Improvement in Diagnosis and Treat-to-Target Management of Hyperuricemia in Gout: Results from the GEMA-2 Transversal Study on Practice

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SCIENCE
Improvement in Diagnosis and Treat-to-Target Management of Hyperuricemia in Gout: Results from the GEMA-2 Transversal Study on Practice
Key Take-Away: 

Over 50% improvement in targeting therapeutic serum urate was observed, but clinical inertia is still exists.Since ultrasonography is not effectively contributive, diagnosis is still mostly clinically based.

Gout is a chronic inflammatory disorder. Urate-lowering medications are the most recommended drugs for the management of gout. Nowadays, these recommendations are reportedly low in general practice it remains unclear whether these recommendations have a true impact on gout.

ABSTRACT: 
Background: 

Gout is a chronic inflammatory disorder. Urate-lowering medications are the most recommended drugs for the management of gout. Nowadays, these recommendations are reportedly low in general practice it remains unclear whether these recommendations have a true impact on gout. One audit of a single outpatient clinic practice demonstrated a good adherence to guidelines; however, this does not reflect global practice or an improvement upon previous standards.

The Gout Evaluation and Management (GEMA) study assessed rheumatology practice in Spain in comparison to the European League Against Rheumatism (EULAR) 2006 recommendations for gout. This GEMA study found that the optimal diagnosis was achieved only in one out of four patients and target sUA in less than one in two. The GEMA-2 research was conceived and developed as a commitment, within the design of GEMA, to evaluate changes in rheumatology practice over time.

Rationale behind the research

  • Although recommendations for diagnosis and management of gout are available to obtain the best possible outcomes adherence to recommendations, such as prescription rates of urate-lowering medications, is reportedly low in general practice and even worsening over time in terms of controlling serum urate (sUA) levels. It remains unknown whether such recommendations have a true impact on gout.
  • Therefore, this trial was conducted to evaluate changes regarding main EULAR guidlines on diagnosis and treatment of gout compared to a previous assessment.

Objective

To evaluate changes in main EULAR recommendations on diagnosis and treatment of gout compared to a previous assessment.

Methods: 

Note: This was an observational cross-sectional study

  • Study outcome measures

Demographic and lifestyle data, associated comorbidities, diagnosis of gout, and evaluation of disease burden, clinical characteristics, and treatments for gout (medications for flares, prophylaxis, and urate-lowering drugs).

 

Results: 

Study Outcomes

  • Diagnosis

Thirty-one out of 38 rheumatology units responded to the pre-study questionnaire with 15 (39.5–48.4%) having predicted that over 50% of their patients had a diagnosis based on crystal identification.

Samples for microscopy were mostly obtained during acute episodes of joint inflammation (124/162 or 76.5%), from nodules suspected to be tophi (28 or 17.3%) and from previously affected but currently non-inflamed joints (12 or 2.4%).

  • Therapeutic Target sUA

Twenty-seven of the rheumatology units (71% to 87%) anticipated that over 50% of their patients would be on target sUA. Baseline sUA was available in 449 (88.7%) and 485 (85.8%) of the patients at baseline and last visit, respectively. Sixty-four percent of all patients (311/485) and 66% of patients on urate-lowering medication (ULT) were at the therapeutic sUA target at their last visit.

ULTs were actively prescribed in 482 (95.3%) patients at last visit: 363 on allopurinol (75.3% of the total with any ULT prescription), 108 (22.4%) on febuxostat, and 11 (2.3%) on benzbromarone.

Allopurinol was the only ULT prescribed at a significantly lower initial dose than the final regimen. The final dose was higher for patients with sUA within the therapeutic target range than for those who did not achieve this at their last visit.

  • Other Management Variables Included in the Recommendations

Prophylaxis of flares had not been implemented in 107 (21.9%) patients. In addition, 373 (77.1%) had been prescribed colchicine, 323 (86.6%) of those starting treatment during development of the flare, for a mean time period of 258±180days (IQR 50–595); 50 (13.4%) patients had been on prophylactic doses above that prescribed for colchicine.

Comorbid conditions were, as in GEMA, most commonly evaluated when passively retrievable from analysis (glucose, lipids, creatinine) or when a previous diagnosis or treatment was recorded in the clinical file (hyperlipidemia, diabetes, hypertension) rather than from active searches such as arterial pressure, height, or weight measurements.

Conclusion: 

This audit recovered the anticipated/surveyed/perception of investigators on what the final rates of gold-standard diagnosis (GSD) and achievement of the targeted therapeutic sUA would be, and they were not by final results, suggesting that surveys are not reliable compared to audits.

This GEMA study evaluated the state of gout management as practiced by hospital-based rheumatologists before the 2006 EULAR guidelines. The study showed lower rates of both GSD and target sUA level. The GEMA-2 study was conducted to evaluate the improvement in the gout management process after the 2006 EULAR recommendations, but before the 2012 ACR guidelines.

Both the crystal-based GSD and a targeted sUA showed improvement in this retrospective audit. In the previous GEMA there was 50%, or above improvement was observed in approximately two-thirds of the patients. Thus, the overall population examined herein represents a difficult-to-treat, not-best-case scenario, albeit not-worst-case clinical situation, thus reinforcing the value of these findings.

There was less than 50% improvement in the rate of GSD from GEMA to GEMA-2. The study determined that a significant (≥ 50%) improvement from the previous audit was achieved in the percentage of patients reaching the sUA target of below 6 mg/dL.Dissemination of the EULAR recommendations at a given treatment facility was associated with better ratios of target sUA, suggesting that increased awareness of gout management had an impact on clinical practice. For those patients who failed to achieve the target sUA, a dose of febuxostat seldom was exceeded to 80 mg/day. The low dose of benzbromarone in combination with allopurinol was infrequently prescribed. Most patients were prescribed prophylaxis with colchicine during the flare. These treatment choices may reflect the presence of underlying comorbidities. Despite this, in out of six patients, changes in ULT were made during an ongoing flare.

In conclusion, an improvement in the diagnosis of gout in clinical rheumatology was reported, but not as much as expected. There was more than 50% increase in the achievement of target sUA as the previous audit.

Rheumatology and Therapy pp 1–11
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