1 in 6 Patients with Gout Experience Second Flare within 1 Year

Samuel Finnikin, MBChB

Credit: University of Birmingham

Using data from the Clinical Practice Research Database (CPRD) GOLD, investigators discovered approximately 1 in 6 patients with incident gout experienced a second flare within a 12-month period, according to research published in BMC Primary Care.¹ The factors linked to the recurrence of flare and urate-lowering therapy (ULT) were comparable, although ULT initiation began later than previously believed.

ULT initiation rates are low in both the UK and internationally, with little known about how clinicians decide to start a patient on ULT. Guidelines recommend considering the frequency of flare, co-prescribing, comorbidities, and disease progression when determining when to initiate, which corresponds with prescribing practice. Many providers note flare frequency as the main reason for prescribing ULT.²

“A potential barrier to use of ULT is the lack of evidence around, and consensus on, who should be offered this treatment and at what point in the disease course,” wrote lead investigator Samuel Finnikin, MBChB, clinical research fellow at the Institute of Applied Health Research, University of Birmingham, UK, and colleagues. “One of the factors contributing to this is a poor understanding of the natural history of gout including the likelihood and frequency of flares following diagnosis. This causes confusion for both clinicians and patients which adversely influences the use of ULT.”

CPRD GOLD is a database which contains information on coded diagnoses, prescribing data, and demographics, and is considered representative of the demographics of the United Kingdom (UK) population. To better understand the frequency of and factors associated with gout flares, as well as factors associated with ULT initiation, patients with a coded incident gout diagnosis who were not previously treated with ULT were included in the study. Post-diagnosis gout flares and initiation of ULT were also recognized using prescribing and coded data and covariants were defined as patient characteristics, co-prescribing, and comorbidities. A cox-proportional hazard model and logistic regression were used to evaluate these factors.

A total of 51,784 eligible patients were identified, of which 18,605 (35.9%, 95% confidence interval [CI] 35.5 – 36.3%) reported ≥1 recurrent flare. Of these patients, 17.4% (95%CI 17.1 – 17.8%) experienced flares within the 12-month period post-diagnosis.

Factors associated with flare included higher body mass index (BMI), heart failure, male sex, Black ethnicity, diuretic use, cardiovascular disease, and chronic kidney disease. The highest hazard ratio (HR) was observed in high serum urate (sUA) levels (≥540 µmol/L HR 4.63, 95%CI 4.03 – 5.31).

Although the initiation of ULT showed similar variables, older age and higher alcohol intake was correlated with lower odds of ULT initiation, but not flares.

ULT was prescribed to 14,318 patients (27.7%, 95%CI 27.3 – 28.0%), with higher rates observed in patients who reported ≥1 recurrent flares than those who did not have recurrent flares (48.5% vs 16.0%, respectively; P <.001). Only 5.7% (n = 2944; 95%CI 5.5 – 5.9%) of patients began ULT within the first year of diagnosis. Of those who experienced ≥1 flares, only 19.3% (n = 3590; 95%CI 18.7 – 19.9%) received ULT within 12 months of the first recurrent flare.

Patients who did not experience recurrent flares had a shorter mean time between diagnosis and the start of ULT compared with those who did (800 days vs 1174 days, respectively; P <.001).

Investigators noted using data collected in a clinical setting as a limitation, because some flares were likely to be managed by the patient without seeking care from a provider. Additionally, it is possible some unrecognized confounders were excluded from the model.

“The potential benefits of ULT should be discussed early in the disease course to allow patients to consider their options through shared decision making,” investigators concluded. “This study should help inform decision making by giving clinicians more insight into the risk of recurrent flares, with a particular focus on serum urate levels as the highest risk factor for recurrent flares.”

References

1. ^{Finnikin S, Mallen CD, Roddy E. Cohort study investigating gout flares and management in UK general practice. BMC Prim Care. 2023;24(1):246. Published 2023 Nov 22. doi:10.1186/s12875-023-02201-7}
2. ^{Rai SK, Choi HK, Choi SH, Townsend AF, Shojania K, De Vera MA. Key barriers to gout care: a systematic review and thematic synthesis of qualitative studies. Rheumatology. 2018;57(7):1282–92.}