Sex differences in cytokines and adipokines in obese patients with PsA and controls undergoing a weight loss intervention

OBJECTIVE

In this post hoc analysis of a previously published study, we compared cytokines and adipokine levels in women and men with psoriatic arthritis (PsA) at baseline (BL) and 6 months (M6) following a weight loss intervention.

METHODS

Patients with PsA (n=41) between 25 and 75 years of age, with body mass index (BMI)≥33 kg/m2 were included in a weight loss intervention with a very low energy diet (VLED) for 12 or 16 weeks depending on BL BMI<40 or ≥40 kg/m2. As controls (n=39), obese individuals, already planned for VLED treatment were recruited and matched for sex, age and weight to the patients with PsA. Cytokines and adipokines were measured at BL and M6.

RESULTS

At BL, serum levels of interleukin (IL)-23, leptin and high molecular weight-adiponectin were higher in women with PsA compared with men, whereas serum levels of interferon (IFN)-γ, IL-12/IL-23 p40 and IL-13 were significantly lower in women. Serum IL-23 was significantly reduced at M6 compared with BL in women but not in men with PsA. In women with PsA, the reduction in IL-23 at M6, ∆IL-23, were positively correlated with ∆Disease Activity Score 28 C reactive protein (CRP) (Spearman's correlation (rS)=0.486, p=0.016), ∆CRP (rS=0.468, p=0.021), ∆leptin (rS=0.683, p<0.001) and negatively correlated with ∆total-adiponectin (rS=-0.433, p=0.035). Also in women, ∆Disease Activity in Psoriatic Arthritis was positively correlated with ∆tumour necrosis factor-α (rS=0.417, p=0.034), ∆IL-1β (rS=0.550, p=0.034), ∆IFN-γ (rS=0.414, p=0.035) and ∆leptin (rS=0.410, p=0.038). None of these correlations were significant in men with PsA.

CONCLUSIONS

Women and men with PsA differed with regard to serum levels of cytokines and adipokines before and after weight loss.

Sex and country differences in gout: cross-country comparison between Sweden and the UK

OBJECTIVE

Compare characteristics, sex differences, and management of gout in Sweden and the UK.

METHOD

The results from two separate primary care gout surveys from Sweden and the UK were compared. Participants aged ≥18 years with gout were sent a questionnaire asking about lifestyle, gout characteristics, uratelowering therapy (ULT), comorbidities, disability, and disease impact. For sex comparison, participants were pooled across countries.

RESULTS

In total, 784 (80% male) participants from Sweden and 500 (87% male) from the UK were included. Swedish patients were significantly older at gout onset, mean (SD) age 72 (12) versus 63 (13) years, (p<0.0001), with more comorbidities, and more frequent use of ULT (48% vs 35%, p=0.0005, age-adjusted). Use of alcohol and diuretics was significantly more common among UK patients, who also reported a higher number of gout flares, mean (SD) 2.2 (1.7) versus 1.6 (3.6), (p=0.003) age-adjusted. Females with gout were older at gout onset, mean (SD) age 67 (13) versus 56 (15), (p<0.0001), more often obese, and reported higher use of diuretics. Furthermore, females reported greater impact of gout, more pain and physical limitations, whereas no sex differences were seen in ULT or flares.

CONCLUSIONS

In the UK, gout was more frequently associated with modifiable risk factors. People with gout in Sweden were more commonly taking ULT and had lower frequency of gout flares and impact of gout. Females with gout more commonly took diuretics, had higher body mass index, and reported greater physical disability, which should be considered when managing gout in women.

Health-related quality of life by gout severity in women and men with gout in primary care: results from a questionnaire study in Western Sweden

OBJECTIVE

We aimed to compare health-related quality of life (HRQoL) by gout severity, overall and by sex.

METHOD

A questionnaire was sent to patients with gout (n = 1444) identified at 12 primary care centres in Western Sweden. The questionnaire asked about comorbidities, gout-specific aspects, and HRQoL, using the RAND 36-Item Health Survey. Responders were divided into 'mild', 'moderate', or 'severe' gout based on the number of self-reported flares (0, 1-2, ≥ 3) during the past 12 months.

RESULTS

Out of 1444 gout patients, 784 (54.3%) responded to the questionnaire. Among the respondents, 673 [560 (83.2%) men and 113 (16.8%) women] provided answers regarding the number of gout flares in the past year. Of these, 322 (47.8%), 218 (32.4%), and 133 (19.8%) were classified as having mild, moderate, and severe gout, respectively. Allopurinol use was more frequent in those with mild disease. In more severe gout, HRQoL was reduced compared to less severe gout [severe vs mild gout, mean values for physical component summary (PCS) score 39.5 vs 43.6, p = 0.002, and mental component summary (MCS) score 46.6 vs 51.1, p < 0.001]. When excluding those with a flare in the past month, the HRQoL was still worse in severe gout (vs mild), although differences were attenuated and not statistically significant for the PCS and for women.

CONCLUSION

Gout severity, defined as the number of flares during the past year, was associated with significant reductions in HRQoL.

Health-related quality of life in gout, psoriatic arthritis, rheumatoid arthritis and ankylosing spondylitis, results from a cross-sectional survey in Western Sweden

OBJECTIVES

Inflammatory joint diseases (IJDs) substantially affect health-related quality of life (HRQoL). We aimed to compare HRQoL between patients with gout, psoriatic arthritis (PsA), rheumatoid arthritis (RA), and ankylosing spondylitis (AS): (i) overall; (ii) stratified by sex; and (iii) between women and men with the same IJD diagnosis.

METHOD

A survey including the RAND36-Item Health Survey for assessing HRQoL was sent to patients with a diagnosis of gout, PsA, RA, or AS, registered at a rheumatology clinic or primary care centre during 2015-2017. HRQoL was compared across IJDs. Because of age differences between diagnoses, age-matched analyses were performed.

RESULTS

In total, 2896/5130 (56.5%) individuals responded to the questionnaire. Of these, 868 had gout, 699 PsA, 742 RA, and 587 AS. Physical component summary (PCS) scores were more affected than mental component summary (MCS) scores for all diagnoses (PCS range: 39.7-41.2; MCS range: 43.7-48.9). Patients with gout reported better PCS scores than patients with PsA, RA, and AS, who reported similar scores in age-matched analysis. MCS scores were close to normative values for the general population and similar across IJDs. When comparing women and men with respective IJDs, women reported worse PCS (range, all IJDs: 34.5-37.4 vs 37.5-42.5) and MCS (PsA: 44.0 vs 46.8; RA: 46.1 vs 48.7) scores.

CONCLUSION

We found that patients with gout reported better PCS scores than patients with other IJDs, for whom the results were similar. Women reported overall worse PCS and MCS scores than men.

Gout in Dalarna, Sweden - a population-based study of gout occurrence and compliance to treatment guidelines

OBJECTIVE

This study aimed to describe the incidence and prevalence of gout, describe the use of allopurinol among prevalent gout cases, and determine persistence with allopurinol and degree of compliance with treat-to-target recommendations before and after the publication of Swedish national guidelines in 2016.

METHOD

Prospectively registered data on gout diagnoses and allopurinol prescriptions were used to calculate incidence and prevalence, and the proportion of prevalent patients on allopurinol. Gout patients starting allopurinol during 2013-2015 versus 2016-2018 were compared regarding persistence and compliance with treat-to-target principles.

RESULTS

The incidence of gout was 221-247 per 100 000 person-years during 2014-2019, prevalence in 2018 was 2.45%. Among prevalent cases, the proportion on allopurinol ranged from 21% to 25%. Allopurinol persistence was better for individuals starting therapy during 2016-2018 compared with 2013-2015 (45% vs 39%, p = 0.031), as were several outcomes related to treat-to-target principles, e.g. measuring baseline serum urate (SU) (84% vs 77%, p < 0.001), follow-up SU (50% vs 36%, p < 0.001), and the proportion of patients reaching an SU level < 360 µmol/L (45% vs 30%, p < 0.001).

CONCLUSION

Incidence and prevalence were slightly higher than in previous Swedish reports. Allopurinol use among prevalent gout patients did not increase during 2014-2019. Only a minor improvement in persistence was seen, and a moderate increase in compliance with guidelines, suggesting a need for improved management and extended patient involvement to increase and optimize the use of urate lowering therapy.

Serum IL-23 significantly decreased in obese patients with psoriatic arthritis six months after a structured weight loss intervention

INTRODUCTION

Patients with psoriatic arthritis (PsA) are frequently obese. We have previously shown decreased disease activity in patients with PsA with a body mass index (BMI) ≥ 33 kg/m² following weight loss treatment with Very Low Energy Diet (VLED), resulting in a median weight loss of 18.6% at six months (M6) after baseline (BL). In this study we assessed the effects of VLED on cytokines and adipokines at M6 in the same patients with PsA and controls (matched on sex, age and weight).

METHODS

VLED (640 kcal/day) during 12 or 16 weeks, depending on BL BMI < 40 or ≥ 40 kg/m², was taken and followed by an energy-restricted diet. Cytokines and adipokines were measured with Magnetic Luminex Assays at BL and M6.

RESULTS

Serum interleukin (IL)-23, (median (interquartile range) 0.40 (0.17-0.54) ng/mL vs. 0.18 (0.10-0.30) ng/mL, p < 0.001) and leptin (26.28 (14.35-48.73) ng/mL vs. 9.25 (4.40-16.24) ng/mL, p < 0.001) was significantly decreased in patients with PsA. Serum total (tot)-adiponectin and high molecular weight (HMW) adiponectin increased significantly. Similar findings were found in controls. Also, in patients with PsA, ∆BMI was positively correlated with ∆IL-23 (r_S = 0.671, p < 0.001). In addition, significant positive correlations were found between ΔBMI and ΔDisease Activity Score (DAS28CRP), ΔCRP, Δtumor necrosis factor (TNF)-α, ΔIL-13, ∆IL-17 and Δleptin, and negative correlations between ΔBMI and Δtot-adiponectin.

CONCLUSIONS

Weight loss was associated with decreased levels of leptin and cytokines, in particular IL-23. These findings may partly explain the anti-inflammatory effect of weight reduction in PsA.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02917434, registered on September 21, 2016, retrospectively registered.

Gender differences in illness perceptions and disease management in patients with gout, results from a questionnaire study in Western Sweden

BACKGROUND

Aims were to examine gender differences in patients with gout with regard to a) self-reported gout severity, b) illness perceptions (IP), c) impact on daily activities and Quality of Life (QoL), d) advice from healthcare professionals, e) having changed dietary- or alcohol habits.

METHODS

Adult patients with gout identified in primary and secondary care in Sweden between 2015 and 2017 (n = 1589) were sent a questionnaire about demographics, gout disease severity, IP (using the Brief Illness Perception Questionnaire, (B-IPQ)) and disease management. T-tests, Chi square tests, ANalysis Of VAriance (ANOVA) and linear regression models were used for gender comparisons.

RESULTS

Eight hundred sixty-eight patients responded to the questionnaire. Women, n = 177 (20%), experienced more severe gout symptoms (p = 0.011), albeit similar frequencies of flares compared to men. Women experienced modest but significantly worse IP with regard to consequences, identity, concerns and emotional response (p < 0.05) as well as daily activities such as sleeping (p < 0.001) and walking (p = 0.042) and QoL (p = 0.004). Despite this and a higher frequency of obesity in women (38 vs 21%, P < 0.001) and alcohol consumption in men (p < 0.001), obese women had received significantly less advice regarding weight reduction (47 vs 65%, p = 0.041) compared to obese men. On the other hand, women reported having acted on dietary advice to a larger degree.

CONCLUSIONS

Despite only modestly worse gout severity and perception, women appear to have been given less information regarding self-management than men. These gender differences should be given attention and addressed in clinical care.

Professionals’ perspectives on existing practice and conditions for nurse-led gout care based on treatment recommendations: a qualitative study in primary healthcare

Background

Gout affects nearly 2 % of the population and is associated with repeated painful flares of arthritis. Preventive urate-lowering therapy is widely available, but only one third of patients receive adequate treatment. Lack of knowledge among healthcare professionals and patients within primary healthcare are implicated as partial explanations for this undertreatment. Nurse-led care has proved to be an effective model when treating patients with gout, but there is a need for more knowledge about factors that can be expected to influence the future implementation of such care. The aim of this study was to describe factors influencing existing gout care in primary healthcare and the conditions for a future implementation of nurse-led gout care based on national treatment recommendations.

Methods

In this qualitative study, focus group discussions with 56 nurses and physicians and individual interviews with eight managers were conducted at nine primary healthcare units in central Sweden. A deductive qualitative content analysis based on the main constructs of the framework Integrated Promoting Action on Research Implementation in Health Services was followed by an inductive analysis within the frames of the main constructs: innovation, recipients and context.

Results

Gout-related contacts with primary healthcare was described as being patient initiated, diagnostics was in some respects complex and nurse-led care was experienced as a favourable primary healthcare model in general (innovation). Gout was seen as a low-priority condition with acute flares and there was inadequate knowledge of gout, including preventive treatment (recipients). Primary healthcare was perceived as having a holistic but fragmented responsibility for gout care, recommendations against keeping waiting lists complicated follow-up appointments and a need for motivation and support when introducing new practices was emphasised (context).

Conclusion

In this study, investigating the perspective of professionals, several factors were found to influence existing gout care. It will be crucial to target these factors in the development of a future implementation strategy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01677-z.

Incident Gout and Risk of First-Time Acute Coronary Syndrome: A Prospective, Population-Based Cohort Study in Sweden

OBJECTIVE

To investigate the risk of first-time acute coronary syndrome (ACS) in a large cohort of primary and secondary care patients with incident gout compared to the general population.

METHODS

Using register data for the period 2007-2017, we conducted a prospective, population-based cohort with 20,146 patients with incident gout (mean age 65.6 years; 67.4% male) and 83,517 matched population controls without prior history of coronary heart disease. We calculated incidence rates (IRs) and hazard ratios (HRs) adjusted for baseline comorbidities and dispensed prescriptions. In a sensitivity analysis, we included gout cases and controls with no previously diagnosed comorbidity (6,075 cases and 44,091 controls).

RESULTS

The IR of first-time ACS was significantly increased in the gout cohort compared to controls (9.1 versus 6.3 of 1,000 person-years). Unadjusted Cox regression showed that gout patients had higher risk of first-time ACS compared to controls (HR 1.44 [95% confidence interval (95% CI) 1.33-1.56]), with a higher HR in women (HR 1.64 [95% CI 1.41-1.90]) than in men (HR 1.36 [95% CI, 1.24-1.50]). In multivariable analysis, the risk diminished but remained significant (HR 1.15 [95% CI 1.06-1.25]). The risk was similar in the sensitivity analysis (HR 1.20 [95% CI 1.01-1.44]) and still higher in women (HR 1.34 [95% CI 0.86-2.08]) than in men (HR 1.18 [95% CI 0.97-1.44]).

CONCLUSION

Patients with incident gout have a 44% increased risk of first-time ACS, higher in women than in men. This risk is largely explained by the underlying comorbidities, but there is still a modestly increased risk that may be due to gout-related factors.

AB1035 END STAGE RENAL DISEASE IN PATIENTS WITH GOUT AND CONTROLS, ETIOLOGICAL DIFFERENCES?

Background

The association between gout and renal disease is well known. However, whether hyperuricemia causes renal disease, or if the association is explained by comorbidities, is still up for debate. Studies on the effects of urate and gout on chronic kidney disease (CKD) show conflicting results. There is a lack of data on the underlying causes of CKD in gout patients.

Objectives

To compare causes of end stage renal disease (ESRD) in patients with gout and population controls.

Methods

This is a population-based and register-based case-control study. Gout cases, aged 18 years or older, were identified by at least one visit to a physician either an in- or outpatient clinic with a registered ICD-10 code for gout (M10) in the Western Regional Healthcare Contact Register (VEGA), between January 1st 2001 through December 31st 2018. For each case five controls without gout were matched by sex, age, and county/place of residence at year of first diagnosis. Cases and controls were excluded if they prior to the first recorded ICD-10 code for gout, had a record of end stage renal disease, defined as codes for renal transplantation or dialysis either in VEGA or the Swedish Kidney Register (SNR). In this cohort, all cases and controls developing ESRD during the follow-up period (2001 to 2018) were identified, and the registered causes of ESRD were compared across the groups.

Results

In total, 48594 gout cases (mean age 68.4 years; 67% male), and their 150618 matched controls (mean age 63.3 years; 67% male) were included. Of the cases and controls, 529 (1.1%) and 128 (0.1%) developed ESRD, respectively. At the time-point of active uremia treatment start (as in start of dialysis or kidney transplantation), the cardiovascular comorbidity burden was higher for the gout patients (Table 1). There was no significant difference in the distribution of ESRD-causes between patients with gout and their controls (Figure 1).

Table 1.

Baseline data

Gout Controls Number (% of total)529 (80.5)128 (19.5)Age at gout diagnosis, mean (median)64.2 (65)63.3 (65)Age at ESRD, mean (median)69.2 (72)68.9 (71)Male sex, n (%)389 (73.5)109 (85.2)No renal failure at baseline, n (%)239 (44.6)77 (60.2)Diabetes, n (%)215 (40.6)44 (34.4)Hypertension, n (%)473 (89.4)110 (85.9)Ischemic heart disease, n (%)*206 (38.9)26 (20.3)Cerebrovascular disease, n (%)89 (16.8)15 (11.7)Hematologic malignancy, n (%)11 (2.1)6 (4.7)Dermatologic malignancy, n (%)12 (2.3)3 (2.3)Other malignancy, n (%)65 (12.3)16 (12.5)

*p<0,001

Figure 1.

Conclusion

In this study, including 48594 cases with gout, of which 529 developed ESRD, there was no apparent difference in the cause of ESRD compared to matched controls. This suggests similar pathophysiological mechanisms of ESRD development in patients with gout and the general population.

Disclosure of Interests

None declared

Incident Gout: Risk of Death and Cause-Specific Mortality in Western Sweden: A Prospective, Controlled Inception Cohort Study

Background

Excess mortality in gout has been attributed to cardiovascular diseases (CVD). Considering the decline in CVD mortality in the general population, we wanted to evaluate overall mortality in gout and cause-specific contributions to mortality beyond CVD and temporal trends.

Methods

All incident cases of gout between 2006 and 2015 in western Sweden and 5 population controls per case matched for age, sex, and county were identified. Comorbidities were identified for 5 years preceding the index date. Follow-up ended at death, migration, or end of study on December 2017. Effect of gout on death risk was calculated using COX regression on the whole population and stratified by sex, adjusted for demographics, and comorbidities. Death incidence rates were compared between the two time periods, 2006-2010 and 2011-2015.

Results

We identified 22,055 cases of incident gout and 98,946 controls, median age (Q1, Q3) 69-68 (57, 79/56, 78) years and 67.6-66.5% males. Except for dementia, all comorbidities were significantly more common at baseline among gout cases. Overall, the risk for death in incident gout was neither increased overall nor in men, but women had a 10% elevated risk. In adjusted models for cause-specific mortality, death from CVD, renal disease, and digestive system diseases were significantly increased in the total gout population while death from dementia, cancer, and lung diseases were significantly decreased. There were no significant differences in overall incident death rate ratios between cases and controls in the two time periods examined.

Conclusions

An increased risk for CVD, renal disease, and diseases of the digestive system in patients with gout highlights the importance of addressing CVD risk factors in gout management. Gout was associated with reduced mortality from dementia, which may have implications on urate lowering therapy and possible effects on dementia risk.

Lifestyle factors and comorbidities in gout patients compared to the general population in Western Sweden: results from a questionnaire study

OBJECTIVE

This study aimed to identify lifestyle factors associated with gout in patients with prevalent gout compared to the general population.

METHOD

Adult patients with gout identified in primary and secondary care in Western Sweden between 2015 and 2017 were sent a questionnaire asking about demographics, lifestyle, and comorbidities. Five age- and gender-matched controls were identified in a random sample of 52 348 individuals aged 16-84 years who participated in the National Public Health survey in Sweden, year 2015. Logistic regression models were used to compare cases and controls with regard to lifestyle factors and comorbidities.

RESULTS

Of the 1589 invited gout patients, 868 (55%) responded. After matching for age and gender, 728 were included in the analysis (82.4% male; mean ± sd age 69.3 ± 10.5 years for men and 71.8 ± 9.9 years for women with gout). Male and female gout patients were significantly more likely to be overweight or obese (men 79% vs 66%; women 78.5% vs 65.3%), to have binge-drinking behaviour (men 29.9% vs 11%; women 13.7% vs 2.9%), and to be ex-smokers, compared to controls. Moreover, male gout patients reported lower levels of physical activity, while diabetes and hypertension were more common in both genders with gout than in controls.

CONCLUSION

In this questionnaire study, gout patients reported significantly more obesity and binge-drinking behaviour and less physical activity than controls. This suggests that there are great unmet needs for the management of lifestyle factors, particularly regarding overweight/obesity and binge drinking, in patients with gout.

Association between perinatal factors and future risk for gout-a nested case-control study

Background

Increased level of urate is the strongest risk factor for gout development but since only a minority of hyperuricemics are affected by gout, other pathogenic factors must be considered. Low birth weight is associated with future morbidities causing hyperuricemia, such as diabetes and renal disease. The purpose of this study was to investigate if, and to what extent, maternal and perinatal factors, including birth weight, are associated with future risk of being diagnosed with gout.

Methods

A population-based retrospective nested case-control registry study based on regional and national health care registers in Sweden. All incident cases of gout born in 1973 and onward who had received ≥1 diagnosis of gout from 2000 through 2019 in the region of western Sweden were included. Up to 5 non-gout controls were matched to each case by age, sex, and county at the year of first gout diagnosis. A range of maternal, gestational, and perinatal factors were analyzed for their potential association to future gout development. This included the health of the mother, gestational length, birth weight, number of siblings, and congenital malformations.

Results

Maternal diabetes, any congenital malformation, and being small for gestational age were factors that significantly increased the risk for future gout development, odds ratio (95% CI) 3.1 (1.3 to 7.4) (p=0.01), 1.33 (1.04 to 1.7) (p=0.02), and 1.75 (1.3 to 2.3) (p<.0001), respectively.

Conclusions

In this study, maternal diabetes and being small for gestational age increased the risk for future gout development in young adults. As of today, these conditions are becoming more prevalent and may contribute to the ongoing gout epidemic. These results require both confirmation and further delineation of underlying mechanisms.

Association between serum urate and CSF markers of Alzheimer's disease pathology in a population-based sample of 70-year-olds

INTRODUCTION

The relationship between urate and biomarkers for Alzheimer's disease (AD) pathophysiology has not been investigated.

METHODS

We examined whether serum concentration of urate was associated with cerebrospinal fluid biomarkers, amyloid beta (Aβ)42, Aβ40, phosphorylated tau (p-tau), total tau (t-tau), neurofilament light (NfL), and Aβ42/Aβ40 ratio, in cognitively unimpaired 70-year-old individuals from Gothenburg, Sweden. We also evaluated whether possible associations were modulated by the apolipoprotein E (APOE) ε4 allele.

RESULTS

Serum urate was positively associated with Aβ42 in males (β = 0.55 pg/mL, P = .04). There was a positive urate-APOE ε4 interaction (1.24 pg/mL, P interaction = .02) in relation to Aβ42 association. The positive urate and Aβ42 association strengthened in male APOE ε4 carriers (β = 1.28 pg/mL, P = .01).

DISCUSSION

The positive association between urate and Aβ42 in cognitively healthy men may suggest a protective effect of urate against deposition of amyloid protein in the brain parenchyma, and in the longer term, maybe against AD dementia.

Cardiovascular risk factors in gout, psoriatic arthritis, rheumatoid arthritis and ankylosing spondylitis: a cross-sectional survey of patients in Western Sweden

Objectives

We aimed to compare traditional (trad) cardiovascular risk factors (CVRFs) among patients with gout, psoriatic arthritis (PsA), rheumatoid arthritis (RA) and ankylosing spondylitis (AS) stratified by sex.

Methods

A survey was sent to patients with gout (n=1589), PsA (n=1200), RA (n=1246) and AS (n=1095). Patients were retrieved from Sahlgrenska University Hospital, the hospitals of Uddevalla and Skövde, and 12 primary care centres in Western Sweden. The prevalence of self-reported trad-CVRFs was compared between diagnoses by age standardisation with the 2018 population of Sweden as the standard population.

Results

In total, 2896 (56.5%) of 5130 patients responded. Hypertension was the most frequently found comorbidity, reported by 65% of patients with gout, 41% with PsA, 43% with RA and 29% with AS. After age standardisation, women and men with gout had significantly more obesity (body mass index ≥30 kg/m²), hypertension, diabetes, hyperlipidaemia and multiple trad-CVRFs, compared with those with PsA, RA and AS. Obesity was significantly more common in PsA than in RA. In women, obesity, hypertension and multiple trad-CVRFs were more frequently reported in PsA than in RA and AS, whereas similar prevalence of CVRFs and coexistence of multiple trad-CVRFs were found in men with PsA, RA and AS.

Conclusions

Women and men with gout had the highest prevalence of trad-CVRFs. Differences in occurrence of CVRFs by sex were found in patients with PsA, RA and AS. In women, patients with PsA had higher occurrence of trad-CVRFs than those with RA and AS, whereas in men the distribution of CVRFs was similar in PsA, RA and AS.

Incidence of extra-articular manifestations in ankylosing spondylitis, psoriatic arthritis and undifferentiated spondyloarthritis: results from a national register-based cohort study

OBJECTIVES

To estimate the incidence and strength of association of extra-articular manifestations [EAMs, here: anterior uveitis (AU), IBD and psoriasis] in patients with AS, undifferentiated SpA (uSpA) and PsA, compared with controls.

METHODS

Three mutually exclusive cohorts of patients aged 18-69 years with AS (n = 8517), uSpA (n = 10 245) and PsA (n = 22 667) were identified in the Swedish National Patient Register 2001-2015. Age-, sex- and geography-matched controls were identified from the Swedish Population Register. Follow-up began 1 January 2006, or six months after the first SpA diagnosis, whichever occurred later, and ended at the first date of the EAM under study, death, emigration, 70 years of age, and 31 December 2016. Incidence rates (IRs) and incidence rate ratios were calculated for each EAM, and stratified by sex and age.

RESULTS

Incidence rate ratios for incident AU, IBD and psoriasis were significantly increased in AS (20.2, 6.2, 2.5), uSpA (13.6, 5.7, 3.8) and PsA (2.5, 2.3, n.a) vs controls. Men with AS and uSpA had significantly higher IRs per 1000 person-years at risk for incident AU than women with AS (IR 15.8 vs 11.2) and uSpA (IR 10.1 vs 6.0), whereas no such sex difference was demonstrated in PsA or for the other EAMs.

CONCLUSIONS

AU, followed by IBD and psoriasis, is the EAM most strongly associated with AS and uSpA. Among the SpA subtypes, AS and uSpA display a largely similar pattern of EAMs, whereas PsA has a considerably weaker association with AU and IBD.

OP0208 INCIDENT GOUT: RISK OF DEATH AND CAUSE-SPECIFIC MORTALITY IN WESTERN SWEDEN – A NESTED CASE CONTROL STUDY

Background:

Excess mortality in gout has been attributed to it’s positive association with many comorbidities. Lately, a negative association with dementia has been suggested in some cohort studies. Data is limited on how this reflects in cause-specific mortality of gout patients.

Objectives:

Our aims were to determine the relative risks in incident gout patients compared to general population 1) for overall death 2) for cause-specific mortality.

Methods:

All incident cases of gout (definition: 1≥ ICD-10 code for gout (M10/M14.0) in the population based health care database VEGA; no gout diagnosis ≥5 years previously) between 2006-2015 in western Sweden were identified. Five population controls per case matched on age, sex and place of residence were identified. Comorbidities, defined by ICD-10 codes, (alcohol related disorders, hypertension, ischemic heart disease, heart failure, cerebrovascular disease, diabetes, dyslipidemia, obesity, renal disease, dementia, lung diseases and cancer) were identified for 5 years preceding index date for cases and controls in VEGA. Patients were followed until the earliest of death, migration or study end 31 of December 2017. Cause of death was identified through the national cause of death register and grouped as death due to: CVD, renal disease, dementia, infections, diabetes, diseases of the digestive system, lung diseases, cancer and other. COX regression analyses, adjusted for baseline demographics and comorbidities, were used to compare mortality in cases and controls, taking competing cause of death into account by the Fine and Gray method.

Results:

From the total adult population of western Sweden between 2006 and 2015 (yearly average of 1264150 individuals), we identified 24320 cases of incident gout and 119781 controls, who were followed on average 5.3 and 5.6 years respectively. At baseline mean age was (SD) 67.3 years (15.3) and 67.6% were men. At baseline, income and level of education was significantly lower in gout cases compared to controls, whereas all comorbidities were significantly more common among gout cases (data not shown) except for dementia which was significantly more common in controls, 4.2% versus 2.5% in cases, p<.0001. The HR for overall death was increased in gout patients (HR: 1.08 (95% CL: 1.05-1.11) (Table 1). Gout cases had significantly increased risk for death by CVD, renal disease, infections, diseases of the digestive system and significantly decreased risk for death by dementia and cancer (Table 1). Point estimates were similar in men and women (data not shown).

Table 1.

Causes of death by exposure status and cause-specific mortality overall, gout cases compared to controls, adjusted hazard ratios by the Fine and Gray method, 95% confidence intervals

Causes of deathCause of death, n (%)Hazard ratios (95% CI)Gout cases, n = 24320Controls, n= 119781Model 1Model 2Cardiovascular disease3527 (14.5)11369 (9.5)1.61 (1.55-1.67)1.20 (1.16-1.26)Renal disease140 (0.6)239 (0.2)2.79 (2.26-3.44)1.68 (1.31-2.16)Dementia287 (1.2)2922 (2.4)0.45 (0.40-0.51)0.68 (0.60-0.77)Infections437 (1.8)1631 (1.4)1.27 (1.14-1.41)1.15 (1.03-1.28)Diabetes250 (1.0)665 (0.6)1.80 (1.55-2.08)1.02 (0.87-1.20)Diseases digestive system226 (0.9)725 (0.6)1.49 (1.29-1.74)1.36 (1.16-1.59)Lung diseases306 (1.3)1216 (1.0)1.20 (1.06-1.36)0.89 (0.78-1.01)Cancer1179 (4.9)6067 (5.1)0.92 (0.87-0.98)0.94 (0.88-0.99)Other655 (2.7)2899 (2.4)1.08 (0.99-1.17)1.09 (0.99-1.19)All-cause mortality7007 (28.8)27733 (23.2)1.32 (1.29-1.36)1.08 (1.05-1.11)

Model 1: adjusted for age and sex

Model 2: adjusted for baseline values for: age, sex, marital status, income, education, born outside of Sweden, alcohol related disorders, hypertension, ischemic heart disease, heart failure, cerebrovascular disease, diabetes, dyslipidemia, obesity, renal disease, dementia, lung diseases and cancer

Conclusion:

This study demonstrates a modest increase in overall mortality in gout patients and a decreased risk of death from dementia reflecting it’s inverse relation to gout.

Disclosure of Interests:

None declared

OP0192 INCIDENT GOUT AND RISK OF FIRST-TIME ACUTE CORONARY SYNDROME: A PROSPECTIVE, POPULATION-BASED, COHORT STUDY IN SWEDEN

Background:

Gout is associated with an increased risk of cardiovascular disease (CVD), but it is not clear whether this risk is intrinsic to gout itself or to underlying comorbidities. Although the impact of gout on CVD has been studied previously, the results have been conflicting and studies from European countries are scarce.

Objectives:

To investigate the risk of first-time acute coronary syndrome (ACS) in patients with incident gout in western Sweden, compared to the general population.

Methods:

Using data from the population-based health care database VEGA, we identified all patients with incident gout diagnosis at either primary or specialized health care units in western Sweden, in the period 2007– 2017 (20,287 cases; mean age, 65.6 years; 67.4% males). Cases regarded as incident, if they did not have any recorded diagnosis of gout in the previous seven years. For each case, up to five controls matched on age, sex, and county at the date of first gout diagnosis were identified from the census register (84,240 controls). Cases and controls with prior history of ischemic heart disease were excluded. The follow-up began at the first diagnosis of gout, and ended at the earliest of an ACS event, emigration, death, or 31 December 2017. To estimate the risk of first-time ACS, we used incident rate (IR) and univariable and multivariable Cox regression analysis with adjustments for the following cardiovascular risk factors: the diagnoses of hypertension, diabetes, hyperlipidemia, obesity, renal disease, heart failure, cardiomyopathy, psoriasis, chronic obstructive pulmonary disease, alcoholism, cancer, cerebrovascular, and atherosclerotic disease, as well as for the dispensed prescriptions of statins, anticoagulants, anti-hypertensive, anti-diabetic, anti-hyperlipidemic, anti-obesity, and vasodilator drugs.

Results:

The IR of first-time ACS was 9.0 events per 1,000 person-years in the gout cohort, compared to 6.3 in the control cohort. The IRs were lower for women than men, both in the gout (IR, 8.2 vs 9.4) and in the control cohort (IR, 5.0 vs 7.0). Univariable analysis showed that patients with gout have a higher risk of first-time ACS, as compared to the general population (Figure 1, Table 1), but the increased risk is largely diminished after adjustments for cardiovascular risk factors (Table 1).

Table 1.

Risk of first-time ACS in patients with incident gout, as compared to the general population.

Unadjusted HR95% CIp-valueAdjusted HR95% CIp-valueACS Overall1.431.32-1.55<.00011.151.05-1.240.0013 Men1.351.23-1.48<.00011.121.02-1.230.0230 Women1.631.41-1.89<.00011.211.03-1.410.0207Figure 1.

Event-free survival curve for patients with gout and controls during the follow-up, where event is first-time acute coronary syndrome.

Conclusion:

Patients with incident gout have a 43% higher risk of first-time ACS, as compared to the general population. This increased risk is largely explained by the increased occurrence of comorbidities in gout, but there is still a modestly increased risk that may be due to gout related factors. Our results underline the importance of cardiovascular risk assessment and the need for appropriate management of the underlying cardiovascular risk factors in patients with gout.

Disclosure of Interests:

None declared

AB0633 HEALTH RELATED QUALITY OF LIFE IN GOUT, PSORIATIC ARTHRITIS, RHEUMATOID ARTHRITIS AND ANKYLOSING SPONDYLITIS: RESULTS FROM A QUESTIONNAIRE STUDY

Background:

Gout, psoriatic arthritis (PsA), rheumatoid arthritis (RA), ankylosing spondylitis (AS), are common inflammatory joint diseases (IJD) that substantially affect HRQoL (Health Related Quality of Life). To our knowledge, this is the first study comparing HRQoL in gout, PsA, RA and AS in the same setting.

Objectives:

To compare HRQoL assessed with the Short Form health survey (SF-36) between gout, PsA, RA and AS.

Methods:

We performed a cross-sectional questionnaire study in Sweden. Individuals ≥18 years and with at least one ICD-10 diagnosis for gout, PsA, RA, or AS, recorded at a health care visit to a physician at a rheumatology clinic (for all diagnoses) or at a primary care center (for gout patients) from 2015 through 2017 were identified. Patients with gout (n=1589), PsA (n=1200), RA (n=1246) and AS (n=1095) were sent a questionnaire including questions regarding Visual Analogue Scales (VAS) for General Health, Pain, Fatigue, Health Asssessment Questionnaire (HAQ), as well as the SF-36. The eight domains (a higher score indicating a better health status) as well as the overall physical (PCS) and mental (MCS) component scores (a value of 50 corresponds to unaffected HRQoL) of the SF-36 are presented. Respondents were matched on age, sex. ANOVA was used for between group comparisons of mean values. For non-normally distributed data, Kruskal Wallis test was used. For comparing distributions, the Chi-Square test was used.

Results:

In total, 2896 (56.5%) individuals responded. After matching for age, sex, 249 individuals per diagnosis group remained. Gout patients reported significantly higher scores on SF-36 subscales as well as PCS (consistent with results seen before matching for age and sex). Lower values of HRQoL were noted in physical domains as compared to mental domains in all IJDs. Disability measured by HAQ was significantly lower in gout and VAS scores were more favourable compared to other IJDs.

Conclusion:

Patients with gout report higher HRQOL compared to PsA, RA, AS.

Table 1.

Age-matched comparisons across diagnoses

GoutPsARAASp-valuep-valueGout vs PsAp-valueGout vs RAp-valueGout vs ASp-valuePsA vs RAp-valuePsA vs ASp-valueRA v ASTotal (n)249249249249N/AAge, mean (SD)62.5 (11.2)64.2 (10.2)63.1 (11.6)62.8 (10.5)NSEducation ≤12 years, n (%)132 (53.0)148 (59.4)160 (64.3)139 (55.8)NSHAQ, mean (SD)0.19 (0.40)0.48 (0.55)0.60 (0.63)0.58 (0.58)************NSNSNSVAS General Health, mean (SD)2.6 (2.3)3.7 (2.4)3.8 (2.6)4.0 (2.3)************NSNSNSVAS Pain, mean (SD)2.6 (2.4)4.0 (2.6)3.8 (2.6)4.2 (2.4)************NSNSNSVAS Fatigue, mean (SD)3.6 (2.6)4.5 (2.7)4.3 (2.6)4.9 (2.5)**********NSNS*SF-36 domains,median (IQR)Physical function90.0 (75.0-95.0)70.0 (51.3-95.0)70.0 (45.0-90.0)75.0 (50.0-90.0)************NSNSNSRole physical100.0 (33.3-100.0)50.0 (0.0-100.0)50.0 (0.0-100.0)50.0 (0.0-100.0)************NSNSNSBodily pain72.0 (42.0-100.0)52.0 (41.0-74.0)52.0 (41.0-74.0)52.0 (41.0-64.0)************NSNSNSGeneral Health67.0 (47.8-80.8)56.0 (35.0-72.0)55.0 (37.0-72.0)50.0 (35.0-71.0)************NSNSNSVitality65.0 (50.0-77.5)57.5 (37.5-75.0)57.5 (42.5-72.5)50.0 (32.5-70.0)********NSNSNSSocial function100.0 (68.8-100.0)81.3 (57.8-100.0)81.3 (67.2-100.0)81.3 (50.0-100.0)**********NSNSNSRole emotional100.0 (66.7-100.0)100.0 (33.3-100.0)100.0 (33.3-100.0)100.0 (33.3-100.0)**NS****NSNSNSMental health82.0 (66.0-92.0)78.0 (60.0-92.0)78.0 (60.0-92.0)73.0 (60.0-88.0)**NS***NSNSNSSF-36 summary scores,median (IQR)Physical component score48.4 (38.8-54.7)40.2 (28.5-50.2)40.2 (28.2-49.0)38.7 (30.1-48.2)************NSNSNSMental component score51.7 (43.7-56.5)51.0 (39.2-56.4)50.7 (39.6-56.3)47.7 (37.1-55.3)*NSNS*NSNSNS

HAQ=Health Assessment questionnaire

IRQ=Interquartile range

SD=Standard deviation

VAS=Visual Analogue Scale

NS=non-significant

*=significant at p<0.05

**=significant at p<0.01

***=significant at p<0.001

Disclosure of Interests:

None declared.

POS0295 NO CAUSAL EFFECTS OF GENETICALLY DETERMINED SERUM URATE LEVELS ON THE RISK OF ALL-CAUSE AND SITE-SPECIFIC CANCER: A MENDELIAN RANDOMIZATION STUDY

Background:

Positive associations between urate levels and gout and the risk of some cancer types (urogenital, prostate, gastrointestinal and lung) have been reported in a number of observational studies; however, whether the relationship is causal remains uncertain.

Objectives:

The study aim was to evaluate a causal effect of genetically determined serum urate (SU) concentrations on cancer risks (overall and major cancer types) in individuals with European ancestry using Mendelian randomization (MR) analyses design.

Methods:

We used the individual-level data from two population-based Swedish cohorts including middle-aged subjects (mean follow-up = 21.2 years), Malmö Diet Cancer and Malmö Preventive Project (MDC/MPP), for one-sample MR setting. Data from a total of 17,597 individuals (n = 17,597 for SU at baseline, diagnoses during follow-up: 5659 for all-cause, 516 for bladder, 545 for lung, 791 for bowel, 1521 for prostate and 729 for breast cancer) was included. For two-sample MR, summary-statistic data for SU was obtained from Global Urate Genetic Consortium (GUGC: n = 110,347), while UK-Biobank data was employed for several major cancer outcomes (n = 36,815 for all-cause, 2,245 for bladder, 2,590 for lung, 4,488 for bowel, 6,474 for prostate and 10,274 for breast cancer). The definitions for cancer endpoints were matched for ICD9 and 10 codes between MDC/MPP and UK-Biobank cohorts. For both MR settings, a set of 26 urate-associated single nucleotide variants was selected to build-up the SU instrument (SU-instr) to test for a causal effect of SU on cancer outcomes. Statistical analysis, adjusted for age and sex, was done using multiple conventional MR methodologies and MR package in R (v4.0.2). A p < 0.05 was designated as statistically significant.

Results:

We found no causal effect of our SU-instr on neither all-cause nor site-specific cancer across all MR analyses (all p > 0.05). In MDC/MPP, SU-instr did not show a causal effect on the risk of all-cause [OR = 1.06, p = 0.32], bladder [OR = 0.96, p = 0.84], lung [OR = 1.26, p = 0.17], bowel [OR = 0.96, p = 0.81], prostate [OR = 1.05, p = 0.62], and breast [OR = 0.99, p = 0.98] cancer. Similar findings were made in the two-sample settings. Detailed results are provided in Table 1.

Conclusion:

Our MR study, using a series of causal inference approaches, does not support a causal effect of genetically determined SU for major cancer outcomes. There is no evidence to support changing SU levels by lifestyle or pharmacological intervention to attenuate the risk of major cancer types.

Table 1.

Results from a range of MR analyses for causal effect of SU on cancer risk in MDC/MPP (one-sample MR) and GUGC and UK-Biobank (two-sample MR) cohorts

One-sample MRCancer typeIVW2SLSGRSOR(95% CI)p-causalp-HetOR(95% CI)p-causalOR(95% CI)p-causalBladder0.96(0.68; 1.36)0.840.550.99(0.70; 1.42)0.990.94(0.67; 1.34)0.76Lung1.26(0.90; 1.77)0.170.891.29(0.91; 1.82)0.141.26(0.90; 1.77)0.17Bowel0.96(0.72; 1.28)0.810.440.95(0.72; 1.27)0.770.97(0.73; 1.28)0.83Prostate1.05(0.84; 1.31)0.620.841.04(0.83; 1.30)0.721.04(0.83; 1.30)0.69Breast0.99(0.74; 1.33)0.980.110.98(0.73; 1.32)0.920.98(0.73; 1.32)0.94All-cause1.06(0.93; 1.21)0.320.61.07(0.94; 1.21)0.281.07(0.94; 1.21)0.29Two-sample MRCancer typeIVWWeighted medianMR-EggerOR(95% CI)p-causalp-HetOR(95% CI)p-causalOR(95% CI)p-causalBladder1.02(0.88; 2.16)0.770.361.03(0.86; 2.10)0.71.03(0.83; 2.13)0.75Lung0.86(0.73; 1.08)0.070.040.86(0.73; 1.09)0.090.84(0.66; 1.16)0.15Bowel0.82(0.69; 1.02)0.03< 0.00010.89(0.78; 1.06)0.060.92(0.72;1.67)0.52Prostate1.00(0.91; 2.64)0.970.720.98(0.88; 2.17)0.770.94(0.83; 1.45)0.37Breast0.97(0.88; 1.95)0.670.00021.00(0.91; 2.70)0.990.95(0.81; 1.59)0.46All-cause0.96(0.90; 1.20)0.18< 0.00010.97(0.92; 1.23)0.210.93(0.86; 1.12)0.11

OR; odds ratio, 95% CI; 95% confidence interval, IVW; Inverse variance weighted method, 2SLS; two-stage least square, GRS; genetic risk score, p-Het; p-value for heterogeneity.

Disclosure of Interests:

None declared

Impact of psoriasis disease activity and other risk factors on serum urate levels in patients with psoriasis and psoriatic arthritis-a post-hoc analysis of pooled data from three phase 3 trials with secukinumab

Objectives

Our aims were to determine if the Psoriasis Area Severity Index (PASI) score and serum urate (SU) levels were associated at baseline and whether the change in PASI score during 12 weeks of treatment resulted in a significant change in SU, adjusted for relevant confounders.

Methods

Data from patients with psoriasis/PsA (n = 1042/204) in three phase 3 randomized control trials treated with secukinumab (dose 300 mg, n = 628) or placebo (n = 414) were pooled. At baseline, values for SU, PASI and the following covariates were assessed: age, sex, BMI, estimated glomerular filtration rate, and medication with diuretics. To assess the changes in PASI (ΔPASI) and SU (Δurate), the differences (week 12 minus baseline) in patients receiving the active drug were used. Multivariable linear regression, adjusting for covariates, was used to assess the association between PASI and SU at baseline with all patients pooled and to assess the association between Δurate and ΔPASI over 12 weeks of treatment with secukinumab.

Results

The degree of skin involvement of psoriasis showed a statistically significant, albeit modest, association with SU (R² = 0.014, P < 0.0001 univariately), whereas known risk factors for hyperuricaemia had a much larger impact cross-sectionally at baseline (R² = 0.33, P < 0.0001). Furthermore, a substantial improvement in PASI score resulted in only a modest decrease of SU over 12 weeks of treatment with secukinumab (R² = 0.014, P < 0.0001 univariately).

Conclusions

There is a statistically significant, albeit modest, association with both extent and change in PASI score and SU in patients with psoriasis, compatible with a potential pathophysiological relationship between urate and psoriasis.

Trial Registration

ERASURE: clinicaltrials.gov, https://clinicaltrials.gov, NCT01365455; FIXTURE: clinicaltrials.gov, https://clinicaltrials.gov, NCT01358578; SCULPTURE: clinicaltrials.gov, https://clinicaltrials.gov, NCT01406938

The absolute risk of gout by clusters of gout-associated comorbidities and lifestyle factors-30 years follow-up of the Malmö Preventive Project

Background

Gout is predicted by a number of comorbidities and lifestyle factors. We aimed to identify discrete phenotype clusters of these factors in a Swedish population-based health survey. In these clusters, we calculated and compared the incidence and relative risk of gout.

Methods

Cluster analyses were performed to group variables with close proximity and to obtain homogenous clusters of individuals (n = 22,057) in the Malmö Preventive Project (MPP) cohort. Variables clustered included obesity, kidney dysfunction, diabetes mellitus (DM), hypertension, cardiovascular disease (CVD), dyslipidemia, pulmonary dysfunction (PD), smoking, and the use of diuretics. Incidence rates and hazard ratios (HRs) for gout, adjusted for age and sex, were computed for each cluster.

Results

Five clusters (C1–C5) were identified. Cluster C1 (n = 16,063) was characterized by few comorbidities. All participants in C2 (n = 750) had kidney dysfunction (100%), and none had CVD. In C3 (n = 528), 100% had CVD and most participants were smokers (74%). C4 (n = 3673) had the greatest fractions of obesity (34%) and dyslipidemia (74%). In C5 (n = 1043), proportions with DM (51%), hypertension (54%), and diuretics (52%) were highest. C1 was by far the most common in the population (73%), followed by C4 (17%). These two pathways included 86% of incident gout cases. The four smaller clusters (C2–C5) had higher incidence rates and a 2- to 3-fold increased risk for incident gout.

Conclusions

Five distinct clusters based on gout-related comorbidities and lifestyle factors were identified. Most incident gout cases occurred in the cluster of few comorbidities, and the four comorbidity pathways had overall a modest influence on the incidence of gout.

[Consequences of Gout and Hyperuricemia]

Hyperuricemia (HU) and gout are strongly associated with CVD, associations that are most likely due to shared etiologies rather than causality. HU is for example causally related to the metabolic syndrome and in particular to obesity. Gout and HU can both be caused by and lead to decreased kidney function. On the other hand, there are observational data suggesting that HU may protect against neurodegenerative diseases such as Alzheimer and Parkinson's disease. Ongoing RCTs with urate and urate lowering therapy (ULT) will help to resolve some of these controversies. Nevertheless, gout is a "curable disease" by ULT, a treatment which in adequate doses may also have positive effect on several associated co-morbidities.

[Gout - a common and well known disease]

Hyperuricemia is defined by a blood urate level > 405 µmol/L, the cut-off value at which urate forms crystals in vivo. In 15-20% these individuals develop gout, clinically characterized by attacks of acute arthritis, initially and most commonly affecting MTP 1 or other joints, tendons and soft tissues of the foot. These attacks usually subside within 1 to 2 weeks. Over time attacks occur more frequently and can transform into chronic arthritis characterized by tophi. The gold standard for diagnosis relies on identification of urate crystals by polarization microscopy in aspirated joint fluid. This procedure is rarely performed in primary care where the majority of patients are seen, and gout is usually diagnosed by clinical criteria. New imaging technologies (ultrasound, dual-energy CT) can be helpful when aspiration is not available and when the diagnosis is unclear. Gout has a prevalence of 1.7% and incidence rate of approximately 200 per 100000 person-years in Sweden, figures that increase over time.

[Large health benefits can be achieved by better treatment of gout]

Urate lowering therapy (ULT) should, according to recent guidelines, be initiated in the majority of cases already after the first attack of gout. Allopurinol is the first line choice of ULT and should be started with low dose, which is increased until the treatment target is reached. The treatment target should be a blood urate of < 360 µmol/l or < 300 µmol/l (in the presence of topfi), which should be maintained until topfi have resolved. NSAID/cox-inhibitors, colchicine and glucocorticoids are all valid short-term treatments of gout attacks. ULT should not be paused/terminated during attacks and can be initiated during an attack that is adequately treated. Recent RCTs of ULT treatment have demonstrated the importance of thorough and adequate information to the patient and regular follow-up until treatment targets are reached. Such a strategy improve both compliance and outcomes of ULT treatment.

Occupational exposure to inorganic dust and risk of gout: a population-based study

Background

Risk factors operating independently of hyperuricemia could be of importance in determining why only a minority of people with hyperuricemia develop gout. Exposure to inorganic dust has been linked to other inflammatory diseases and could influence the development of gout.

Objectives

To evaluate if occupational exposure to inorganic dust increases the risk of gout.

Methods

Individuals aged 30–65 years with a first gout diagnosis in 2006–2012 in the population-based healthcare database of the Western Swedish Healthcare Region (VEGA) and population controls matched by age and sex were included. Data on occupation was collected from the Swedish occupational register. Exposure status was assigned by means of a job exposure matrix. Data on gout-related comorbidities was collected from VEGA. Alcohol use disorder and obesity were related both to gout and exposure to inorganic dust and were adjusted for in multivariate analyses. ORs were calculated using conditional logistic regression.

Results

5042 gout cases and 20 682 controls were included. Exposure to inorganic dust was associated with gout in both unadjusted (OR 1.12, 95% CI 1.04 to 1.20) and multivariate (OR 1.08, 95% CI 1.00 to 1.16) analyses of the whole population. In sex-stratified multivariate analyses, dust exposure was significantly associated with gout in women (adjusted OR 1.26, 95% CI 1.05 to 1.51), but not in men (adjusted OR 1.05, 95% CI 0.97 to 1.13).

Conclusions

We describe for the first time an association between exposure to inorganic dust and gout. After adjusting for confounders, the findings were statistically significant for women but not for men.

Global epidemiology of gout: prevalence, incidence, treatment patterns and risk factors

Gout is the most common inflammatory arthritis and occurs when hyperuricaemia, sustained elevation of serum urate levels resulting in supersaturation of body tissues with urate, leads to the formation and deposition of monosodium urate crystals in and around the joints. Recent reports of the prevalence and incidence of gout vary widely according to the population studied and methods employed but range from a prevalence of <1% to 6.8% and an incidence of 0.58-2.89 per 1,000 person-years. Gout is more prevalent in men than in women, with increasing age, and in some ethnic groups. Despite rising prevalence and incidence, suboptimal management of gout continues in many countries. Typically, only a third to half of patients with gout receive urate-lowering therapy, which is a definitive, curative treatment, and fewer than a half of patients adhere to treatment. Many gout risk factors exist, including obesity, dietary factors and comorbid conditions. As well as a firmly established increased risk of cardiovascular disease and chronic kidney disease in those with gout, novel associations of gout with other comorbidities have been reported, including erectile dysfunction, atrial fibrillation, obstructive sleep apnoea, osteoporosis and venous thromboembolism. Discrete patterns of comorbidity clustering in individuals with gout have been described. Increasing prevalence and incidence of obesity and comorbidities are likely to contribute substantially to the rising burden of gout.

PARE0021 TARGETED INITIATIVE TO FACILITATE THE IMPLEMENTATION OF EXISTING EFFECTIVE GOUT TREATMENT IN SWEDEN

Background:

Gout is a very painful rheumatic condition origin from excess uric acid in the bloodstream, which results in an accumulation of uric acid crystals in the joints and a severe local inflammatory response. Gout is treated in primary care and the current treatment has satisfactory results on disease management, thus patients can expect a controlled disease without flares. In Sweden however, only 30-40 % (1) of the patients receives adequate urate lowering treatment and prevent the disabling flares.

Objectives:

As a patient association, the Swedish Rheumatism Association (SRA) has identified an opportunity to use scientific evidence and data to improve awareness in both patients and physicians in order to make the existing treatment available and to shift the gout treatment from flare management to prevention.

Methods:

With SRA funding we created the Gout network, consisting of researchers, health professionals and patient research partners. Through meetings and operational support developed strategies to educate patients suffering from gout and to alert physicians in the primary care of the most recent research to aid the management of gout. We also fund a specific research project aimed to create an implementation plan to establish a treatment routine for gout in primary care with already existing resources.

Results:

A high quality patient education material is under development and consists of an information video lecture and a comprehensive online patient school providing information about the diagnosis, preventive treatment, possible life style change along with other resources that will support the gout patient, both for self-care and in relation to healthcare. For the healthcare profession we have together with a clinical research expert and a patient research partner developed a fact sheet with the latest scientific updates on gout.

Conclusion:

Accessible, high quality diagnosis information about gout is currently missing in Sweden. This collaboration initiative provides high quality facts to raise the general awareness and to educate and empower patients to get the effective therapy that is available today.

References:

[1] Incidence and prevalence of gout in Western Sweden Dehlin M, Drivelegka P, Sigurdardottir V, Svärd A & Jacobsson LTH.Arthritis Research & Therapy 18,: 164 (2016)

Disclosure of Interests:

Li Alemo Munters: None declared, Ingela Loell: None declared, Suzanna Jansson: None declared, Lennart T.H. Jacobsson Consultant of: AbbVie, Eli Lilly, Janssen, Novartis and Pfizer, Mats Dehlin: None declared

Association between serum level of urate and subclinical atherosclerosis: results from the SCAPIS Pilot

BACKGROUND

Hyperuricemia is closely associated with cardiovascular disease (CVD). However, it has not been definitively established whether this association is independent of traditional cardiovascular risk factors (CVRFs) and whether it is gender-dependent. The aim of this study was to investigate in a population-based cohort (age range, 50-64 years) stratified by sex the association between the serum urate (SU) concentration and subclinical atherosclerosis, as reflected in the coronary artery calcification (CAC) score, common carotid intima-media thickness (CIMT), and carotid plaque score.

METHODS

The study involved participants in the Swedish CArdioPulmonary bioImage Study (SCAPIS) Pilot cohort (N = 1040; 48.8% males). This pilot cohort is part of the large population-based SCAPIS with 30,000 participants in the age range of 50-64 years, aimed at improving risk prediction for CVD. Subjects with a self-reported previous history of CVD (N = 68) or gout (N = 3) were excluded. The CAC score was assessed with the Agatston method using computed tomography. CIMT and carotid plaques were quantified by ultrasound. The associations between the SU quartiles and different levels of CAC, CIMT, and carotid plaques were assessed by multivariable logistic regression.

RESULTS

Age, BMI, education level, smoking, physical activity, hs-CRP, hypertension, and dyslipidemia showed no differences between males and females, while CAC (score > 0) and diabetes were both twice as common in men than in women (58% vs 26% and 8% vs 4%, respectively). Higher SU quartiles were in both sexes associated with BMI, hs-CRP, and the prevalence of hypertension, and in women, they were also associated with the prevalence of dyslipidemia. The three upper quartiles of SU (>308μmol/L) were linked to higher CAC scores in men, when adjusting for CVRFs, but not in women. CIMT and carotid plaques showed no correlation to SU in either sex.

CONCLUSIONS

Higher levels of SU are associated with the presence of CAC in men but not in women, whereas SU is not associated with CIMT or carotid plaques in either men or women. This implies that the biological effects of SU differ in men and women or that SU has varying effects on different vascular beds or during the different stages of the atherosclerotic process.

Dual energy CT findings in gout with rapid kilovoltage-switching source with gemstone scintillator detector

Background

A definite diagnosis of gout requires demonstration of monosodium urate crystals in synovial fluid or in tophi, which in clinical practice today seldom is done. Dual energy CT (DECT) has repeatedly been shown to be able to detect monosodium urate crystals in tissues, hence being an alternative method to synovial fluid microscopy. The vast majority of these studies were performed with CT scanners with two X-ray tubes. In the present study we aim to investigate if and at what locations DECT with rapid kilovoltage-switching source with gemstone scintillator detector (GSI) can identify MSU crystals in patients with clinically diagnosed gout. We also performed a reliability study between two independent readings.

Methods

Patients with new or established gout who had been examined with DECT GSI scanning of the feet at Sahlgrenska University Hospital, Mölndal between 2015 and 2018 were identified. Their medical records were sought for gout disease characteristics using a structured protocol. Urate deposits in MTP1, MTP 2–5, ankle/midfoot joints and tendons were scored semiquantatively in both feet and presence of artifacts in nail and skin as well as beam hardening and noise were recorded. Two radiologists performed two combined readings and scoring of the images, thus consensus was reached over the scoring at each occasion (Espeland et al., BMC Med Imaging. 2013;13:4). The two readings were compared with kappa statistics.

Results

DECT GSI could identify urate deposits in the feet of all 55 participants with gout. Deposits were identified in the MTP-joints of all subjects but were also present in ankle/midfoot joints and tendons in 96 and 75% respectively. Deposition of urate was predicted by longer disease duration (Spearman’s Rho 0.64, p < .0001) and presence of tophi (p = 0.0005). Artifacts were common and mostly found in the nails (73%), a minority displayed skin artifacts (31%) while beam hardening and noise was rare. The agreement between the two readings was good (Κ = 0.66, 95% CI = 0.61–0.71).

Conclusion

The validity of DECT GSI in gout is supported by the identification of urate in all patients with clinical gout and the good correlations with clinical characteristics. The occurrence of artifacts was relatively low with expected locations.

Gout, Hyperuricemia, and Crystal-Associated Disease Network Consensus Statement Regarding Labels and Definitions for Disease Elements in Gout

OBJECTIVE

The language currently used to describe gout lacks standardization. The aim of this project was to develop a consensus statement on the labels and definitions used to describe the basic disease elements of gout.

METHODS

Experts in gout (n = 130) were invited to participate in a Delphi exercise and face-to-face consensus meeting to reach consensus on the labeling and definitions for the basic disease elements of gout. Disease elements and labels in current use were derived from a content analysis of the contemporary medical literature, and the results of this analysis were used for item selection in the Delphi exercise and face-to-face consensus meeting.

RESULTS

There were 51 respondents to the Delphi exercise and 30 attendees at the face-to-face meeting. Consensus agreement (≥80%) was achieved for the labels of 8 disease elements through the Delphi exercise; the remaining 3 labels reached consensus agreement through the face-to-face consensus meeting. The agreed labels were monosodium urate crystals, urate, hyperuric(a)emia, tophus, subcutaneous tophus, gout flare, intercritical gout, chronic gouty arthritis, imaging evidence of monosodium urate crystal deposition, gouty bone erosion, and podagra. Participants at the face-to-face meeting achieved consensus agreement for the definitions of all 11 elements and a recommendation that the label "chronic gout" should not be used.

CONCLUSION

Consensus agreement was achieved for the labels and definitions of 11 elements representing the fundamental components of gout etiology, pathophysiology, and clinical presentation. The Gout, Hyperuricemia, and Crystal-Associated Disease Network recommends the use of these labels when describing the basic disease elements of gout.

Gout, Hyperuricaemia and Crystal-Associated Disease Network (G-CAN) consensus statement regarding labels and definitions of disease states of gout

OBJECTIVE

There is a lack of standardisation in the terminology used to describe gout. The aim of this project was to develop a consensus statement describing the recommended nomenclature for disease states of gout.

METHODS

A content analysis of gout-related articles from rheumatology and general internal medicine journals published over a 5-year period identified potential disease states and the labels commonly assigned to them. Based on these findings, experts in gout were invited to participate in a Delphi exercise and face-to-face consensus meeting to reach agreement on disease state labels and definitions.

RESULTS

The content analysis identified 13 unique disease states and a total of 63 unique labels. The Delphi exercise (n=76 respondents) and face-to-face meeting (n=35 attendees) established consensus agreement for eight disease state labels and definitions. The agreed labels were as follows: 'asymptomatic hyperuricaemia', 'asymptomatic monosodium urate crystal deposition', 'asymptomatic hyperuricaemia with monosodium urate crystal deposition', 'gout', 'tophaceous gout', 'erosive gout', 'first gout flare' and 'recurrent gout flares'. There was consensus agreement that the label 'gout' should be restricted to current or prior clinically evident disease caused by monosodium urate crystal deposition (gout flare, chronic gouty arthritis or subcutaneous tophus).

CONCLUSION

Consensus agreement has been established for the labels and definitions of eight gout disease states, including 'gout' itself. The Gout, Hyperuricaemia and Crystal-Associated Disease Network recommends the use of these labels when describing disease states of gout in research and clinical practice.

Urate and risk of Alzheimer's disease and vascular dementia: A population-based study

INTRODUCTION

Low serum urate (sU) has been suggested to increase the risk of dementia since a reduction might impair antioxidant capacity. On the other hand, high sU is associated with increased cardiovascular risk which might increase the risk of dementia, especially for vascular dementia.

METHODS

In 1968-1969, a population-based sample of 1462 women aged 38 to 60 years was examined and were followed up over 44 years (mean 33.1 years). We examined whether sU (determined in 1968-1969 and 1992-1994) is associated with risk of late-life dementia.

RESULTS

During 44 years of follow-up, a higher sU (per standard deviation of 76.5 μmol/L) was associated with lower risk for dementia (n = 320; hazard ratio [HR] 0.81; confidence interval [CI] 0.72-0.91), Alzheimer's disease (n = 152; HR 0.78; CI 0.66-0.91), and vascular dementia (n = 52; HR 0.66; CI 0.47-0.94).

DISCUSSION

Our findings support the hypothesis that sU has a protective role in the development of dementia, regardless of dementia subtype. This may have important implications in the treatment of dementia and treatment goals for hyperuricemia in patients with gout.

The Validity of Gout Diagnosis in Primary Care: Results from a Patient Survey

OBJECTIVE

Validate primary care diagnosis of gout by the Mexico and the Netherlands classification criteria.

METHODS

Questionnaires on gout characteristics were sent to all individuals aged ≥ 18 with ≥ 1 International Classification of Diseases, 10th ed. diagnosis of gout at 12 primary care centers.

RESULTS

Positive predictive values for gout diagnosis ranged from 71% for the Netherlands criteria to 80% for the Mexico criteria. Maximum inflammation within 24 h was the most common reported symptom (86%).

CONCLUSION

The vast majority of gout cases in primary care fulfill classification criteria and are valid for research purposes.

Comparative effectiveness of abatacept, rituximab, tocilizumab and TNFi biologics in RA: results from the nationwide Swedish register

OBJECTIVES

Current guidelines rank abatacept, rituximab, tocilizumab and TNF-inhibitors (TNFi) as having equal effectiveness for the treatment of RA, at least as second line therapies. These recommendations are mainly based on meta-analysis of randomized controlled trials, with few direct drug-drug comparisons. Our objective was to compare the real-world absolute and relative effectiveness among RA patients starting any of the available biologic DMARDs (bDMARDs).

METHODS

We used the Swedish Rheumatology Register to identify patients with RA initiating TNFi, rituximab, abatacept or tocilizumab in 2010-2016 as first bDMARD (n = 9333), or after switch from TNFi as first bDMARD (n = 3941). National Swedish registers provided additional covariates and censoring events. Effectiveness was assessed 3 and 12 months after treatment start, as the proportion remaining on therapy and with EULAR Good Response, HAQ improvement >0.2, zero swollen/tender joints and CDAI remission. Adjusted differences were estimated with multivariable linear regression.

RESULTS

Patients starting non-TNFi (vs TNFi) as first bDMARD had a higher proportion remaining on drug and reaching most response outcomes as first bDMARD (1-year EULAR Good Response/HAQ improvement: TNFi 24.9/25.4%, rituximab 28.6/37.2%, abatacept 31.9/33.7%, tocilizumab 50.9/43.1%). After switch from a first TNFi, rituximab and tocilizumab, but not abatacept, were associated with significantly better response measures than TNFi (1-year EULAR Good Response/HAQ improvement: TNFi 11.6/16.1%, rituximab 24.8/33.2%, abatacept 13.1/17.5%, tocilizumab 34.1/29.4%). Differences remained significant after adjusting for potential confounders.

CONCLUSION

Treatment outcomes among RA patients treated in Swedish clinical practice are in line with a superior effectiveness of non-TNFi bDMARDs, in particular tocilizumab and rituximab, compared with TNFi.

Comorbidity in gout at the time of first diagnosis: sex differences that may have implications for dosing of urate lowering therapy

Background

The aim of this study is to examine the occurrence of comorbidities at the time of first diagnosis of gout compared with matched population controls, overall and by sex, as well as to examine the crude and age-standardized prevalence of these comorbidities in men and women with gout at first diagnosis.

Methods

A population-based study used data from Swedish national and regional registers, including 14,113 gout patients aged ≥ 20 years, with a first recorded diagnosis of gout between 1 January 2006 and 31 December 2012, and 65,782 population controls, matched by age, sex and county. Prevalence ratios (95% confidence intervals) comparing gout cases and controls were calculated, overall and by sex. Crude and age-standardized prevalence (95% confidence interval) of all comorbidities in gout patients were calculated, to show differences between sexes, taking also the higher age at diagnosis in women into account.

Results

All examined comorbidities were 1.2–2.5-fold more common in gout patients at diagnosis than in population controls in both sexes. Women with gout were on average 6 years older than men at first gout diagnosis and most comorbidities, including obesity and diuretic use, were or tended to be more frequent in women than in men. When standardizing for age, women had a higher prevalence of thromboembolism (6.6% vs 5.2%) and chronic obstructive pulmonary disease (3.1% vs 2.4%). Men, on the other hand, had a higher prevalence of coronary heart disease (9.4% vs 6.4%), atrial fibrillation (9.0% vs 6.0%), congestive heart failure (7.7% vs 6.6%) and stroke (4.1% vs 3.3%).

Conclusions

The occurrence of most comorbidities was significantly increased at first diagnosis of gout in both sexes. Women were older at diagnosis and had higher occurrence of most comorbidities, including obesity and diuretic use, factors that increase serum urate, and this needs to be taken into account when starting and optimizing urate lowering therapy. These sex differences were attenuated when standardizing for age and the occurrence of cardiovascular diseases was actually higher in men.

Electronic supplementary material

The online version of this article (10.1186/s13075-018-1596-x) contains supplementary material, which is available to authorized users.

Risk of cardiac rhythm disturbances and aortic regurgitation in different spondyloarthritis subtypes in comparison with general population: a register-based study from Sweden

Objectives

To describe the incidence of atrioventricular (AV) block II–III, atrial fibrillation (AF), pacemaker implantation (PM) and aortic regurgitation in patients with ankylosing spondylitis (AS), undifferentiated spondyloarthritis (uSpA) and psoriatic arthritis (PsA) compared with the general population (GP) and with each other.

Methods

A prospective nationwide study with cohorts of patients with AS (n=6448), PsA (n=16 063) and uSpA (n=5190) and a GP (n=2 66 435) cohort, identified in 2001–2009 in the Swedish National Patient and Population registers. Follow-up began on 1 January 2006 and ended at event, death, emigration or 31 December 2012. Age-standardised and sex-standardised incidence rates and hazard ratios (HRs) were calculated.

Results

The highest incidence rates were noted for AF (5.5–7.4 events per 1000 person-years), followed by PM (1.0–2.0 events per 1000 person-years). HRs for AV block, AF, PM and aortic regurgitation were significantly increased in AS (HRs 2.3, 1.3, 2.1 and 1.9), uSpA (HRs 2.9, 1.3, 1.9 and 2.0) and PsA (HRs 1.5, 1.5, 1.6 and 1.8) compared with the GP cohort. The highest HRs were seen for AV block in male uSpA (HR 4.2) and AS (HR 2.5) compared with GP. Compared with PsA, significantly increased HRs were noted for PM (HR 1.5) in AS and for AV block (HR 1.8) in uSpA.

Conclusions

Patients with SpA are at increased risk of aortic regurgitation, cardiac rhythm disturbances and, as a probable consequence, also PM. Particularly for AF, the most common arrhythmia, increased caution is warranted, whereas AV block should be looked for especially in men with AS or uSpA.

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Pituitary dysfunction in granulomatosis with polyangiitis

PURPOSE

Granulomatosis with polyangiitis (GPA) is a multisystem disease, characterized by necrotizing small-vessel vasculitis, which mainly affects the respiratory tract and the kidneys. Pituitary involvement in GPA is rare, present in about 1% of all cases of GPA. To date, only case reports or small case series have been published. Herein we report clinical features, imaging findings, treatment and outcomes in three patients with GPA-related pituitary dysfunction (PD).

METHODS

A retrospective analysis of three cases of GPA-related PD was conducted, followed by systematic review of the English medical literature using PubMed.

RESULTS

The three cases include three women aged between 32 and 37 years. PD was the presenting feature in one and two developed PD in the course of the disease. All patients had a pituitary lesion on MRI. Conventional treatment with high doses of glucocorticoids and cyclophosphamide led to resolution or improvement of the MRI abnormalities, whereas it was not effective in restoring PD. A systematic review identified 51 additional patients, showing that GPA can lead to partial or global PD, either at onset or, during the course of the disease. Secondary hypogonadism is the predominant manifestation, followed by diabetes insipidus (DI). Sellar mass with central cystic lesion is the most frequent radiological finding.

CONCLUSION

GPA should be carefully considered in patients with a sellar mass and unusual clinical presentation with DI and systemic disease. Although conventional induction-remission treatment improves systemic symptoms and radiological pituitary abnormalities, hormonal deficiencies persist in most of the patients. Therefore, follow-up should include both imaging and pituitary function assessment.

Incidence of and risk factors for nephrolithiasis in patients with gout and the general population, a cohort study

BACKGROUND

Nephrolithiasis (NL) is known to be associated with gout, although there are few comparative studies on risk and risk factors for NL in gout compared to population cohorts. In this cohort study we investigated: (1) overall incidence of NL in gout (cases) and general population controls; (2) risk and risk factors (common comorbidities and medications) for first-time NL in cases and controls separately.

METHODS

Cases (n = 29,968) and age-matched and sex-matched controls (n = 138,678) were identified from the regional healthcare database in western Sweden (VEGA). The analyzed risk factors (comorbidities and current medication use) for first-time NL, and socioeconomic factors were retrieved from VEGA and other national Swedish registers. For cases, follow up began on 1 January 2006 or on the first diagnosis of gout if this occurred later, and for controls on their index patient's first diagnosis of gout. Follow up ended on death, emigration or 31 December 2012. Incidence rates (IR) per 1000 person-years and hazard ratios (HR) were calculated. The incidence calculations were performed for cases (regardless of prior NL) and their controls. HRs with first occurrence of NL as outcome were calculated only in those without previous NL.

RESULTS

In cases there were 678 NL events (IR: 6.16 events per 1000 person-years (95% CI: 5.70-6.64) and in controls 2125 NL events (IR 3.85 events per 1000 person-years (95% CI: 3.69-4.02), resulting in an age-sex-adjusted incidence rate ratio of 1.60 (95% CI:1.47-1.74). Point estimates for predictive factors were similar in cases and controls, except for a significant interaction for losartan which increased the risk of NL only in controls (HR = 1.49 (95% CI: 1.03-2.14). Loop diuretics significantly decreased the risk of NL by 30-34% in both cases and controls. Further significant predictors of NL in gout cases were male sex, diabetes and obesity and in controls male sex and kidney disease.

CONCLUSIONS

The risk (age and sex adjusted) of NL was increased by 60% in cases compared to controls. None of the commonly used medications increased the risk of NL in gout patients.

Are ankylosing spondylitis, psoriatic arthritis and undifferentiated spondyloarthritis associated with an increased risk of cardiovascular events? A prospective nationwide population-based cohort study

Background

To investigate the risk of first-time acute coronary syndrome (ACS), stroke and venous thromboembolism (VTE) in patients with ankylosing spondylitis (AS), psoriatic arthritis (PsA) and undifferentiated spondyloarthritis (uSpA), compared to each other and to the general population (GP).

Methods

This is a prospective nationwide cohort study. Cohorts with AS (n = 6448), PsA (n = 16,063) and uSpA (n = 5190) patients and a GP (n = 266,435) cohort, were identified 2001–2009 in the Swedish National Patient and Population registers. The follow-up began 1 January 2006, or 6 months after the first registered spondyloarthritis (SpA) diagnosis thereafter, and ended at ACS/stroke/VTE event, death, emigration or 31 December 2012. Crude and age- and sex-standardized incidence rates (SIRs) and hazard ratios (HRs) were calculated for incident ACS, stroke or VTE, respectively.

Results

Standardized to the GP cohort, SIRs for ACS were 4.3, 5.4 and 4.7 events per 1000 person-years at risk in the AS, PsA and uSpA cohort, respectively, compared to 3.2 in the GP cohort. SIRs for stroke were 5.4, 5.9 and 5.7 events per 1000 person-years at risk in the AS, PsA and uSpA cohort compared to 4.7 in the GP cohort. Corresponding SIRs for VTE were 3.6, 3.2 and 3.5 events per 1000 person-years at risk compared to 2.2 in the GP cohort. Age-and sex-adjusted HRs (95% CI) for ACS events were significantly increased in AS (1.54 (1.31–1.82)), PsA (1.76 (1.59–1.95)) and uSpA (1.36 (1.05–1.76)) compared to GP. Age-adjusted HRs for ACS was significantly decreased in female AS patients (0.59 (0.37–0.97)) compared to female PsA patients. Age-and sex-adjusted HRs for stroke events were significantly increased in AS (1.25 (1.06–1.48)) and PsA (1.34 (1.22–1.48)), and nonsignificantly increased in uSpA (1.16 (0.91–1.47)) compared to GP. For VTE the age-and sex-adjusted HRs for AS, PsA and uSpA were equally and significantly increased with about 50% compared to GP.

Conclusions

Patients with AS, PsA and uSpA are at increased risk for ACS and stroke events, which emphasizes the importance of identification of and intervention against cardiovascular risk factors in SpA patients. Increased alertness for VTE is warranted in patients with SpA.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-017-1315-z) contains supplementary material, which is available to authorized users.

Factors associated with initiation and persistence of urate-lowering therapy

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.

Comparisons between comorbid conditions and health care consumption in rheumatoid arthritis patients with or without biological disease-modifying anti-rheumatic drugs: a register-based study

Background

Symptoms and prognosis of patients with rheumatoid arthritis (RA) have improved with more intensive therapy, including the biological disease-modifying anti-rheumatic drugs (bDMARDs). Real life data concerning how comorbidities are distributed among patients treated or not treated with bDMARDs are scarce. Our objective was to investigate differences in comorbidity and health care consumption in RA patients, with and without bDMARDs.

Methods

This cross-sectional study was performed in the Southwestern part of Sweden. Patients, aged ≥ 18 years and diagnosed with RA in secondary health care during 2009–2010, were identified in the regional health care database. Aggregated data of comorbidity and health care consumption were retrieved between 2006 and 2010. RA patients treated with bDMARDs on 31st December 2010 were identified in the Swedish Rheumatology Quality Register (SRQ), which includes the biologics register Anti-Rheumatic Therapy in Sweden (ARTIS). Descriptive, comparative, univariate and multiple logistic regression analyses were used to identify factors associated with bDMARDs.

Results

Seven thousand seven hundred and twelve (7712) RA patients were identified (age 64.8 ± 14.9 years, women 74.3%), of whom 1137 (14.7%) were treated with bDMARDs. Overall, the most common comorbidities were infections (69.2%), hypertension (41.1%), chronic respiratory disease (15.3%), ischemic heart disease (14.0%) and malignancy (13.7%). Patients without bDMARDs were older and had more comorbidity. In the multiple logistic regression analysis, older age, cerebrovascular and chronic respiratory disease, heart failure, depression and malignancy were all associated with no present bDMARDs. Infections were associated with bDMARDs. Patients treated with bDMARDs consumed more secondary outpatient care but less visits in primary health care compared to patients without bDMARDs.

Conclusions

Patients treated with bDMARDs versus no bDMARDs were younger and had significantly lower period prevalence for most common comorbidities, with the exception of infections. Differences in comorbidities between RA patients with or without bDMARDs should be taken into consideration when evaluating effectiveness and safety of bDMARDs in ordinary care.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-016-1354-7) contains supplementary material, which is available to authorized users.

Childhood hospitalisation with infections and later development of ankylosing spondylitis: a national case-control study

BACKGROUND

The role of environmental exposures in the pathogenesis of ankylosing spondylitis (AS) remains unclear. In particular, two types of exposures have been suspected to play a role: mechanical stress and infections. The objective of this case-control study was to determine if childhood infections are associated with later development of AS.

METHODS

The cases with AS were identified through the Swedish national outpatient specialised-care register, based on having been given at least one AS diagnosis in the register between 2001 and 2010. Five controls per case were identified in the Swedish population register, matched at the time-point of the index case's first spondyloarthritis diagnosis on sex, birth year, and county. All cases/controls matched prior to the age of 17 years were excluded, as well as all cases/controls given a diagnosis of reactive arthritis or juvenile arthritis at any time point, or any other diagnosis of a rheumatic disease, psoriasis, iridocyclitis, or inflammatory bowel disease before the time-point of matching. All events of hospitalisation with an infection before the age of 17 years were retrieved from the register, and categorised according to the focus of the infection. Odds ratios (ORs) and confidence intervals (CIs) were determined through conditional logistic regression analyses.

RESULTS

Of the 2453 cases with AS and 10,257 controls, 17.4 % of the cases and 16.3 % of the controls had been hospitalised with an infection before the age of 17 years (OR 1.08, 95 % CI 0.96-1.22). Appendicitis (1.5 % cases; 2.5 % controls; OR 0.59, 95 % CI 0.41-0.83), respiratory tract infections (cases 11.2 %; controls 9.2 %; OR 1.24, 95 % CI 1.07-1.44) and, in particular, tonsillitis (cases 3.7 %; controls 2.8 %; OR 1.31, 95 % CI 1.03-1.67) were associated with AS. There were no associations between AS and any other type of infection, and the point estimates were similar in several sensitivity analyses.

CONCLUSIONS

Childhood appendicitis was associated with a decreased risk, whereas respiratory tract infections were associated with an increased risk for later development of AS. These findings support a possible relationship between childhood infections and later development of AS, although the study is limited to infections resulting in inpatient care.