Review shows 'urgent need' for high-quality, prospective studies on gout care strategies
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There is a lack of high-quality treatment studies in patients hospitalized for gout flares, and zero prospective studies on ways to improve urate-lowering therapy use and prevent readmission, according to data published in Rheumatology.
“Despite effective treatments, hospitalizations for gout flares have increased dramatically, doubling in the United States between 1993 and 2011, from 4.4 to 8.8 admissions per 100,000 adults, respectively; doubling in Canada between 2000 and 2011, from 3.8 to 7.6 admissions per 100,000 adults; and increasing by 58.4% in England between 2006 and 2017, from 7.9 to 12.5 admissions per 100,000 adults,” Mark D. Russell, MB BChir, MA, MRCP, of King’s College London, and colleagues wrote. “This contrasts with the decline in hospitalizations from rheumatoid arthritis.”
“There are multiple contributing factors to the epidemic of gout hospitalizations: The prevalence of gout has increased in Western countries in recent years on a background of an aging population with rising prevalence of obesity and the metabolic syndrome; the management of gout is frequently suboptimal in primary care, rheumatology clinics and inpatient settings, and only a minority of patients achieve the [serum urate] levels required to prevent flares,” they added. “What is not known is how best to implement evidence-based treatments during hospitalizations for gout.”
To analyze the implementation of treatment strategies, and their effectiveness, in patients hospitalized for gout flares, Russell and colleagues conducted a systematic review. The researchers searched MEDLINE, Embase and the Cochrane library for studies that examined interventions during hospital admissions, or emergency department attendances, for adult patients with gout flares, published from database inception to April 8. Search terms included “gout,” “hospitalization” and their synonyms.
Eligible study types were randomized controlled trials, non-randomized controlled trials, prospective cohort studies, retrospective cohort studies, case-control studies and case series with at least five patients. Case reports were excluded. Initially, the researchers identified 4,197 studies in their review. However, after excluding duplicates and ineligible records, a total of 19 studies were ultimately included in the analysis.
Among the included studies, five were randomized controlled trials, one was a prospective cohort study and 13 were retrospective analyses. Eleven studies assessed outcomes after pharmacological interventions, including six on urate-lowering therapy, two on prednisolone compared with indomethacin, one examining indomethacin versus ketorolac, one on anakinra, and one on adrenocorticotropic hormone. In addition, eight studies
analyzed outcomes after non-pharmacological interventions, including seven on inpatient rheumatology consultation and one study assessing an inpatient gout management protocol.
Among the five included randomized controlled studies, one was at high risk of bias, while three had some concerns for bias and one was at low risk for bias, the researchers wrote. Additionally, all non-randomized studies had potential sources of bias. The researchers added that “no studies to date” have prospectively examined strategies aimed at preventing hospital readmission for gout flare.
“This systematic review highlights an urgent need for prospective studies of strategies to prevent hospitalizations from gout,” Russell and colleagues wrote. “Gout is a highly treatable yet poorly managed condition, and many admissions from gout are likely to be preventable with better use of existing treatments. Effective implementation of strategies designed to improve uptake of [urate-lowering therapy (ULT)] in hospitalized patients, alongside prophylaxis against flares and treat-to-target ULT optimization, is essential if the epidemic of hospital admissions from this treatable condition is to be countered.”
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