By Wayne Kuznar
San Diego, CA—A high percentage of patients with gout treated by rheumatologists are not at treatment goals as recognized by the American College of Rheumatology (ACR), even after 6 months or more of higher-dose urate-lowering therapy (ULT), according to the results from a national survey. Patients with more severe disease were less likely to be at treatment goal.
New ACR guidelines recommend that these patients should be considered for an increase in ULT dose or other treatment change, but no change was made in nearly half of encounters, said Max I. Hamburger, MD, Managing Partner, Rheumatology Associates of Long Island, Melville, NY, at the 2013 ACR meeting. “These findings suggest that even amongst rheumatologists,…management may not be optimal, in particular for the most severe patients,” Dr Hamburger said.
In 2012, the ACR issued guidelines for the management of gout that recommended treating serum uric acid to a target of <6 mg/dL (or <5 mg/dL in selected patients), in an effort to durably improve the signs and symptoms of gout, including palpable and visible tophi.
Dr Hamburger and colleagues recruited a national sample of 127 rheumatologists to report encounters with patients with gout. The data collected included patient demographics, history with the rheumatologist’s practice, gout symptoms, rheumatologist assessment of disease control, gout medications, and treatment changes at the time of each visit. Approximately 2380 patient encounter forms were submitted.
The patients (mean age, 61 years; 79% male) were grouped by increasing disease severity using the following ACR grouping scenarios:
- Scenarios 1 to 3 (intermittent symptoms, no tophi)
- Scenarios 4 to 6 (intermittent symptoms, ≥1 tophus)
- Scenarios 7 to 9 (chronic tophaceous gouty arthropathy).
Higher-dose ULT was defined as >300 mg daily of allopurinol or ≥80 mg daily of febuxostat.
Of the patients, 72% were seen by a rheumatologist for at least 6 months. More than two thirds (68%) of encounters were ACR scenarios 1 to 3, 4% were 4 to 6, and 28% were 7 to 9.
A total of 93% of the patients in scenarios 1 to 3, and 91% in scenarios 4 to 6 were deemed to have controlled disease. “Even 81% of patients considered to have the most severe forms of gout were judged by the rheumatologist to be controlled,” said Dr Hamburger.
Only 14% of the patients in the scenarios 1 to 3 group received higher-dose ULT compared with 28% in scenarios 4 to 6, and 40% in scenarios 7 to 9. Approximately 20% of the patients were receiving higher-dose ULT.
Half of the patients receiving higher-dose ULT had a serum uric acid level above target based on their latest serum uric acid, said Dr Hamburger. Goal attainment was lower among patients with more severe disease; the serum uric acid level remained >6 mg/dL in 61% of the patients in scenarios 7 to 9. Despite elevated serum uric acid, 45% of encounters did not result in an increased ULT dose or a treatment change at this visit.
Even with ≥6 months at higher-dose ULT, only 55% of patients overall, and only 40% in scenarios 7 to 9, had a serum uric acid level at or below guideline recommendations. Sixteen percent of patients had a serum uric acid level between 6.0 mg/dL and 6.8 mg/dL, despite ≥6 months of high-dose ULT.
Approximately 29% of the patients receiving long-term higher-dose ULT had a serum uric acid level >6.8 mg/dL, including 23% of the patients in scenarios 7 to 9 with a serum uric acid level >8.0 mg/dL.
“Gout management is currently suboptimal and inadequately aggressive for many patients,” Dr Hamburger said.