Khanna Puja, Khanna Dinesh, Storgard Chris, Baumgartner Scott, Morlock Robert
a Department of Internal Medicine , University of Michigan , Ann Arbor , MI , USA.
b Research & Development, Ardea Biosciences, Inc. , San Diego , CA , USA.
Postgrad Med. 2016 Jan;128(1):34-40. doi: 10.1080/00325481.2016.1113840. Epub 2015 Nov 17.
Gout continues to be underdiagnosed and poorly managed despite the potential for cure. US and European management guidelines recommend treating to target serum urate (sUA) levels of <6 mg/dL (or <5 mg/dL to durably improve severe symptoms), with use of regular sUA monitoring, but studies suggest relatively poor adherence to these recommendations. This study investigates the real-world state of gout management in the United States by describing the characteristics of a large patient population treated in primary care and rheumatology settings.
A retrospective chart audit, conducted among 124 primary care physicians and 125 rheumatologists, included 1245 patients with gout. Physicians completed structured case report forms capturing 12 months of sUA laboratory values, flare counts, comorbidities, types and doses of treatment, treatment duration, diagnosis date, physician specialty and socio-demographic factors. Focusing on the xanthine oxidase inhibitors (n = 858), descriptive statistics and multivariate models characterized relationships between patient characteristics, disease control, and treatment.
Only 83 (11%) patients achieved disease control, defined as a 12-month average sUA ≤6 mg/dL, no flares, and no tophi. Patients with greatest disease severity (defined as sUA >6 mg/dL, ≥2 flares per year, and tophi) were more likely to have kidney disease and other comorbidities. In a multivariate model, predictors of more severe gout were rheumatologist (vs primary care) management, febuxostat (vs allopurinol) use and presence of comorbid conditions.
Our findings confirm the inadequacy of gout management in the real-world setting. Regular monitoring, including sUA measurement as recommended in guidelines, is important to assess gout control. Our analyses also demonstrate that patients with more severe gout are more likely to have comorbid conditions, be treated by a specialist and use newer therapies.
尽管痛风有可能治愈，但仍存在诊断不足和管理不善的情况。美国和欧洲的管理指南建议将血清尿酸（sUA）水平控制在<6 mg/dL（或<5 mg/dL以持久改善严重症状），并定期监测sUA，但研究表明对这些建议的依从性相对较差。本研究通过描述在初级保健和风湿病科接受治疗的大量患者群体的特征，调查美国痛风管理的实际情况。
对124名初级保健医生和125名风湿病学家进行的回顾性病历审核，纳入了1245例痛风患者。医生填写结构化病例报告表，记录12个月的sUA实验室值、发作次数、合并症、治疗类型和剂量、治疗持续时间、诊断日期、医生专业和社会人口统计学因素。以黄嘌呤氧化酶抑制剂（n = 858）为重点，描述性统计和多变量模型分析了患者特征、疾病控制和治疗之间的关系。
只有83例（11%）患者实现了疾病控制，定义为12个月平均sUA≤6 mg/dL，无发作，无痛风石。疾病严重程度最高的患者（定义为sUA>6 mg/dL，每年≥2次发作，有痛风石）更有可能患有肾脏疾病和其他合并症。在多变量模型中，痛风更严重的预测因素包括由风湿病学家（而非初级保健医生）管理、使用非布司他（而非别嘌醇）以及存在合并症。
我们的研究结果证实了现实环境中痛风管理的不足。定期监测，包括按照指南建议测量sUA，对于评估痛风控制情况很重要。我们的分析还表明，痛风更严重的患者更有可能患有合并症，由专科医生治疗并使用更新的疗法。
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