SAN DIEGO – A high percentage of gout patients treated by rheumatologists do not meet the treatment goals established by the American College of Rheumatology, even after 6 months of higher-dose urate-lowering therapy, results from a national survey found.
"These findings suggest that even among rheumatologists, gout management may not be optimal and may be inadequately aggressive in the most severe patients," Dr. Max Hamburger said at the annual meeting of the American College of Rheumatology. "It seems that there is further study needed to determine the long-term impact of the new ACR guidelines."
In 2012 the ACR published updated guidelines for the management of gout and hyperuricemia (Arth. Care and Res. 2012;64:1431-46). The recommendations included a call for treat-to-target serum uric acid (sUA) of below 6 mg/dL at a minimum, and below 5 mg/dL in select patients. "The intent of this treat-to-target was to durably improve signs and symptoms of gout and also to address palpable and visible tophi," said Dr. Hamburger, a rheumatologist who practices in Melville, N.Y. "The extent to which current practice among rheumatologists aligns with the guidelines is unknown. The areas in which the guidelines may help improve gout treatment also remains to be determined."
Dr. Max Hamburger
He and his associates set out to assess symptoms, treatment, and outcomes among gout patients treated by rheumatologists in the United States and to identify gaps that might exist in current practice with the new ACR recommendations. They recruited a national sample of rheumatologists to report gout patient encounters prospectively during Jan. 15 to Feb. 22, 2013. Rheumatologists were eligible for the study if they were board certified or board eligible in rheumatology, if they spent at least 70% of their time on patient care, if they were in practice for at least 2 years, and if they saw at least four gout patients per month.
The researchers collected anonymous patient data, including demographics, history with the rheumatology practice, gout symptoms and severity, rheumatologist assessment of disease control, and gout medications and treatment changes at the time of each visit. They applied the ACR working case scenarios and grouped patients by increasing level of disease severity. Patients in the scenarios 1-3 group had intermittent symptoms and no tophi (mild disease); patients in the scenarios 4-6 group had intermittent symptoms and 1 tophus or more (moderate disease), and patients in the scenarios 7-9 group had chronic tophaceous gouty arthropathy (more severe disease). Higher-dose ULT was defined as greater than 300 mg/day of allopurinol or 80 mg or more per day of febuxostat (Uloric).
Dr. Hamburger reported results from 127 rheumatologists who received 2,380 valid patient encounter forms. Most of the patients (79%) were male, their mean age was 61 years, and 72% were seen by a rheumatologist for 6 months or longer. Based on ACR scenario groupings, 68% were in the scenarios 1-3 group, 4% were in the scenarios 4-6 group, and 28% were in the scenarios 7-9 group.
Most patients in the scenarios 1-3 group were judged by the rheumatologists to have controlled disease, compared with 91% of patients in the scenarios 4-6 group and 81% of patients in the scenarios 7-9 group. In addition, 14% of patients in the scenarios 1-3 group were on higher-dose ULT, compared with 28% in the scenarios 4-6 group and 40% in the scenarios 7-9 group. Nearly one-quarter of all patients (24%) were on higher-dose ULT.
Among patients on higher-dose ULT, 45% of those in the scenarios 1-3 group had an sUA greater than 6 mg/dL, compared with 53% in the scenarios 4-6 group and 61% in the scenarios 7-9 group. "Despite elevated sUA, 45% of encounters did not result in an increased ULT dose or treatment change at this visit," Dr. Hamburger said.
Even with 6 months or more at higher-dose ULT, only 55% of patients overall had an sUA at or below guideline recommendations of 6 mg/dL, including only 40% of patients in the scenarios 7-9 group. In addition, 16% of patients overall had an sUA between 6 and 6.8 mg/dL, despite being on higher-dose ULT for 6 months or longer.
Dr. Hamburger acknowledged certain limitations of the study, including the fact that "rheumatologist participation in this market research may be biased based on willingness to participate in online data collection over the reporting period," he said. In addition, "a varying number of encounter forms were provided by each participant and based on estimated patient volume. Not all participants reported on 100% of their patients during the reporting period."