Background/Purpose: While there appears to be consensus that non-pharmacological uric acid lowering therapies (diet and lifestyle modifications) should be initiated in every patient presenting with gout, there is much less agreement as to when urate lowering drugs should be considered. Expert opinion ranges from starting uric acid lowering therapy after the first attack of gouty arthritis through a more cautious approach where therapy is only started in patients with more than 3 attacks per year.  We aimed to assemble a population-based cohort of patients with newly diagnosed gout to determine the risk of additional flares after an initial gout attack and explore the role of various demographic, clinical and laboratory predictors that may aid the clinician in quantifying this risk.

Methods: We examined a population-based incidence cohort of patients with gout, diagnosed according to the New York, Rome or ACR preliminary criteria during two time periods:  January 1^st 1989 – December 31^st 1992 and January 1^st 2009 – December 31^st 2010. All subjects were followed longitudinally through their complete community medical records, until 5 years after their first gout attack, death, migration or July 1^st 2012 – whichever came first. Person-year methods were used to estimate and compare flare rates over time. Frailty models (accounting for multiple flares per subject) were used to explore risk factors of subsequent flares.

Results:

429 patients with incident gout (158 patients in the 1989-1992 time period and 271 patients in the 2009-2010 time period) were followed for a mean of 4.2 years. The majority of patients were male (73%) and the mean age (SD) at gout onset was 59.7 (17.3).  Isolated podagra was the most common form of joint involvement at disease onset (64.0%) and the mean (SD) serum uric acid level was 8.1 (1.9) mg/dl. 248 patients developed at least 1 subsequent flare (cumulative incidence of first flare was 61.6% by 5 years in 1989-1992 vs 60.3% by 5 years in 2009-2010; p=0.70), with a total of 582 subsequent flares during the entire follow-up period. The rate of subsequent flares increased significantly from 2.82 per 10 person-years (py) in 1989-1992 to 3.49 per 10 py in 2009-2010 (rate ratio [RR]: 1.23; 95% confidence interval [CI]: 1.04, 1.47). Men were at higher risk for subsequent flares than women (HR 1.51, 95% CI 1.14, 2.00). Other predictors were a high serum uric acid level (>6mg/dL in women and >7mg/dL in men) at baseline (HR 2.20, 95% CI 1.49, 3.27), polyarticular involvement (HR 1.46, 95%CI 1.00, 2.13) and diuretic use (HR 1.30, 95%CI 1.03, 1.65). Age and body mass index were not significant predictors of subsequent flare risk.

Conclusion:

The majority of patients in our population-based cohort did develop at least one subsequent flare after an initial diagnosis of gout. The rate of subsequent flare was higher in patients diagnosed in 2009-2010 compared to those diagnosed in 1989-1992. Male sex, use of diuretics, polyarticular involvement and high uric acid levels at first flare were significant predictors of subsequent flares and should be taken into account when deciding on the timing of initiating uric acid lowering therapy.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/increase-in-risk-of-future-attacks-in-patients-with-incident-gout-a-population-based-study-over-20-years/