0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Research Letter |

Eligibility for and Prescription of Urate-Lowering Treatment in Patients With Incident Gout in England FREE

Chang-Fu Kuo, MD1; Matthew J. Grainge, PhD2; Christian Mallen, MD3; Weiya Zhang, PhD4; Michael Doherty, MD4
[+] Author Affiliations
1Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
2Division of Epidemiology and Public Health, University of Nottingham, Nottingham, England
3Arthritis Research UK Primary Care Centre, Keele University, Keele, England
4Division of Rheumatology, Orthopaedics and Dermatology, University of Nottingham, Nottingham, England
JAMA. 2014;312(24):2684-2686. doi:10.1001/jama.2014.14484.
Text Size: A A A
Published online

Gout is caused by urate crystal deposition secondary to persistent hyperuricemia. Current guidelines recommend urate-lowering treatment to prevent crystal deposition and encourage crystal dissolution for patients with more severe gout or concomitant conditions.1,2 However, after the first diagnosis, it remains unclear when such treatment is appropriate. We investigated the timing of eligibility for and prescription of urate-lowering treatment following first gout diagnosis and factors associated with prescription.

Approvals with a waiver of informed consent were obtained from the Trent Multicenter Research Ethics Committee and the independent scientific advisory committee. Patients diagnosed with incident gout in 1997-2010 were identified using the Clinical Practice Research Datalink, containing anonymized information including patient demographics, diagnoses, examination findings, laboratory results, and prescribed medications from approximately 8% of the UK population.3 General practitioners in 486 English practices are trained to record these data and their recording quality has been validated.

All patients were followed up from the first date of diagnosis until death, transfer out, or August 31, 2013. Using Kaplan-Meier plots, we estimated cumulative probabilities of patients fulfilling current indications for urate-lowering treatment (multiple attacks, tophi, chronic kidney disease, urolithiasis, diuretic use)1,2 and receiving treatment. Gout diagnosis and treatment indications were ascertained using physician diagnosis, laboratory results, and prescriptions. Variations in prescription rates explained by patient-level factors (age, sex, race, individual socioeconomic status, diagnosis year, Charlson Comorbidity Index score) and practice-level factors (total and gout patient number, median birth year, sex ratio, practice region and socioeconomic status, and the proportion of patients having comorbidities included in the Charlson Comorbidity Index) were calculated using a 2-level linear model. Marginal Cox proportional hazards models allowed assessment of multiple factors (age, sex, year of diagnosis, Charlson Comorbidity Index score, and treatment indications) associated with prescription. A 2-sided P value of less than .05 was considered statistically significant. Analyses were performed using SAS version 9.3 (SAS Institute Inc).

Of 52 164 patients with incident gout, the mean age at diagnosis was 62.5 years and 73% were men. Median time to first treatment indication was 5 months (interquartile range, 0-29 months) and the cumulative probability of fulfilling any indication was 44.26% (95% CI, 43.83%-44.69%) at 0 years from diagnosis, 61.02% (95% CI, 60.60%-61.44%) at 1 year, 86.81% (95% CI, 86.49%-87.13%) at 5 years, and 94.27% (95% CI, 93.98%-94.56%) at 10 years. The cumulative probabilities for prescription at the same time points were 0%, 16.90% (95% CI, 16.58%-17.22%), 30.39% (95% CI, 29.90%-30.81%), and 40.52% (95% CI, 39.96%-41.08%) (Figure).

Place holder to copy figure label and caption
Figure.
Cumulative Probability of Eligibility and Receipt of Prescription for Urate-Lowering Treatment
Graphic Jump Location

The median prescription rate for urate-lowering treatment among practices was 32.5% (interquartile range, 26.3%-39.3%; range, 0%-100%). Patient- and practice-level factors accounted for 7.82% and 13.49%, respectively, of total prescription variance.

Compared with not fulfilling each specific indication, most indications for treatment were associated with increased prescribing. The hazard ratio (HR) was 1.60 (95% CI, 1.55-1.65) for acute gout attacks during the first year following diagnosis, 1.87 (95% CI, 1.56-2.24) for tophi, 1.67 (95% CI, 1.60-1.74) for chronic kidney disease, and 1.57 (95% CI, 1.51-1.63) for diuretic use at diagnosis (Table).

Table Graphic Jump LocationTable.  Baseline Characteristics and Factors Associated With Prescription for Urate-Lowering Treatment

A total of 44% of patients fulfilled indications for urate-lowering treatment at initial diagnosis, and 87% were eligible within 5 years of diagnosis. However, only a minority of those eligible were treated according to current recommendations.1,2

Examined patient- and practice-level factors accounted for only one-fifth of the variance in prescriptions. The unexplained variance may be accounted for by factors not available in the database. Recognized barriers to care include suboptimal patient and physician knowledge of gout, its treatment, and clinical recommendations, and patient and physician preferences for treatment.4,5

Study limitations include the use of general practitioner diagnosis to identify gout patients; however, gout diagnosis in this database has been validated previously.6 For modeling, we assumed that indications for treatment have equal importance, which may not be true.

In conclusion, our study supports including urate-lowering treatment in the information about gout provided to patients around the time of first diagnosis.

Section Editor: Jody W. Zylke, MD, Deputy Editor.

Corresponding Author: Weiya Zhang, PhD, Academic Rheumatology, City Hospital, Clinical Sciences Building, Nottingham NG51PB, England (weiya.zhang@nottingham.ac.uk).

Author Contributions: Dr Kuo had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Zhang and Doherty are joint senior authors.

Study concept and design: Kuo, Zhang, Doherty.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Kuo, Zhang, Doherty.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Kuo, Grainge.

Obtained funding: Kuo, Zhang.

Administrative, technical, or material support: Mallen, Zhang, Doherty.

Study supervision: Grainge, Zhang, Doherty.

Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Zhang reported receiving personal fees from Daiichi Sankyo; and nonfinancial support from the National Institute for Health and Care Excellence, the European League Against Rheumatism, and the British Society of Rheumatology. Dr Doherty reported receiving personal fees from AstraZeneca, Menarini, Nordic Biosciences, Novartis, and Pfizer for work on gout and osteoarthritis advisory boards. No other disclosures were reported.

Funding/Support: This work was funded by the National Science Council of Taiwan project 103-2314-B-182A-070-MY2 and Chang Gung Memorial Hospital project CMRPG3A0624. The study methods and infrastructure were supported by the University of Nottingham. Dr Mallen is funded by an Arthritis Research UK clinician scientist award.

Role of the Funders/Sponsors: The sponsors of the study had no role in design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript and decision to submit the manuscript for publication.

Zhang  W, Doherty  M, Bardin  T,  et al; EULAR Standing Committee for International Clinical Studies Including Therapeutics.  EULAR evidence based recommendations for gout, part II: management. Ann Rheum Dis. 2006;65(10):1312-1324.
PubMed   |  Link to Article
Jordan  KM, Cameron  JS, Snaith  M,  et al; British Society for Rheumatology and British Health Professionals in Rheumatology Standards Guidelines and Audit Working Group (SGAWG).  British Society for Rheumatology and British Health Professionals in Rheumatology guideline for the management of gout. Rheumatology (Oxford). 2007;46(8):1372-1374.
PubMed   |  Link to Article
Williams  T, van Staa  T, Puri  S, Eaton  S.  Recent advances in the utility and use of the General Practice Research Database as an example of a UK primary care data resource. Ther Adv Drug Saf. 2012;3(2):89-99.
PubMed   |  Link to Article
Doherty  M, Jansen  TL, Nuki  G,  et al.  Gout: why is this curable disease so seldom cured? Ann Rheum Dis. 2012;71(11):1765-1770.
PubMed   |  Link to Article
Roddy  E, Zhang  W, Doherty  M.  Concordance of the management of chronic gout in a UK primary-care population with the EULAR gout recommendations. Ann Rheum Dis. 2007;66(10):1311-1315.
PubMed   |  Link to Article
Meier  CR, Jick  H.  Omeprazole, other antiulcer drugs and newly diagnosed gout. Br J Clin Pharmacol. 1997;44(2):175-178.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure.
Cumulative Probability of Eligibility and Receipt of Prescription for Urate-Lowering Treatment
Graphic Jump Location

Tables

Table Graphic Jump LocationTable.  Baseline Characteristics and Factors Associated With Prescription for Urate-Lowering Treatment

References

Zhang  W, Doherty  M, Bardin  T,  et al; EULAR Standing Committee for International Clinical Studies Including Therapeutics.  EULAR evidence based recommendations for gout, part II: management. Ann Rheum Dis. 2006;65(10):1312-1324.
PubMed   |  Link to Article
Jordan  KM, Cameron  JS, Snaith  M,  et al; British Society for Rheumatology and British Health Professionals in Rheumatology Standards Guidelines and Audit Working Group (SGAWG).  British Society for Rheumatology and British Health Professionals in Rheumatology guideline for the management of gout. Rheumatology (Oxford). 2007;46(8):1372-1374.
PubMed   |  Link to Article
Williams  T, van Staa  T, Puri  S, Eaton  S.  Recent advances in the utility and use of the General Practice Research Database as an example of a UK primary care data resource. Ther Adv Drug Saf. 2012;3(2):89-99.
PubMed   |  Link to Article
Doherty  M, Jansen  TL, Nuki  G,  et al.  Gout: why is this curable disease so seldom cured? Ann Rheum Dis. 2012;71(11):1765-1770.
PubMed   |  Link to Article
Roddy  E, Zhang  W, Doherty  M.  Concordance of the management of chronic gout in a UK primary-care population with the EULAR gout recommendations. Ann Rheum Dis. 2007;66(10):1311-1315.
PubMed   |  Link to Article
Meier  CR, Jick  H.  Omeprazole, other antiulcer drugs and newly diagnosed gout. Br J Clin Pharmacol. 1997;44(2):175-178.
PubMed   |  Link to Article
CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

2,491 Views
6 Citations
×

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles
Treat-to-target (T2T) recommendations for gout. Ann Rheum Dis Published online Sep 22, 2016;
Jobs
JAMAevidence.com

The Rational Clinical Examination: Evidence-Based Clinical Diagnosis
Clinical Scenario

The Rational Clinical Examination: Evidence-Based Clinical Diagnosis
Clinical Scenario