Background Current guidelines and recommendations [1-3] recommend urate-lowering treatment (ULT) only for patients with more severe disease or with other concomitant conditions that merit earlier ULT. However, when in the course of gout ULT should be initiated is not explicitly discussed and currently there is no suggestion that ULT should be considered and discussed with the patient when they first receive information on gout at or close to the time of first diagnosis.
Objectives To determine the time at which people diagnosed with clinical gout in the UK are eligible for urate lowering therapy (ULT).
Methods We identified incident gout patients from 1997 to 2010 using the Clinical Practice Research Datalink (CPRD). From time of diagnosis, cumulative probabilities of prescription of ULT and meeting currently recommended eligibility criteria for ULT (defined as having (1) multiple acute attacks; (2) tophi; (3) chronic kidney disease or renal function impairment; (4) urolithiasis or (5) use of diuretic) were both estimated using the method of Kaplan-Meier plot.
Results A total of 52,164 incident gout patients (men: 38,272; 73.37%) were identified. Women tended to be older at time of gout diagnosis than men (mean age at diagnosis 69.2±14.2 years and 60.1±14.9 years respectively; p<0.01). The cumulative probabilities of fulfilling ULT indications were 44.26% at diagnosis and 86.81% 5 years later. However, only 30.39% of patients were prescribed ULT at 5 years from diagnosis. Women were more likely to fulfil indications for ULT in the initial years following gout diagnosis but less likely to receive ULT prescription. Extensive patient- and practice-level factors only accounted for 21.31% of total variance for ULT prescription. Tophi, CKD, further acute attacks, diuretic use and urolithiasis were associated with HRs (95% CI) of 2.20 (1.92–2.53), 1.67 (1.60–1.75), 1.65 (1.57–1.73), 1.30 (1.25–1.36) and 1.03 (0.92–1.15) for ULT prescription, respectively.
Conclusions Most gout patients appear eligible for ULT early in the clinical course of their disease, 44% being eligible at time of diagnosis. However, the timing of ULT initiation lags behind eligibility and many apparently eligible people do not receive ULT. These data support the growing case for full information and discussion of ULT close to the time of first diagnosis and involvement of the patients in management decisions.
Zhang W, Doherty M, Bardin T, Pascual E, Barskova V, Conaghan P, et al. EULAR evidence based recommendations for gout. Part II: Management. Report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis. 2006;65:1312-1324.
Khanna D, Fitzgerald JD, Khanna PP, Bae S, Singh MK, Neogi T, et al. 2012 American College of Rheumatology guidelines for management of gout. Part 1: systematic nonpharmacologic and pharmacologic therapeutic approaches to hyperuricemia. Arthritis Care Res (Hoboken). 2012;64:1431-1446.
Jordan KM, Cameron JS, Snaith M, Zhang W, Doherty M, Seckl J, et al. British Society for Rheumatology and British Health Professionals in Rheumatology guideline for the management of gout. Rheumatology (Oxford). 2007;46:1372-1374.
Acknowledgements This work was funded the National Science Council of Taiwan (project NSC 102-2314-B-182A-104) and Chang Gung Memorial Hospital (project CMRPG3B1671)
Disclosure of Interest None declared