Urate-lowering therapy use, target achievement remain low in United Kingdom
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Despite recently updated guidelines, urate-lowering therapy use, and the achievement of urate targets, remain low for patients with gout in the United Kingdom, according to data published in Lancet Europe.
“Gout is unique among the inflammatory arthritides in that it has curative, long-term treatments in the form of urate-lowering medications, such as allopurinol,” Mark D. Russell, MD, of the Centre for Rheumatic Diseases at King's College in London, told Healio. “However, previous studies had shown that these medications are not used as frequently as they should be or at effective doses. With this study, we investigated whether trends in the use of urate-lowering medications have improved in recent years, particularly following the publication of national and international guidelines.”
To measure the level of improvement in urate-lowering therapy among patients with gout following the introduction of EULAR-BSR guidelines, researchers used the Clinical Practice Research Datalink (CPRD) GOLD dataset as a source. The set includes information on more than 20 million people from general practitioners in the United Kingdom.
The authors conducted a population-level, observational cohort study of people aged 18 years or older who received a gout diagnosis between Jan. 1, 2004, and Oct. 21, 2020. To be included in the analysis, patients were required to be registered with the database for at least 1 year prior to diagnosis to ensure only incident cases were recorded, the authors wrote. Additionally, patients were required to have at least 1 year of follow-up.
The primary outcome measures were the introduction of a new urate-lowering therapy within 12 months of an index gout diagnosis, a recorded serum urate level of 360 µmol/L or less within 12 months of index diagnosis, a serum urate level of 300 µmol/L or less within 12 months of a diagnosis and treat-to-target urate monitoring. These measures, if attained by 24 months, were also recorded as secondary outcome measures.
Predictor variables were selected on their basis of importance as “potential confounders of outcome measures,” and included age at diagnosis, sex, year of diagnosis, country of primary care provider, comorbidities, smoking status, alcohol use and diuretic therapy at the time of diagnosis, the researchers wrote.
In all, the study included 129,972 patients with newly diagnosed gout. Of those, 37,529 (28.9%) initiated urate lowering therapy within 12 months of diagnosis. Over the course of the study, the rate of urate lowering therapy initiation increased from 26.8% for patients diagnosed in 2004 to 36.6% in 2019. In 2020, the percentage of patients initiating urate lowering therapy was 34.7%.
There was no significant improvement in these metrics after the release of the updated guidelines. Additionally, comorbidities such as chronic kidney disease, heart failure and obesity, and diuretic use were associated with increased levels of urate lowering therapy initiation, but lower chances of reaching urate targets within 12 months, according to the researchers.
“Our take home message is that, despite updated guidelines, urate-lowering medications are still not be prescribed frequently enough in the U.K., and most patients do not achieve the target urate levels needed to prevent flares and morbidity,” Russell said. “As rheumatologists, we should encourage the initiation and titration of urate-lowering medications for people with gout. National strategies are needed if best practice care is to be adopted, for example through educational programs and electronic health record prompts.”
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