Few patients with gout receive acute gout prophylaxis (AGP) when initiated with xanthine oxidase inhibitor (XOI) therapy, according to results of an analysis published in Clinical Rheumatology. In addition, researchers noted that discontinuation of XOI within 12 months was significant among patients, and AGP was not associated with a lower risk for acute gout flares after XOI therapy initiation.
Urate-lowering XOIs, used to effectively manage chronic gouty arthritis, can increase risk for acute gout flares. Therefore, guidelines from several organizations have recommended AGP with colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs), or corticosteroids, when an XOI is initiated. Because of the lack of clinical studies evaluating the role of AGP, there is still a discrepancy about choice of medication to be used and duration of treatment with AGP.
Investigators performed a retrospective cohort analysis using data from 2007 to 2017 to determine incidence of AGP prescribing with initiation of an XOI and the real-world effectiveness of AGP therapy in reducing acute gout flares.
Data included 7414 patients with a gout diagnosis who were prescribed an XOI; 6717 (90.6%) did not receive AGP. A majority of patients included in the study (95.7%) received allopurinol and the remaining received febuxostat (4.3%). Patients in the AGP cohort were matched with those in the no AGP cohort in a ratio of 1:10. Of 697 patients who received AGP, 303 (43.5%) received colchicine, 218 (31.3%) an NSAID, and 21 (3.0%) a corticosteroid; 155 (22.2%) received multiple AGP medications.
Compared with 852 patients (12.7%) in the no AGP cohort, 150 (21.5%) of those who received AGP experienced an acute gout flare within 3 months. After matching the cohorts, researchers indicated that this result remained significant at an incidence proportion of 95 (18.3%) for the AGP cohort vs 592 (11.4%; P <.001) for the no AGP cohort. Incidence of flares was higher at both 6 and 12 months for the AGP cohort. Researchers also found significant differences in the incidence of flares at 3 months among patients receiving a corticosteroid in their AGP regimen vs those who did not receive a corticosteroid (33.9% vs 20.5%, respectively; P =.022). In the matched cohort, the incidence proportion was 13 (40.6%) with corticosteroid use vs 82 (16.8%; P <.001) without.
Overall, these findings revealed that the percentage of patients who received AGP with XOI initiation was low, despite recommendations by international guidelines. In addition, the analysis indicated that AGP use was not associated with a reduction in acute flare risk; patients receiving vs not receiving AGP had a significantly higher incidence proportion of acute gout flares. Researchers noted that this could be related to the choice of AGP medication or the effectiveness dependent on various patient characteristics.
Limitations of the analysis included its retrospective nature, lack of inclusion of patient lifestyle factors, a likely underestimation of acute flares due to patient self-management, and possible miscoding or undercoding of diagnostic codes in the analyzed data.
Maes ML, Saseen JJ, Wright G, Claus LW. Utilization of acute gout prophylaxis in the real world: a retrospective database cohort analysis. Published online August 15, 2020. Clin Rheumatol. doi:10.1007/s10067-020-05265-3