (mortality data analysed until 2018). PARTICIPANTS 2673 participants (mean age 64 years; 47% men). PRIMARY AND SECONDARY OUTCOME MEASURES Prevalence of hyperuricaemia in the study population was detected. Associations between hyperuricaemia and mortality were assessed using multivariable adjusted Cox proportional hazards models. METHODS Data from a prospective, population-based study of elderly people (52-76 years) in the Lahti region, Finland, were used. Information on serum uric acid (SUA) levels as well as several other laboratory variables, comorbidities, lifestyle habits and socioeconomic factors was collected, and the association between SUA level and mortality in a 15-year follow-up period was analysed. RESULTS Of 2673 elderly Finnish persons included in the study 1197 (48%) were hyperuricaemic. Hyperuricaemia was extremely prevalent in men (60%). There was an association between elevated SUA and mortality which remained after adjustment for potential confounding factors (age, gender, education, smoking status, body mass index, hypertension and dyslipidaemia). The adjusted HR for all-cause mortality among clearly hyperuricaemic individuals with SUA≥420 µmol/L compared with normouricaemic individuals (SUA<360 µmol/L) was 1.32 (95% CI 1.05 to 1.60) in women and 1.29 (95% CI 1.05 to 1.60) in men. In slightly hyperuricaemic individuals (SUA 360-420 µmol/L) the corresponding HRs were 1.03 (95% CI 0.78 to 1.35) and 1.11 (95% CI 0.89 to 1.39). CONCLUSIONS Hyperuricaemia is very prevalent in the elderly Finnish population and is independently associated with increased mortality.
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Affiliation(s)
- Janis Timsans
- Department of Rheumatology, Päijät-Häme Central Hospital, Lahti, Finland
- Centre for Rheumatic Diseases, Tampere University Hospital, Tampere, Finland
| | - Jenni Emilia Kauppi
- Unit of Physiatry and Rehabilitation Medicine, Päijät-Häme Central Hospital, Lahti, Finland
- University of Helsinki, Helsinki, Finland
| | - Anne Mirjam Kerola
- University of Helsinki, Helsinki, Finland
- Inflammation Center, Helsinki University Central Hospital, Helsinki, Finland
| | - Tiina Maarit Lehto
- Department of Clinical Chemistry, Fimlab Laboratoriot Oy, Lahti, Finland
| | - Hannu Kautiainen
- University of Helsinki, Helsinki, Finland
- Folkhälsan Research Center, Helsinki, Finland
| | - Markku Jaakko Kauppi
- Department of Rheumatology, Päijät-Häme Central Hospital, Lahti, Finland
- University of Helsinki, Helsinki, Finland
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Early urate-lowering therapy in gouty arthritis with acute flares: a double-blind placebo controlled clinical trial. Eur J Med Res 2023; 28:10. [PMID: 36609359 PMCID: PMC9817311 DOI: 10.1186/s40001-022-00982-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 12/30/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Gouty arthritis (GA) is a chronic systemic disease with recurrent acute monoarthritis. In a previous study, a higher incidence of acute flares was observed during the initial marked decrease in serum urate level. Our study evaluated the effect of early urate-lowering therapy in patients with acute GA flares. METHODS This study included 40 patients with acute GA; of them, 20 received colchicine 0.5 mg colchicine twice daily, while 20 received probenecid 500 mg and colchicine 0.5 mg twice daily. We evaluated GA severity and laboratory data for 2 weeks after the initial therapy. Medians and interquartile ranges (IQRs) were calculated to evaluate clinical presentations between these two groups. RESULTS Rapidly decreasing median serum uric acid levels was found in the patients treated with probenecid and colchicine compared with the patients treated with colchicine alone on day 8 (- 1.9 [IQR, - 3.7 to 0] vs 0.8 [IQR, - 0.1-2.2]; P < 0.001). However, the median decrease in visual analog scale score did not differ significantly between the two groups (- 5.5 [IQR, - 8.0 to - 3.0] vs - 3.5 [IQR, - 5.9 to - 2.0]; P = 0.080). CONCLUSION No significant increase was noted in acute gout flare severity or duration among GA patients treated with early aggressive control of hyperuricemia using probenecid plus colchicine.
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Ruiz-Simón S, Calabuig I, Gómez-Garberí M, Andrés M. Gout Screening Identifies a Large Cardiovascular Population at Increased Risk of Mortality. J Clin Rheumatol 2022; 28:409-415. [PMID: 35905448 DOI: 10.1097/rhu.0000000000001890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Gout is prevalent in people with cardiovascular disease, although up to a third of the cases remain unregistered. We aimed to assess whether active gout screening in inpatients with cardiovascular events helps identify patients at higher risk of mortality after discharge. METHODS This study included patients admitted for cardiovascular events. Gout was established by records review and clinical interview. After discharge, electronic medical records were reviewed for mortality and cause of death. The association between gout and subsequent mortality was tested using Cox regression models. RESULTS Of 266 recruited patients, 17 were lost to follow-up, leaving a final sample of 249 patients (93.6%). Thirty-six cases (14.5%) were classified as having gout; 13 of these (36.1%) were identified through the interview. Mean follow-up was 19.9 (SD, 8.6) months. Gout significantly increased the risk of all-cause mortality in the overall sample (hazard ratio [HR], 2.01; 95% confidence interval [CI], 1.13-3.58) and in the subgroup with a prior diagnosis of gout (HR, 2.89; 95% CI, 1.54-5.41). The adjusted HR for all-cause mortality associated with gout was 1.86 (95% CI, 1.01-3.41). Patients with gout carried an increased risk of both cardiovascular and noncardiovascular deaths; age and chronic kidney disease were mortality predictors within the gout population. CONCLUSION Gout was an independent predictor of subsequent all-cause mortality in patients admitted for cardiovascular events. Active screening for gout allowed the detection of a larger population at high risk of mortality and could help tailor patient management to minimize the cardiovascular impact.
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Affiliation(s)
| | - Irene Calabuig
- Rheumatology Unit, Dr. Balmis General University Hospital-Instituto de Investigación Sanitaria y Biomédica de Alicante
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Akari S, Nakamura T, Furusawa K, Miyazaki Y, Kario K. The reality of treatment for hyperuricemia and gout in Japan: A historical cohort study using health insurance claims data. J Clin Hypertens (Greenwich) 2022; 24:1068-1075. [PMID: 35818841 PMCID: PMC9380143 DOI: 10.1111/jch.14539] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/27/2022] [Accepted: 06/01/2022] [Indexed: 11/29/2022]
Abstract
Hyperuricemia causes gout and has also been associated with metabolic syndrome and cardiovascular disease. Uric acid‐lowering drugs (ULDs) are used to reduce uric acid levels for the treatment of hyperuricemia and gout. However, there is a lack of robust and real‐world data on the history and treatment of patients with newly diagnosed hyperuricemia or gout in Japan. This retrospective, longitudinal, historical cohort study determined the characteristics of patients with hyperuricemia and/or gout, and prescription of, and adherence to, ULDs using data from the JMDC Claims Database. The primary evaluation population included 64 677 patients with newly diagnosed hyperuricemia and/or gout. Of these, only 26 501 (41.0%) had a prescription for ULDs at diagnosis. Even when ULDs were prescribed, the persistence rate of prescriptions declined over time, with a 54.4% persistence rate for ULDs at 12 months after the index diagnosis. In subgroups of patients with or without hypertension and diabetes, the rate of ULD prescription continuation was significantly higher in those with comorbidities than in those without (76.8% vs. 42.6% in those with vs. without hypertension, and 78.7% vs. 52.2% in those with vs. without diabetes). These finding suggest that therapeutic interventions to lower serum uric acid levels are under‐utilized for patients with newly diagnosed hyperuricemia and/or gout in Japan.
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Affiliation(s)
- Seigo Akari
- Medical Affairs Department, Sanwa Kagaku Kenkyusho Co., Ltd., Aichi, Japan
| | - Takashi Nakamura
- Medical Affairs Department, Sanwa Kagaku Kenkyusho Co., Ltd., Aichi, Japan
| | - Kenichi Furusawa
- Medical Affairs Department, Sanwa Kagaku Kenkyusho Co., Ltd., Aichi, Japan
| | - Yuichi Miyazaki
- Medical Affairs Department, Sanwa Kagaku Kenkyusho Co., Ltd., Aichi, Japan
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
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Wei J, Choi HK, Neogi T, Dalbeth N, Terkeltaub R, Stamp LK, Lyu H, McCormick N, Niu J, Zeng C, Lei G, Zhang Y. Allopurinol Initiation and All-Cause Mortality Among Patients With Gout and Concurrent Chronic Kidney Disease : A Population-Based Cohort Study. Ann Intern Med 2022; 175:461-470. [PMID: 35073156 PMCID: PMC10445508 DOI: 10.7326/m21-2347] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Two recent randomized clinical trials of escalating doses of allopurinol for the progression of chronic kidney disease (CKD) reported no benefits but potentially increased risk for death. Whether the risk could occur in patients with gout and concurrent CKD remains unknown. OBJECTIVE To examine the relation of allopurinol initiation, allopurinol dose escalation, and achieving target serum urate (SU) level after allopurinol initiation to all-cause mortality in patients with both gout and CKD. DESIGN Cohort study. SETTING The Health Improvement Network U.K. primary care database (2000 to 2019). PARTICIPANTS Patients aged 40 years or older who had gout and concurrent moderate-to-severe CKD. MEASUREMENTS The association between allopurinol initiation and all-cause mortality over 5-year follow-up in propensity score (PS)-matched cohorts was examined. Analysis of hypothetical trials were emulated: achieving target SU level (<0.36 mmol/L) versus not achieving target SU level and dose escalation versus no dose escalation for mortality over 5-year follow-up in allopurinol initiators. RESULTS Mortality was 4.9 and 5.8 per 100 person-years in 5277 allopurinol initiators and 5277 PS-matched noninitiators, respectively (hazard ratio [HR], 0.85 [95% CI, 0.77 to 0.93]). In the target trial emulation analysis, the HR of mortality for the achieving target SU level group compared with the not achieving target SU level group was 0.87 (CI, 0.75 to 1.01); the HR of mortality for allopurinol in the dose escalation group versus the no dose escalation group was 0.88 (CI, 0.73 to 1.07). LIMITATION Residual confounding cannot be ruled out. CONCLUSION In this population-based data, neither allopurinol initiation, nor achieving target SU level with allopurinol, nor allopurinol dose escalation was associated with increased mortality in patients with gout and concurrent CKD. PRIMARY FUNDING SOURCE Project Program of National Clinical Research Center for Geriatric Disorders.
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Affiliation(s)
- Jie Wei
- Health Management Center, Xiangya Hospital, Central South University, Changsha, China (J.W.)
| | - Hyon K Choi
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, and the Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (H.K.C., Y.Z.)
| | - Tuhina Neogi
- Section of Rheumatology, Boston University School of Medicine, Boston, Massachusetts (T.N.)
| | - Nicola Dalbeth
- Department of Medicine, University of Auckland, Auckland, New Zealand (N.D.)
| | - Robert Terkeltaub
- Rheumatology, Allergy-Immunology Section, San Diego VA Medical Center, San Diego, California (R.T.)
| | - Lisa K Stamp
- Department of Medicine, University of Otago, Christchurch, New Zealand (L.K.S.)
| | - Houchen Lyu
- Department of Orthopedics, General Hospital of Chinese PLA, Beijing, and Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China (H.L.)
| | - Natalie McCormick
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, and the Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, and Arthritis Research Canada, Richmond, British Columbia, Canada (N.M.)
| | - Jingbo Niu
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas (J.N.)
| | - Chao Zeng
- Department of Orthopaedics, Xiangya Hospital, Central South University, and Hunan Key Laboratory of Joint Degeneration and Injury, and National Clinical Research Center of Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China (C.Z.)
| | - Guanghua Lei
- Department of Orthopaedics, Xiangya Hospital, Central South University, and National Clinical Research Center of Geriatric Disorders, Xiangya Hospital, Central South University, and Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, China (G.L.)
| | - Yuqing Zhang
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, and the Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (H.K.C., Y.Z.)
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Allopurinol to reduce cardiovascular morbidity and mortality: A systematic review and meta-analysis. PLoS One 2021; 16:e0260844. [PMID: 34855873 PMCID: PMC8638940 DOI: 10.1371/journal.pone.0260844] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 11/17/2021] [Indexed: 12/02/2022] Open
Abstract
Aims To compare the effectiveness of allopurinol with no treatment or placebo for the prevention of cardiovascular events in hyperuricemic patients. Methods and results Pubmed, Web of Science and Cochrane library were searched from inception until July 2020. Randomized controlled trials (RCT) and observational studies in hyperuricemic patients without significant renal disease and treated with allopurinol, versus placebo or no treatment were included. Outcome measures were cardiovascular mortality, myocardial infarction, stroke, or a combined endpoint (CM/MI/S). For RCT’s a random effects meta-analysis was performed. For observational studies a narrative synthesis was performed. Of the original 1995 references we ultimately included 26 RCT’s and 21 observational studies. We found a significantly reduced risk of combined endpoint (Risk Ratio 0.65 [95% CI] [0.46 to 0.91]; p = 0.012) and myocardial infarction (RR 0.47 [0.27 to 0.80]; p = 0.01) in the allopurinol group compared to controls. We found no significant effect of allopurinol on stroke or cardiovascular mortality. Of the 15 observational studies with sufficient quality, allopurinol was associated with reduced cardiovascular mortality in 1 out of 3 studies that reported this outcome, myocardial infarction in 6 out of 8, stroke in 4 out of 7, and combined end-point in 2 out of 2. Cardiovascular benefit was only observed when allopurinol therapy was prolonged for more than 6 months and when an appropriate allopurinol dose was administered (300 mg or more/day) or sufficient reduction of serum urate concentration was achieved (<0.36 mmol/l). Conclusions Data from RCT’s and observational studies indicate that allopurinol treatment reduces cardiovascular risk in patients with hyperuricemia. However, the quality of evidence from RCTs is low to moderate. To establish whether allopurinol lowers the risk of cardiovascular events a well-designed and adequately powered randomized, placebo-controlled trial is needed in high-risk patients with hyperuricemia. Systematic review registration PROSPERO registration CRD42018089744
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Hay CA, Prior JA, Belcher J, Mallen CD, Roddy E. Mortality in Patients With Gout Treated With Allopurinol: A Systematic Review and Meta‐Analysis. Arthritis Care Res (Hoboken) 2021; 73:1049-1054. [DOI: 10.1002/acr.24205] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 03/31/2020] [Indexed: 12/20/2022]
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Suissa S, Suissa K, Hudson M. Effectiveness of Allopurinol in Reducing Mortality: Time-Related Biases in Observational Studies. Arthritis Rheumatol 2021; 73:1749-1757. [PMID: 33645906 DOI: 10.1002/art.41710] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/12/2021] [Accepted: 02/24/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The treatment of gout with allopurinol is effective at reducing urate levels and the frequency of flares. Several observational studies have shown important reductions in mortality with allopurinol use, with wide variations in results. We undertook this review to assess the extent of bias in these studies, particularly time-related biases such as immortal time bias. METHODS We searched the literature to identify all observational studies describing the effect of allopurinol use versus nonuse on all-cause mortality. RESULTS We identified 12 observational studies, of which 3 were affected by immortal time bias and 3 by immeasurable time bias, while the remaining 6 studies avoided these time-related biases. Reductions in all-cause mortality with allopurinol use were observed among the studies with immortal time bias, with a pooled hazard ratio (HR) of death associated with allopurinol of 0.71 (95% confidence interval [95% CI] 0.50-1.01), as well as in those with immeasurable time bias (pooled HR 0.62 [95% CI 0.56-0.67]). The 6 studies that avoided these biases demonstrated a null effect of allopurinol on mortality (pooled HR 0.99 [95% CI 0.87-1.11]), though the lack of an analysis based on treatment adherence may have attenuated the effect. CONCLUSION Observational studies are important to provide real-world data on medication effects. The observational studies showing significantly decreased mortality with allopurinol treatment cannot be used as evidence, however, mainly due to time-related biases that tend to greatly exaggerate the potential benefit of treatments. The ALL-HEART randomized trial, which is currently underway and evaluates the effect of adding allopurinol to usual care (compared to no added treatment), will provide reliable evidence on mortality.
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Affiliation(s)
- Samy Suissa
- Jewish General Hospital and McGill University, Montreal, Quebec, Canada
| | - Karine Suissa
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Marie Hudson
- Jewish General Hospital and McGill University, Montreal, Quebec, Canada
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Cicero AFG, Fogacci F, Cincione RI, Tocci G, Borghi C. Clinical Effects of Xanthine Oxidase Inhibitors in Hyperuricemic Patients. Med Princ Pract 2021; 30:122-130. [PMID: 33040063 PMCID: PMC8114083 DOI: 10.1159/000512178] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 10/07/2020] [Indexed: 12/13/2022] Open
Abstract
This review aims to critically present the available clinical evidence supporting the treatment of chronic hyperuricemia with xanthine oxidase inhibitors. For this reason, the studies published on uric acid (UA)-lowering drugs in the English language from 2000 to August 2019 have been carefully reviewed. The terms "serum uric acid," "xanthine oxidase," "allopurinol," "febuxostat," and "topiroxostat" were incorporated into an electronic search strategy, alone and in combinations, in both MEDLINE (National Library of Medicine, Bethesda, MD) and the Cochrane Register of Controlled Trials (The Cochrane Collaboration, Oxford, UK). Even if new urate-lowering drugs seem of particular efficacy for acute treatment of refractory hyperuricemia, their use is supported by relatively small clinical evidence. On the contrary, large long-term clinical trials have demonstrated that xanthine oxidase inhibitors (XOIs, namely, allopurinol and febuxostat) are effective, safe, and relatively well-tolerated in most of the patients. They have mainly been tested in the elderly, in patients affected by chronic diseases such as heart failure and cancer, and in patients taking a large number of drugs, confirming their safety profile. Recent data also show that they could exert some positive effects on vascular health, renal function, and glucose metabolism. Their cost is also low. In conclusion, XOIs remain the first choice of UA-lowering drug for chronic treatment.
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Affiliation(s)
- Arrigo F G Cicero
- Hypertension Research Unit, Medical and Surgical Sciences Department, University of Bologna, Bologna, Italy,
- IRCCS Policlinico di S.Orsola, Bologna, Italy,
| | - Federica Fogacci
- Hypertension Research Unit, Medical and Surgical Sciences Department, University of Bologna, Bologna, Italy
| | | | - Giuliano Tocci
- Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome Sapienza, Sant'Andrea Hospital, Rome, Italy
- IRCCS Neuromed, Pozzilli, Italy
| | - Claudio Borghi
- Hypertension Research Unit, Medical and Surgical Sciences Department, University of Bologna, Bologna, Italy
- IRCCS Policlinico di S.Orsola, Bologna, Italy
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Calabuig I, Gómez-Garberí M, Andrés M. Gout Is Prevalent but Under-Registered Among Patients With Cardiovascular Events: A Field Study. Front Med (Lausanne) 2020; 7:560. [PMID: 33117824 PMCID: PMC7552997 DOI: 10.3389/fmed.2020.00560] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 08/06/2020] [Indexed: 11/13/2022] Open
Abstract
Objectives: Gout is an independent cardiovascular (CV) risk factor with significant morbidity and mortality. We aimed to estimate the prevalence of gout, characteristics and management in a hospitalized population for CV disease, a topic that remains to be defined. Methods: An observational, descriptive, cross-sectional study was carried out in patients admitted for CV events in the Cardiology, Neurology, and Vascular Surgery units of a tertiary center. Patients were selected following a non-consecutive, systematic sampling. Data about CV disease and gout were obtained from face-to-face interviews and patients' records. Gout diagnosis was established using the 2015 ACR/EULAR clinical classification criteria. The registration rate of gout was assessed by auditing patients' records and hospital discharge reports of CV events from the units of interest in the previous 2 years. To predict the presence of gout, multivariate logistic regression models were built to study the possible explanatory variables. Results: Two hundred and sixty six participants were recruited, predominantly males (69.9%) and Caucasians (96.6%) with a mean age of 68 years. Gout was identified in 40 individuals; thus, the prevalence was 15.0% (95% CI 10.9-19.2%). In 35% of cases, the diagnosis was absent from patients' records. Gout was found in 1.4-2.6% of hospital discharge reports of CV events, also indicating under-registration. The disease was long-standing, but with low reported rates of flares, involved joints, and tophi. At admission, only half of the gout patients were on urate-lowering therapy, being 38.5% of them on serum urate <6 mg/dl. The only independent predictor of gout was the existence of previous hyperuricemia (median serum urate in previous 5 years ≥7 mg/dl), with an odds ratio of 2.9 (95% CI 1.2-7.1); if hyperuricemia is not included in the model, the only independent predictor was chronic kidney disease (odds ratio 3.0; 95% CI 1.4-6.6). Conclusion: Gout is highly prevalent among patients admitted for CV events, with significant lack of awareness and suboptimal management, despite being a well-established independent CV risk factor.
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Affiliation(s)
- Irene Calabuig
- Sección de Reumatología, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
| | | | - Mariano Andrés
- Sección de Reumatología, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain.,Departamento de Medicina Clínica, Universidad Miguel Hernández, Alicante, Spain
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Pascual E, Andres M, Sivera F. Gout. J Clin Rheumatol 2020; 26:208-212. [DOI: 10.1097/rhu.0000000000001492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Chen J, Ge J, Zha M, Miao JJ, Sun ZL, Yu JY. Effects of Uric Acid-Lowering Treatment on Glycemia: A Systematic Review and Meta-Analysis. Front Endocrinol (Lausanne) 2020; 11:577. [PMID: 33013687 PMCID: PMC7493655 DOI: 10.3389/fendo.2020.00577] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 07/15/2020] [Indexed: 12/15/2022] Open
Abstract
Background: Serum uric acid levels have been shown to be associated with increased risk of diabetes. However, it remains unclear whether uric acid-lowering therapy (ULT) is associated with improved glycemic status. This study aimed to summarize evidence from randomized controlled trials (RCTs) to investigate whether ULT reduces fasting blood glucose (FBG) and glycated hemoglobin A1c (HbA1c) levels. Methods: PubMed, Embase, and the Cochrane Library were searched from inception until April 10, 2019. Moreover, in order to maximize the search for articles on the same topic, the reference lists of included studies, relevant review articles and systematic reviews were reviewed. Parallel RCTs investigating the effect of ULT on FBG or HbA1c levels were considered for inclusion. An English language restriction was applied. Data were screened and extracted independently by two researchers. Meta-analyses were performed using random-effects models to calculate the weighted mean differences (WMDs) and 95% confidence intervals (CIs). Results: Four trials with 314 patients reported the effect of ULT with allopurinol on FBG and 2 trials with 141 patients reported the effect of ULT with allopurinol on HbA1c. Treatment with allopurinol resulted in a significant decrease in FBG (WMD: -0.61 mmol/L, 95% CI: -0.93 to -0.28), but only a trend of reduction in HbA1c (WMD: -0.47%, 95% CI: -1.16 to 0.22). Notably, the subgroup analyses showed that treatment with allopurinol was associated with reduced FBG levels in patients without diabetes (WMD: -0.60 mmol/L, 95% CI: -0.99 to -0.20), but not in patients with diabetes. In addition, the dose of allopurinol treatment ≥200 mg daily resulted in a reduction of FBG levels (WMD: -0.59 mmol/L, 95% CI: -0.95 to -0.23), whereas low-dose allopurinol (<200 mg daily) had no effect on FBG levels. Conclusions: The findings suggest that ULT with allopurinol may be effective at reducing glycemia, but such an improvement does not appear to be observed in patients with diabetes. The findings require confirmation in additional trials with larger sample sizes.
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Affiliation(s)
- Juan Chen
- Department of Endocrinology, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Jing Ge
- Department of Endocrinology, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Min Zha
- Department of Endocrinology, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Jun-Jun Miao
- Department of Endocrinology, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Zi-Lin Sun
- Department of Endocrinology, Zhongda Hospital, Institute of Diabetes, Medical School, Southeast University, Nanjing, China
- *Correspondence: Zi-Lin Sun
| | - Jiang-Yi Yu
- Department of Endocrinology, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
- Jiang-Yi Yu
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Gong M, Wen S, Nguyen T, Wang C, Jin J, Zhou L. Converging Relationships of Obesity and Hyperuricemia with Special Reference to Metabolic Disorders and Plausible Therapeutic Implications. Diabetes Metab Syndr Obes 2020; 13:943-962. [PMID: 32280253 PMCID: PMC7125338 DOI: 10.2147/dmso.s232377] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 03/09/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Obesity and hyperuricemia mutually influence metabolic syndrome. This study discusses the metabolic relationships between obesity and hyperuricemia in terms of pathophysiology, complications, and treatments. METHODS We searched for preclinical or clinical studies on the pathophysiology, complications, and therapy of obesity and hyperuricemia on the PubMed database. RESULTS In this systemic review, we summarized our searching results on topics of pathophysiology, complications and therapeutic strategy. In pathophysiology, we firstly introduce genetic variations for obesity, hyperuricemia and their relationships by genetic studies. Secondly, we talk about the epigenetic influences on obesity and hyperuricemia. Thirdly, we describe the central metabolic regulation and the role of hyperuricemia. Then, we refer to the character of adipose tissue inflammation and oxidative stress in the obesity and hyperuricemia. In the last part of this topic, we reviewed the critical links of gut microbiota in the obesity and hyperuricemia. In the following part, we review the pathophysiology of major complications in obesity and hyperuricemia including insulin resistance and type 2 diabetes mellitus, chronic kidney disease, cardiovascular diseases, and cancers. Finally, we recapitulate the therapeutic strategies especially the novel pharmaceutic interventions for obesity and hyperuricemia, which concurrently show the mutual metabolic influences between two diseases. CONCLUSION The data reviewed here delineate the metabolic relationships between obesity and hyperuricemia, and provide a comprehensive overview of the therapeutic targets for the management of metabolic syndromes.
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Affiliation(s)
- Min Gong
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University, Shanghai201399, People’s Republic of China
| | - Song Wen
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University, Shanghai201399, People’s Republic of China
| | - Thiquynhnga Nguyen
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University, Shanghai201399, People’s Republic of China
| | - Chaoxun Wang
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University, Shanghai201399, People’s Republic of China
| | - Jianlan Jin
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University, Shanghai201399, People’s Republic of China
| | - Ligang Zhou
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University, Shanghai201399, People’s Republic of China
- Correspondence: Ligang Zhou Department of Endocrinology, Shanghai Pudong Hospital, Fudan University, Shanghai201399, ChinaTel +8613611927616 Email
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Risk of Acute Myocardial Infarction Among New Users of Allopurinol According to Serum Urate Level: A Nested Case-Control Study. J Clin Med 2019; 8:jcm8122150. [PMID: 31817395 PMCID: PMC6947524 DOI: 10.3390/jcm8122150] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 12/03/2019] [Indexed: 12/22/2022] Open
Abstract
Objectives: To test the hypothesis that allopurinol reduces the risk of acute myocardial infarction (AMI) in hyperuricemic patients and to assess whether the effect is dependent on dose, duration and serum uric acid (SUA) level attained after treatment. Methods: Nested case-control study over the period 2002–2015. From a cohort of patients aged 40–99 years old, we identified incident AMI cases and randomly selected five controls per case, matched for exact age, sex and index date. Adjusted odds ratios (AOR) and 95% CI were computed through unconditional logistic regression. Only new users of allopurinol were considered. Results: A total of 4697 AMI cases and 18,919 controls were included. Allopurinol use was associated with a reduced risk of AMI mainly driven by duration of treatment (AOR ≥180 days = 0.71; 95% CI: 0.60–0.84). Among long-term users (≥180 days), the reduced risk was only observed when the SUA level attained was below 7 mg/dL (AOR<6 mg/dL = 0.64; 95% CI: 0.49–0.82; AOR6–7mg/dL = 0.64; 95%CI:0.48-0.84); AOR>7mg/dL = 1.04; 95% CI: 0.75–1.46; p for trend = 0.001). A dose-effect was observed but faded out once adjusted for the SUA level attained. The reduced risk of AMI occurred in both patients with gout and patients with asymptomatic hyperuricemia. Conclusions: The results confirm a cardioprotective effect of allopurinol which is strongly dependent on duration and SUA level attained after treatment.
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Pérez Ruiz F, Richette P, Stack AG, Karra Gurunath R, García de Yébenes MJ, Carmona L. Failure to reach uric acid target of <0.36 mmol/L in hyperuricaemia of gout is associated with elevated total and cardiovascular mortality. RMD Open 2019; 5:e001015. [PMID: 31673414 PMCID: PMC6803010 DOI: 10.1136/rmdopen-2019-001015] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 08/26/2019] [Accepted: 09/20/2019] [Indexed: 12/22/2022] Open
Abstract
Objective To determine the impact of achieving serum uric acid (sUA) of <0.36 mmol/L on overall and cardiovascular (CV) mortality in patients with gout. Methods Prospective cohort of patients with gout recruited from 1992 to 2017. Exposure was defined as the average sUA recorded during the first year of follow-up, dichotomised as ≤ or >0.36 mmol/L. Bivariate and multivariate Cox proportional hazards models were used to determine mortality risks, expressed HRs and 95% CIs. Results Of 1193 patients, 92% were men with a mean age of 60 years, 6.8 years' disease duration, an average of three to four flares in the previous year, a mean sUA of 9.1 mg/dL at baseline and a mean follow-up 48 months; and 158 died. Crude mortality rates were significantly higher for an sUA of ≥0.36 mmol/L, 80.9 per 1000 patient-years (95% CI 59.4 to 110.3), than for an sUA of <0.36 mmol/L, 25.7 per 1000 patient-years (95% CI 21.3 to 30.9). After adjustment for age, sex, CV risk factors, previous CV events, observation period and baseline sUA concentration, an sUA of ≥0.36 mmol/L was associated with elevated overall mortality (HR=2.33, 95% CI 1.60 to 3.41) and CV mortality (HR=2.05, 95% CI 1.21 to 3.45). Conclusions Failure to reach a target sUA level of 0.36 mmol/L in patients with hyperuricaemia of gout is an independent predictor of overall and CV-related mortality. Targeting sUA levels of <0.36 mmol/L should be a principal goal in these high-risk patients in order to reduce CV events and to extend patient survival.
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Affiliation(s)
| | - Pascal Richette
- Service de Rhumatologie, Hopital Lariboisiere Centre Viggo Petersen, Paris, France.,Inserm UMR1132 Bioscar, Universite Paris Diderot UFR de Medecine, Paris, France
| | - Austin G Stack
- Division of Nephrology, University Hospital Limerick, Limerick, Ireland.,Graduate Entry Medical School, University of Limerick, Limerick, Ireland
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Su CY, Shen LJ, Hsieh SC, Lin LY, Lin FJ. Comparing Cardiovascular Safety of Febuxostat and Allopurinol in the Real World: A Population-Based Cohort Study. Mayo Clin Proc 2019; 94:1147-1157. [PMID: 31272565 DOI: 10.1016/j.mayocp.2019.03.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 03/08/2019] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To determine and compare the risk of cardiovascular events and mortality of febuxostat and allopurinol use. PATIENTS AND METHODS We conducted a cohort study using the Taiwan National Health Insurance Research Database. New users of febuxostat and allopurinol between April 1, 2012 and December 31, 2015 were identified, and the two groups were 1:1 matched by propensity score, benzbromarone use history, renal impairment, and time of drug initiation. The risk of major adverse cardiovascular events (MACEs), venous thromboembolism (VTE), heart failure (HF) hospitalization, atrial fibrillation hospitalization, cardiovascular (CV) death, and all-cause mortality was assessed using Cox proportional hazards models. The dose-response relationship between xanthine oxidase inhibitor use and adverse CV outcomes were also determined. RESULTS A total of 44,111 patients were included for each group, and all baseline covariates were well matched. Febuxostat users were at a significantly higher risk for HF hospitalization (hazard ratio [HR], 1.22; 95% CI, 1.13-1.33), atrial fibrillation hospitalization (HR, 1.19; 95% CI, 1.05-1.36), and CV death (HR, 1.19; 95% CI, 1.03-1.36) than allopurinol users, whereas no difference was found for the major adverse cardiac events composite endpoint, venous thromboembolism, myocardial infarction, ischemic stroke, and all-cause mortality. The elevated risk of HF hospitalization was consistent throughout the primary and sensitivity analyses. In addition, febuxostat increased the risk of adverse CV outcomes in a dose-dependent manner. CONCLUSION The use of febuxostat, compared with allopurinol, was associated with a significantly increased risk of adverse CV events. Higher febuxostat doses had a greater impact. Further studies are needed to investigate the mechanisms linking febuxostat to adverse CV outcomes.
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Affiliation(s)
- Ching-Yen Su
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Li-Jiuan Shen
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - Song-Chou Hsieh
- Division of Rheumatology, Immunology and Allergy, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Lian-Yu Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Fang-Ju Lin
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan.
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Weisman A, Tomlinson GA, Lipscombe LL, Perkins BA, Hawker GA. Association between allopurinol and cardiovascular outcomes and all-cause mortality in diabetes: A retrospective, population-based cohort study. Diabetes Obes Metab 2019; 21:1322-1329. [PMID: 30734980 DOI: 10.1111/dom.13656] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 01/28/2019] [Accepted: 02/06/2019] [Indexed: 12/25/2022]
Abstract
AIM To assess the association between allopurinol and mortality and cardiovascular outcomes in an allopurinol-treated diabetes cohort. MATERIALS AND METHODS We conducted a population-based retrospective cohort study in Ontario, Canada. Eligible subjects were ≥ 66 years old with diabetes and a first prescription for allopurinol between 1 April, 2002 and 31 March, 2012 and were followed until 31 March, 2016. The primary outcome was a composite: all-cause mortality, non-fatal cardiovascular event (myocardial infarction, revascularization procedure, or stroke) or congestive heart failure (CHF). Secondary outcomes were components of the primary outcome and pneumonia as a negative tracer. Allopurinol was modelled as time-varying exposed versus unexposed, daily dose category and cumulative dose using sex-specific multivariable Cox proportional hazards models. RESULTS Over a median follow-up of 4.65 years (interquartile range 1.79-7.81), 16 266/23 103 males and 10 571/15 313 females experienced the primary outcome. Allopurinol was associated with a reduction in the primary outcome [adjusted hazard ratios (aHR) 0.77 (95% confidence interval 0.75-0.80) and 0.81 (0.78-0.84) for males and females, respectively], driven by marked reductions in all-cause mortality and modest reductions in cardiovascular events/CHF. There was no effect of cumulative allopurinol dose on any outcome, and allopurinol was also associated with reduced risk of pneumonia in males [aHR 0.88 (0.83, 0.93)]. CONCLUSIONS Allopurinol was associated with reduced mortality and cardiovascular outcomes. However, lack of cumulative dose effect and a positive tracer outcome in males suggests residual bias. Future research assessing whether allopurinol prevents vascular complications in diabetes requires a clinical trial.
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Affiliation(s)
- Alanna Weisman
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - George A Tomlinson
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University Health Network/Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Lorraine L Lipscombe
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Bruce A Perkins
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Gillian A Hawker
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Abeles AM, Pillinger MH. Gout and cardiovascular disease: crystallized confusion. Curr Opin Rheumatol 2019; 31:118-124. [DOI: 10.1097/bor.0000000000000585] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Ramsubeik K, Ramrattan LA, Kaeley GS, Singh JA. Effectiveness of healthcare educational and behavioral interventions to improve gout outcomes: a systematic review and meta-analysis. Ther Adv Musculoskelet Dis 2018; 10:235-252. [PMID: 30515250 PMCID: PMC6262501 DOI: 10.1177/1759720x18807117] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 09/21/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND We aimed to systematically review the effectiveness of healthcare behavioral and education interventions for gout patients on clinical outcomes. METHODS We searched multiple databases to identify trials or observational studies of educational or behavioral interventions in gout. Risk of bias was assessed with the Cochrane tool for randomized control trials (RCTs) and the Newcastle-Ottawa Scale for observational studies. We estimated odds ratios (ORs) for categorical and standardized mean difference (SMD) for continuous measures using a random-effects model. RESULTS Overall, eight (five RCTs and three observational) studies met the inclusion criteria and examined pharmacist-led interventions (n = 3), nurse-led interventions (n = 3) and primary care provider interventions (n = 2). Compared with the control intervention (usual care in most cases), a higher proportion of those in the educational/behavioral intervention arm achieved serum urate (SU) levels <6 mg/dl, 47.2% versus 23.8%, the OR was 4.86 [95% confidence interval (CI), 1.48, 15.97; 4 RCTs] with moderate quality evidence. Compared with the control intervention, a higher proportion of those in the educational/behavioral intervention arm were adherent to allopurinol, achieved at least a 2 mg/dl decrease in SU, achieved an SU < 5 mg/dl, had a reduction in the presence of tophi at 2 years, had improved quality of life as assessed with SF-36 physical component scores, had a higher knowledge about gout and higher patient satisfaction (moderate-low quality evidence). CONCLUSION Educational and behavioral interventions can improve gout outcomes in the short-intermediate term. Randomized trials are needed to assess its impact on long-term gout outcomes.
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Affiliation(s)
- Karishma Ramsubeik
- Division of Rheumatology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Laurie Ann Ramrattan
- Division of Rheumatology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Gurjit S. Kaeley
- Division of Rheumatology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Jasvinder A. Singh
- Division of Clinical Immunology and Rheumatology, University of Alabama, Birmingham VA Medical Center, Faculty Office Tower 805B, 510 20th Street South, Birmingham, AL, 35294, USA
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Katsiki N, Borghi C. The future of febuxostat after the Cardiovascular Safety of Febuxostat and Allopurinol in Patients with Gout and Cardiovascular Morbidities (CARES) trial: who CARES? Expert Opin Pharmacother 2018; 19:1853-1856. [DOI: 10.1080/14656566.2018.1532503] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Niki Katsiki
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, Thessaloniki, Greece
| | - Claudio Borghi
- Department of Medical and Surgical Sciences, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
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Klein RW, Kabadi S, Cinfio FN, Bly CA, Taylor DC, Szymanski KA. Budget impact of adding lesinurad for second-line treatment of gout: a US health plan perspective. J Comp Eff Res 2018; 7:807-816. [PMID: 29792516 DOI: 10.2217/cer-2017-0103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
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.
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Affiliation(s)
- Robert W Klein
- Medical Decision Modeling, Inc., 3500 DePauw Blvd #1037, Indianapolis, IN 46268, USA
| | - Shaum Kabadi
- AstraZeneca LP, 101 Orchard Ridge Drive, Gaithersburg, MD 20878, USA
| | - Frank N Cinfio
- Medical Decision Modeling, Inc., 201 N. Illinois #1175, Indianapolis, IN 46204, USA
| | - Christopher A Bly
- Medical Decision Modeling, Inc., 201 N. Illinois #1175, Indianapolis, IN 46204, USA
| | - Douglas Ca Taylor
- Ironwood Pharmaceuticals, 301 Binney Street, Cambridge, MA 02142, USA
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Abstract
PURPOSE OF REVIEW To discuss alternate models of long-term gout management RECENT FINDINGS: Nurse-led care of gout appears to improve the uptake of and adherence to urate-lowering treatment in a research setting. Less impressive improvements were achieved with pharmacist-led remote management of gout; however, both strategies were more effective than usual primary care provider management of gout. Individualised education about gout, patient involvement in decision-making, and access to trained support in managing side-effects and gout flares can improve the uptake of fine and adherence to urate-lowering treatment. This may be best achieved with nurse-led care of gout. However, further research is required to evaluate if the model of nurse-led care of gout can be implemented in routine clinical practice and in different healthcare systems.
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Pillinger MH, Bangalore S, Klein AB, Baumgartner S, Morlock R. Cardiovascular Disease and Gout: Real-World Experience Evaluating Patient Characteristics, Treatment Patterns, and Health Care Utilization. J Manag Care Spec Pharm 2018; 23:677-683. [PMID: 28530520 PMCID: PMC10397893 DOI: 10.18553/jmcp.2017.23.6.677] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gout, hyperuricemia, and cardiovascular disease (CVD) are prevalent conditions in the United States, and while they share common risk factors such as obesity, hypertension, hypercholesterolemia, and type 2 diabetes mellitus, relatively little is known about what patient and disease characteristics may link CVD with hyperuricemia and gout and how the presence of both diseases affects management decisions differently than for patients with gout alone. OBJECTIVE To identify differences in patient characteristics, patterns of urate-lowering therapy (ULT) use, and gout control in gout patients with and without cardiovascular comorbidity. METHODS Data were assessed from a survey of U.S. physicians who performed in-depth patient chart audits of their last 5 consecutive adult patients with confirmed gout as determined by the medical record and clinical notes. Comorbidities, gout symptoms, length of current treatment, sociodemographic factors, and physician type were identified from the chart review. Descriptive statistics and logistic regression described differences among patients with and without comorbid CVD and assessed ULT use and gout control. RESULTS Of the 1,159 patient charts that were reviewed, 738 patients had CVD and gout, and 421 had gout alone. Patients with CVD had longer duration of gout (mean [SD] = 52 [68.2] vs. 34 [47.2] months; P < 0.001) and were more likely to have clinician-reported tophi (28% vs. 15%; P < 0.001), organ/joint damage (19% vs. 9%; P < 0.001), and more flares (2.1% vs. 1.8%; P = 0.017) in the previous 12 months. Time from gout diagnosis to start of ULT was delayed for those with CVD (mean [SD] = 24.3 [56.6] vs. 15.5 [33.2] months; P = 0.023), but these patients were more likely to be receiving ULT (83% vs. 59%; P < 0.001). Gout patients with CVD were more likely to have a variety of additional comorbidities than those without CVD, such as obesity (28% vs. 18%; P < 0.001), diabetes (26% vs. 12%; P < 0.001), osteoarthritis (25% vs. 11%; P < 0.001), chronic kidney disease (17% vs. 5%; P < 0.001), and prostate disease (males, n = 933; 10% vs. 2%; P < 0.001). Gout patients with CVD were more likely to have an emergency department visit (12% vs. 7%; P = 0.003) for gout in the previous 12 months. In patients with CVD, ULT use was associated with better gout control. CONCLUSIONS Gout patients with CVD were more likely to have additional comorbidities, more gout-related symptoms, and a delay in initiating treatment, which may be associated with the greater severity of disease in these patients. These data suggest that gout patients with CVD may constitute a less healthy group in need of earlier, more aggressive therapy. DISCLOSURES This study was supported by AstraZeneca. Pillinger reports consultancies at AstraZeneca, SOBI, Crealta/Horizon; investigator-initiated grants from Takeda (closed 2016); and was an investigator on industry-sponsored clinical trials for Takeda. Klein is employed by AstraZeneca. At the time of this study, Baumgartner was employed by Ardea Biosciences, a wholly owned subsidiary of AstraZeneca and owns stock in AstraZeneca. Baumgartner and Morlock are consultants to Ardea Biosciences. Morlock reports consulting fees from Genentech, Ironwood Pharmaceuticals, Astellas, and Abbot Medical Optics outside of this study. Bangalore reports consultancies at Pfizer, Merck, Abbott Vascular, Medicines Company, AstraZeneca, and the National Heart, Lung, and Blood Institute. The authors did not receive any honoraria for this publication. Study concept and design were primarily contributed by Morlock, along with the other authors. Morlock collected the data, and data interpretation was performed by all the authors. All authors equally contributed to preparation and revision of the manuscript. Preliminary results from this study were presented at the AMCP Managed Care & Specialty Pharmacy Annual Meeting 2016; San Francisco, California; April 19-22, 2016.
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Affiliation(s)
| | - Sripal Bangalore
- 2 Division of Cardiology, New York University, New York, New York
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Rakic M, Dittrich T, Elger BS, Shaw D. Enhancing patients' autonomy by involving them in research ethics committees. Int J Qual Health Care 2017; 29:896-900. [PMID: 29077835 DOI: 10.1093/intqhc/mzx128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 09/22/2017] [Indexed: 01/15/2023] Open
Abstract
Objective Although clinical trial participants are the most affected by research ethics committee's decisions, they are not formally represented on Swiss committees. We aimed to find out what patients think about the idea of being members of such committees. Design Latent thematic analysis was used to analyse the interviews. Setting Patients were recruited in a Swiss university hospital. Participants The study involved 26 patients suffering from diabetes or gout. Interventions We conducted semi-structured interviews. Main Outcome Measures We explored what patients think of being established members of research ethics committees. Results We identified three different attitudes among our participants regarding participation in research ethics committees: (i) positive attitude regarding the idea of being members of such committees, (ii) ambivalent attitude and (iii) negative attitude. Patients belonging to the first group (i) often mentioned that they wanted their health condition to be more visible. Patients from the second group (ii) mentioned positive as well as negative aspects. Patients from the third group (iii) said that patients in general did not have enough background knowledge to be able to gain an overview of a whole clinical trial. Conclusions Our study adds important knowledge about the idea of patients becoming research ethics committee members by exploring their perceptions of being members. Stable patients tended to be interested in the idea of participation and some specific recommendations could be derived (patients could have an advisory instead of a decision-making role on committees). However, further studies with more patients and further quantitative research are needed.
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Affiliation(s)
- Milenko Rakic
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056 Basel, Switzerland
| | - Tolga Dittrich
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056 Basel, Switzerland
| | - Bernice S Elger
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056 Basel, Switzerland
| | - David Shaw
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056 Basel, Switzerland
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Ishii T, Taguri M, Tamura K, Oyama K. Evaluation of the Effectiveness of Xanthine Oxidoreductase Inhibitors on Haemodialysis Patients using a Marginal Structural Model. Sci Rep 2017; 7:14004. [PMID: 29070821 PMCID: PMC5656650 DOI: 10.1038/s41598-017-13970-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 10/03/2017] [Indexed: 02/07/2023] Open
Abstract
A lower serum uric acid (UA) level has been associated with a higher mortality rate in haemodialysis patients. We investigated the long-term confounding factors of UA and mortality, and fitted a marginal structural model (MSM) based on the causal effect of xanthine oxidoreductase inhibitors (XORi). In total, 2429 patients on regular dialysis from April 2013 to March 2016 were included, and divided into quintiles by serum UA with Kaplan Meier (KM) curves and log rank analysis. Baseline characteristics were evaluated for relationships with all-cause mortality and cardiovascular disease (CVD) using the Cox hazard model. The MSM was used to control for time-dependent confounders of the XORi treatment effect. KM curves indicated that patients in the highest UA quintile had better outcomes than those in the lowest UA quintile. UA was not correlated with all-cause mortality or CVD events in the Cox model; however, the hazard ratio (HR) for mortality was 0.96 for the baseline administration of XORi. The MSM analysis for the effect of XORi treatment on all-cause mortality revealed a HR of 0.24 (95% confidence interval: 0.15-0.38) in all cohorts. These results suggest that XORi improved all-cause mortality in end-stage renal disease, irrespective of the serum UA level.
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Affiliation(s)
- Takeo Ishii
- Department of Internal Medicine, Yokohama City, Yokohama-Daiichi Hospital, Yokohama, 220-0011, Japan. .,Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, 236-0004, Japan.
| | - Masataka Taguri
- Department of Biostatistics, Yokohama City University Graduate School of Medicine, Yokohama, 236-0004, Japan
| | - Kouichi Tamura
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, 236-0004, Japan.
| | - Kunio Oyama
- Department of Internal Medicine, Yokohama City, Yokohama-Daiichi Hospital, Yokohama, 220-0011, Japan
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29
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Zhang T, Pope JE. Cardiovascular effects of urate-lowering therapies in patients with chronic gout: a systematic review and meta-analysis. Rheumatology (Oxford) 2017; 56:1144-1153. [PMID: 28379501 DOI: 10.1093/rheumatology/kex065] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Indexed: 12/22/2022] Open
Abstract
Objectives To determine if urate-lowering treatment (ULT) in gout can reduce cardiovascular (CV) outcomes. Methods Randomized trials were searched for treatment with ULT in gout. Eligible trials had to report CV safety of a ULT. Potential medications included allopurinol, febuxostat, pegloticase, rasburicase, probenecid, benzbromarone, sulphinpyrazone, losartan, fenofibrate and sodium-glucose linked transporter 2 inhibitors. Results A total of 3084 citations were found, with 642 duplicates. After the primary screen, 35 studies were selected for review. Several trials did not report CV events. Six were not randomized controlled trials (RCTs). Four studies reported no events in either intervention arm while the other four had 40 events in the febuxostat group ( n = 3631) and 5 in allopurinol group ( n = 1154). Overall, the pooled analysis did not show a significant difference between the two [febuxostat vs allopurinol: relative risk (RR) 1.69 (95% CI 0.54, 5.34), P = 0.37]. CV events did not decrease over time. Comparing shorter studies (<52 weeks) to longer ones did not reveal any statistical differences. However, in long-term studies with febuxostat vs allopurinol, results were nearly significant, with more CVE occurring with febuxostat treatment. Comparing any ULT to placebo (eight studies, n = 2221 patients) did not demonstrate a significant difference in non-Anti-Platelet Trialists' Collaboration events [any ULT vs placebo: RR 1.47 (95% CI 0.49, 4.40), P = 0.49] or all-cause mortality [any ULT vs placebo: RR 1.45 (95% CI 0.35, 5.77), P = 0.60]. Conclusion RCT data do not suggest differences in CV events among ULTs in gout. Trials had few events despite high-risk patients being enrolled and may have been too short to show CV reduction by controlling inflammatory attacks and lowering uric acid.
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Affiliation(s)
- Tony Zhang
- Department of Rheumatology, Schulich School of Medicine & Dentistry, Western University of Canada, St Joseph Health Care, London, ON Canada
| | - Janet E Pope
- Department of Rheumatology, Schulich School of Medicine & Dentistry, Western University of Canada, St Joseph Health Care, London, ON Canada
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Slot O. Gout in a rheumatology clinic: results of EULAR/ACR guidelines-compliant treatment. Scand J Rheumatol 2017; 47:194-197. [DOI: 10.1080/03009742.2017.1350746] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- O Slot
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spinal Disorders, Rigshospitalet Glostrup, Glostrup, Denmark
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Abstract
PURPOSE OF REVIEW The complexity of gout continues to unravel with each new investigation. Gout sits at the intersection of multiple intrinsically complex processes, and its prevalence, impact on healthcare costs, and association with important co-morbidities make it increasingly relevant. The association between gout and type 2 diabetes, hypertension, hyperlipidemia, cardiovascular disease, renal disease, and obesity suggest that either gout, or its necessary precursor hyperuricemia, may play an important role in the manifestations of the metabolic syndrome. In this review, we analyze the complex interconnections between gout and metabolic syndrome, by reviewing gout's physiologic and epidemiologic relationships with its major co-morbidities. RECENT FINDINGS Increasing evidence supports gout's association with metabolic syndrome. More specifically, both human studies and animal models suggest that hyperuricemia may play a role in promoting inflammation, hypertension and cardiovascular disease, adipogenesis and lipogenesis, insulin and glucose dysregulation, and liver disease. Fructose ingestion is associated with increased rates of hypertension, weight gain, impaired glucose tolerance, and dyslipidemia and is a key driver of urate biosynthesis. AMP kinase (AMPK) is a central regulator of processes that tend to mitigate against the metabolic syndrome. Within hepatocytes, leukocytes, and other cells, a fructose/urate metabolic loop drives key inhibitors of AMPK, including AMP deaminase and fructokinase, that may tilt the balance toward metabolic syndrome progression. Preliminary evidence suggests that agents that block the intracellular synthesis of urate may restore AMPK activity and help maintain metabolic homeostasis. Gout is both an inflammatory and a metabolic disease. With further investigation of urate's role, the possibility of proper gout management additionally mitigating metabolic syndrome is an evolving and important question.
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Affiliation(s)
- Gabrielle E Thottam
- Department of Medicine, Roger Williams Medical Center, Providence, RI, USA.,Crystal Diseases Study Group, Division of Rheumatology, Department of Medicine, New York University School of Medicine, 301 East 17th Street, Suite 1410, New York, NY, 10003, USA
| | - Svetlana Krasnokutsky
- Crystal Diseases Study Group, Division of Rheumatology, Department of Medicine, New York University School of Medicine, 301 East 17th Street, Suite 1410, New York, NY, 10003, USA.,Rheumatology Section, Department of Medicine, VA New Harbor Health Care System, New York Campus, New York, NY, USA
| | - Michael H Pillinger
- Crystal Diseases Study Group, Division of Rheumatology, Department of Medicine, New York University School of Medicine, 301 East 17th Street, Suite 1410, New York, NY, 10003, USA. .,Rheumatology Section, Department of Medicine, VA New Harbor Health Care System, New York Campus, New York, NY, USA.
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32
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Rakic M, Wienand I, Shaw D, Nast R, Elger BS. Autonomy and Fear of Synthetic Biology: How Can Patients' Autonomy Be Enhanced in the Field of Synthetic Biology? A Qualitative Study with Stable Patients. SCIENCE AND ENGINEERING ETHICS 2017; 23:375-388. [PMID: 27138379 DOI: 10.1007/s11948-016-9786-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 04/12/2016] [Indexed: 06/05/2023]
Abstract
We analyzed stable patients' views regarding synthetic biology in general, the medical application of synthetic biology, and their potential participation in trials of synthetic biology in particular. The aim of the study was to find out whether patients' views and preferences change after receiving more detailed information about synthetic biology and its clinical applications. The qualitative study was carried out with a purposive sample of 36 stable patients, who suffered from diabetes or gout. Interviews were transcribed verbatim, translated and fully anonymized. Thematic analysis was applied in order to examine stable patients' attitudes towards synthetic biology, its medical application, and their participation in trials. When patients were asked about synthetic biology in general, most of them were anxious that something uncontrollable could be created. After a concrete example of possible future treatment options, patients started to see synthetic biology in a more positive way. Our study constitutes an important first empirical insight into stable patients' views on synthetic biology and into the kind of fears triggered by the term "synthetic biology." Our results show that clear and concrete information can change patients' initial negative feelings towards synthetic biology. Information should thus be transmitted with great accuracy and transparency in order to reduce irrational fears of patients and to minimize the risk that researchers present facts too positively for the purposes of persuading patients to participate in clinical trials. Potential participants need to be adequately informed in order to be able to autonomously decide whether to participate in human subject research involving synthetic biology.
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Affiliation(s)
- Milenko Rakic
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland.
| | - Isabelle Wienand
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| | - David Shaw
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| | - Rebecca Nast
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| | - Bernice S Elger
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
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33
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Abstract
PURPOSE Xanthine oxidase catalyzes the oxidation of xanthine to uric acid. This process generates excessive reactive oxygen species (ROS) that play an important role in atherogenesis. Recent studies show that LRR and PYD domains-containing protein 3 (NLRP3), a component of the inflammasome, may be involved in the formation of foam cells, a hallmark of atherosclerosis. This study was designed to study the role of various scavenger receptors and NLRP3 inflammasome in xanthine oxidase and uric acid-induced foam cell formation. METHODS AND RESULTS Human vascular smooth muscle cells (VSMCs) and THP-1 macrophages were treated with xanthine oxidase or uric acid. Xanthine oxidase treatment (of both VSMCs and THP-1 cells) resulted in foam cell formation in concert with generation of ROS and expression of cluster of differentiation 36 (CD36) and oxidized low density lipoprotein (lectin-like) receptor 1 (LOX-1), but not of scavenger receptor A (SRA). Uric acid treatment resulted in foam cell formation, ROS generation and expression of CD36, but not of LOX-1 or SRA. Further, treatment of cells with xanthine oxidase, but not uric acid, activated NLRP3 and its downstream pro-inflammatory signals- caspase-1, interleukin (IL)-1β and IL-18. Blockade of LOX-1 or NLRP3 inflammasome with specific siRNAs reduced xanthine oxidase-induced foam cell formation, ROS generation and activation of NLRP3 and downstream signals. CONCLUSIONS Xanthine oxidase induces foam cell formation in large part through activation of LOX-1 - NLRP3 pathway in both VSMCs and THP-1 cells, but uric acid-induced foam cell formation is exclusively through CD36 pathway. Further, LOX-1 activation is upstream of NLRP3 activation. Graphical Abstract Steps in the formation of foam cells in response to xanthine oxidase and uric acid. Xanthine oxidase stimulates LOX-1 expression on the cell membrane of macrophages and vascular smooth muscle cells (VSMCs) and increases generation of ROS, which activate NLRP3 inflammasome and downstream pro-inflammatory mediators such as Caspase-1, IL-1β and IL-18. Xanthine oxidase also induces CD36 expression. Activation of both LOX-1 and CD36 (LOX-1> > CD36) participates in the transformation of macrophages and VSMCs into foam cells. Uric acid formed from xanthine-xanthine oxidase interaction stimulates CD36 expression and triggers foam cell formation independent of NLRP3 activation.
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34
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Dehlin M, Ekström EH, Petzold M, Strömberg U, Telg G, Jacobsson LTH. Factors associated with initiation and persistence of urate-lowering therapy. Arthritis Res Ther 2017; 19:6. [PMID: 28095891 PMCID: PMC5240247 DOI: 10.1186/s13075-016-1211-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 12/15/2016] [Indexed: 12/27/2022] Open
Abstract
Background Gout is the most common inflammatory arthritic disease and is caused by crystal deposition secondary to persistent hyperuricemia. Etiological treatment with urate-lowering therapy (ULT) has been available since the 1950s but previous studies have demonstrated suboptimal degree of treatment. In recent years we have seen recommendations for ULT earlier in the course of the disease, but there are few contemporary reports reflecting the current situation. Therefore we set out to investigate proportion receiving and persisting with ULT after gout diagnosis and predictors thereof. Method A population-based cohort study using regional and national population-based registers. Cohort of patients (n = 7709) from western Sweden with incident gout aged 18 years and above from 2011 to 2013. An incident case of gout was defined as having been given a diagnosis of gout (ICD-10 M10, M14.0-14.1) not preceded by a gout diagnosis or a dispensation of ULT during the previous 5 years. Main outcome measures were cumulative incidence and predictors for start of, and persistence with, ULT in gout. Results Within the first year after first gout diagnosis, 32% received ULT. Male sex, presence of diabetes or cardiovascular comorbidity, reduced kidney function but not diagnosed “end-stage kidney failure” increased the likelihood of receiving ULT. Of those starting ULT a majority (75%) did not persist with ULT treatment within the first 2 years. Age <50 years, lack of comorbidities, and “normal kidney function” or “end-stage kidney failure” were associated with non-persistence with ULT. Conclusions Only a minority of patients received ULT and a majority of these did not persist with treatment over the next 2 years. However, the older patients with renal impairment and comorbidities, possibly suffering from a more severe gout disease, were more likely to receive and persist with treatment. There is thus still room for considerable improvement with regards to management of ULT in gout. Electronic supplementary material The online version of this article (doi:10.1186/s13075-016-1211-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mats Dehlin
- Department of Rheumatology, University of Gothenburg, Gothenburg, Sweden.
| | | | - Max Petzold
- Swedish National Data Service, University of Gothenburg, Gothenburg, Sweden.,Health Metrics, University of Gothenburg, Gothenburg, Sweden
| | - Ulf Strömberg
- Health Metrics, University of Gothenburg, Gothenburg, Sweden
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35
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Andrés M, Bernal JA, Sivera F, Quilis N, Carmona L, Vela P, Pascual E. Cardiovascular risk of patients with gout seen at rheumatology clinics following a structured assessment. Ann Rheum Dis 2017; 76:1263-1268. [PMID: 28093417 DOI: 10.1136/annrheumdis-2016-210357] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 11/29/2016] [Accepted: 12/26/2016] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Gout-associated cardiovascular (CV) risk relates to comorbidities and crystal-led inflammation. The aim was to estimate the CV risk by prediction tools in new patients with gout and to assess whether ultrasonographic carotid changes are present in patients without high CV risk. METHODS Cross-sectional study. Consecutive new patients with crystal-proven gout underwent a structured CV consultation, including CV events, risk factors and two risk prediction tools-the Systematic COronary Evaluation (SCORE) and the Framingham Heart Study (FHS). CV risk was stratified according to current European guidelines. Carotid ultrasound (cUS) was performed in patients with less than very high CV risk. The presence of carotid plaques was studied depending on the SCORE and FHS by the area under the curve (AUC) of receiver operating curves. RESULTS 237 new patients with gout were recruited. CV stratification by scores showed a predominance of very high (95 patients, 40.1%) and moderate (72 patients, 30.5%) risk levels. cUS was performed in 142 patients, finding atheroma plaques in 66 (46.5%, 95% CI 37.8 to 54.2). Following cUS findings, patients classified as very high risk increased from 40.1% up to 67.9% (161/237 patients). SCORE and FHS predicted moderately (AUC 0.711 and 0.683, respectively) the presence of atheroma plaques at cUS. CONCLUSIONS The majority of patients presenting with gout may be at very high CV risk, indicating the need for initiating optimal prevention strategies at this stage. Risk prediction tools appear to underestimate the presence of carotid plaque in patients with gout.
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Affiliation(s)
- Mariano Andrés
- Sección de Reumatología, Hospital General Universitario de Alicante, Alicante, Spain.,Departamento de Medicina Clínica, Universidad Miguel Hernández, Alicante, Spain
| | - José Antonio Bernal
- Sección de Reumatología, Hospital General Universitario de Alicante, Alicante, Spain
| | - Francisca Sivera
- Sección de Reumatología, Hospital General Universitario de Elda, Alicante, Spain
| | - Neus Quilis
- Sección de Reumatología, Hospital General Universitario de Elda, Alicante, Spain
| | | | - Paloma Vela
- Sección de Reumatología, Hospital General Universitario de Alicante, Alicante, Spain.,Departamento de Medicina Clínica, Universidad Miguel Hernández, Alicante, Spain
| | - Eliseo Pascual
- Sección de Reumatología, Hospital General Universitario de Alicante, Alicante, Spain.,Departamento de Medicina Clínica, Universidad Miguel Hernández, Alicante, Spain
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36
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Stewart J, Manmathan G, Wilkinson P. Primary prevention of cardiovascular disease: A review of contemporary guidance and literature. JRSM Cardiovasc Dis 2017; 6:2048004016687211. [PMID: 28286646 PMCID: PMC5331469 DOI: 10.1177/2048004016687211] [Citation(s) in RCA: 177] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 11/22/2016] [Accepted: 12/02/2016] [Indexed: 12/25/2022] Open
Abstract
Cardiovascular disease is a significant and ever-growing problem in the United Kingdom, accounting for nearly one-third of all deaths and leading to significant morbidity. It is also of particular and pressing interest as developing countries experience a change in lifestyle which introduces novel risk factors for cardiovascular disease, leading to a boom in cardiovascular disease risk throughout the developing world. The burden of cardiovascular disease can be ameliorated by careful risk reduction and, as such, primary prevention is an important priority for all developers of health policy. Strong consensus exists between international guidelines regarding the necessity of smoking cessation, weight optimisation and the importance of exercise, whilst guidelines vary slightly in their approach to hypertension and considerably regarding their approach to optimal lipid profile which remains a contentious issue. Previously fashionable ideas such as the polypill appear devoid of in-vivo efficacy, but there remain areas of future interest such as the benefit of serum urate reduction and utility of reduction of homocysteine levels.
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Affiliation(s)
- Jack Stewart
- Department of Cardiology, Ashford & St Peter's NHS Foundation Trust, London, UK; Institute of Cardiovascular Research, Biological Sciences, University of London, Surrey, UK
| | | | - Peter Wilkinson
- Department of Cardiology, Ashford & St Peter's NHS Foundation Trust, London, UK
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37
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Sloop GD, Bialczak JK, Weidman JJ, St. Cyr J. Uric acid increases erythrocyte aggregation: Implications for cardiovascular disease. Clin Hemorheol Microcirc 2016; 63:349-359. [DOI: 10.3233/ch-152023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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38
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Chen JH, Lan JL, Cheng CF, Liang WM, Lin HY, Tsay GJ, Yeh WT, Pan WH. Effect of Urate-Lowering Therapy on All-Cause and Cardiovascular Mortality in Hyperuricemic Patients without Gout: A Case-Matched Cohort Study. PLoS One 2015; 10:e0145193. [PMID: 26683302 PMCID: PMC4684295 DOI: 10.1371/journal.pone.0145193] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 11/30/2015] [Indexed: 02/07/2023] Open
Abstract
Objectives An increased risk of mortality in patients with hyperuricemia has been reported. We examined (1) the risk of all-cause and cardiovascular disease (CVD) mortality in untreated hyperuricemic patients who did not receive urate-lowering therapy (ULT), and (2) the impact of ULT on mortality risk in patients with hyperuricemia. Methods In this retrospective case-matched cohort study during a mean follow-up of 6.4 years, 40,118 Taiwanese individuals aged ≥17 years who had never used ULT and who had never had gout were examined. The mortality rate was compared between 3,088 hyperuricemic patients who did not receive ULT and reference subjects (no hyperuricemia, no gout, no ULT) matched for age and sex (1:3 hyperuricemic patients/reference subjects), and between 1,024 hyperuricemic patients who received ULT and 1,024 hyperuricemic patients who did not receive ULT (matched 1:1 based on their propensity score and the index date of ULT prescription). Cox proportional hazard modeling was used to estimate the respective risk of all-cause and CVD (ICD-9 code 390–459) mortality. Results After adjustment, hyperuricemic patients who did not receive ULT had increased risks of all-cause (hazard ratio, 1.24; 95% confidence interval, 0.97–1.59) and CVD (2.13; 1.34–3.39) mortality relative to the matched reference subjects. Hyperuricemic patients treated with ULT had a lower risk of all-cause death (0.60; 0.41–0.88) relative to hyperuricemic patients who did not receive ULT. Conclusion Under-treatment of hyperuricemia has serious negative consequences. Hyperuricemic patients who received ULT had potentially better survival than patients who did not.
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Affiliation(s)
- Jiunn-Horng Chen
- School of Medicine, China Medical University, Taichung, Taiwan
- Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
- * E-mail:
| | - Joung-Liang Lan
- School of Medicine, China Medical University, Taichung, Taiwan
- Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Chi-Fung Cheng
- Department of Public Health, China Medical University, Taichung, Taiwan
- Graduate Institute of Biostatistics, Biostatistics Center, China Medical University, Taichung, Taiwan
| | - Wen-Miin Liang
- Department of Public Health, China Medical University, Taichung, Taiwan
- Graduate Institute of Biostatistics, Biostatistics Center, China Medical University, Taichung, Taiwan
| | - Hsiao-Yi Lin
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Internal Medicine, Veterans General Hospital, Taipei, Taiwan
| | - Gregory J Tsay
- School of Medicine, China Medical University, Taichung, Taiwan
- Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Wen-Ting Yeh
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | - Wen-Harn Pan
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli County, Taiwan
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Huang CC, Huang PH, Chen JH, Lan JL, Tsay GJ, Lin HY, Tseng CH, Lin CL, Hsu CY. An Independent Risk of Gout on the Development of Deep Vein Thrombosis and Pulmonary Embolism: A Nationwide, Population-Based Cohort Study. Medicine (Baltimore) 2015; 94:e2140. [PMID: 26705202 PMCID: PMC4697968 DOI: 10.1097/md.0000000000002140] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Previous studies indicated that gout is a risk factor of cardiovascular diseases. This study aimed to determine if patients with gout have an increased risk of deep vein thrombosis (DVT) or pulmonary embolism (PE).We used the Longitudinal Health Insurance Database, a subset of the national insurance claim dataset, which enrolled 1 million Taiwanese to identify 57,981 patients with gout and 115,961 reference subjects matched by sex, age, and entry date of diagnosis. The risk of DVT and PE was analyzed using the Cox proportional hazards model.In this Taiwanese dataset observed from 2000 to 2010, we found the incidence of DVT was 5.26 per 10 person-years in the gout cohort, which was twofold higher than the incidence of 2.63 per 10 person-years in the reference cohort. After adjusting for age, sex, and 9 comorbidities, the hazard ratio (HR) of developing DVT was 1.66 (95% confidence interval [CI] = 1.37-2.01). Among patients with gout, the youngest age group had the highest increase in the risk of developing DVT (HR [95% CI] = 2.04 [1.24-3.37] for ages 20 to 49 years, 1.80 [1.28-2.51] for ages 50 to 64 years, and 1.45 [1.11-1.91] for ages ≥65 years). The incidence of PE was about one-fifth that of DVT in gout patients, but the effect of gout on the risk was similar (HR [95% CI] = 1.53 [1.01-2.29]).Our analysis confirmed that gout increased the risk of DVT and PE. Further exploration is needed in the future.
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Affiliation(s)
- Chien-Chung Huang
- From the Division of Immunology and Rheumatology, Department of Internal Medicine (C-CH, P-HH, J-HC, J-LL, GJT), Department of Neurology (C-HT), and Management Office for Health Data (C-LL, C-YH), China Medical University Hospital, Taichung, Taiwan; School of Medicine (J-HC, J-LL, GJT, C-HT), Rheumatology Research Laboratory (C-CH, P-HH, J-HC, J-LL, GJT), Graduate Institute of Clinical Medical Science (C-YH), China Medical University, Taichung, Taiwan; Division of Immunology and Rheumatology, Department of Internal Medicine, Veterans General Hospital, Taichung, Taiwan (H-YL); and School of Medicine, National Yang-Ming Medical University, Taipei, Taiwan (H-YL)
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