From the *Medicine Service, Veterans Affairs Nebraska-Western Iowa Health Care System; †Division of Rheumatology, University of Nebraska Medical Center; ‡Pharmacy Service, Veterans Affairs Nebraska-Western Iowa Health Care System; and §Department of Biostatistics, University of Nebraska Medical Center, Omaha, NE; and ∥School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, MO.
J Clin Rheumatol. 2017 Sep;23(6):317-323. doi: 10.1097/RHU.0000000000000561.
Patient and provider factors, including allopurinol medication adherence, affect gout treatment outcomes.
The aim of this study was to examine associations of patient and provider factors with optimal gout management.
Linking longitudinal health and pharmacy dispensing records to questionnaire data, we assessed patient and provider factors among 612 patients with gout receiving allopurinol during a recent 1-year period. Associations of patient (medication adherence and patient activation) and provider factors (dose escalation, low-dose initiation, and anti-inflammatory prophylaxis) with serum urate (SU) goal achievement of less than 6.0 mg/dL were examined using multivariable logistic regression. Medication adherence was assessed as a mediator of these factors with goal achievement.
A majority of patients (63%) were adherent, whereas a minority received dose escalation (31%). Medication adherence was associated with initiation of daily allopurinol doses of 100 mg/d or less (odds ratio [OR], 1.82; 95% confidence interval [CI], 1.20-2.76). In adjusted models, adherence (OR, 2.35; 95% CI, 1.50-3.68) and dose escalation (OR, 2.48; 95% CI, 2.48-4.25) were strongly associated with SU goal attainment. Low starting allopurinol dose was positively associated with SU goal attainment (OR, 1.11; 95% CI, 1.02-1.20) indirectly through early adherence, but also had a negative direct association with SU goal attainment (OR, 0.21; 95% CI, 0.12-0.37).
Medication adherence and low starting dose combined with dose escalation represent promising targets for future gout quality improvement efforts. Low starting dose is associated with better SU goal attainment through increased medication adherence, but may be beneficial only in settings where appropriate dose escalation is implemented.
患者和医生的因素，包括别嘌醇药物的依从性，会影响痛风的治疗效果。
本研究旨在探讨患者和医生的因素与最佳痛风管理之间的关系。
通过将纵向健康和药物配药记录与问卷调查数据相联系，我们评估了 612 名在最近 1 年内接受别嘌醇治疗的痛风患者的患者（药物依从性和患者激活）和医生（剂量升级、低剂量起始和抗炎预防）因素与血尿酸（SU）目标达标率<6.0mg/dL 的关系。使用多变量逻辑回归评估这些因素与达标率之间的关系。使用目标达标来评估药物依从性作为这些因素的中介。
大多数患者（63%）是依从的，而只有少数患者接受了剂量升级（31%）。药物依从性与每天服用 100mg/d 或更低剂量的别嘌醇的起始相关（优势比[OR]，1.82；95%置信区间[CI]，1.20-2.76）。在调整后的模型中，依从性（OR，2.35；95%CI，1.50-3.68）和剂量升级（OR，2.48；95%CI，2.48-4.25）与 SU 目标达标密切相关。低起始别嘌醇剂量与 SU 目标达标呈正相关（OR，1.11；95%CI，1.02-1.20），这主要是通过早期的依从性间接产生的，但也与 SU 目标达标呈负相关（OR，0.21；95%CI，0.12-0.37）。
药物依从性和低起始剂量加上剂量升级是未来痛风质量改进的有希望的目标。低起始剂量与更高的药物依从性相关，从而更好地达到 SU 目标，但仅在适当剂量升级实施的情况下可能有益。
