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 in Rochester, Minnesota, between Jan 1st 1989 and Dec 31^st 1992. All subjects were followed longitudinally through their complete community medical records, until death, migration or July 1^st 2012. We used descriptive statistics to delineate the frequency and number of subsequent flares of gouty arthritis in our cohort. In addition, we utilized a conditional frailty model (accounting for multiple flares per subject) to explore risk factors of subsequent flares after an initial diagnosis of gout.

Results:

158 patients with incident gout were identified among Rochester residents within the 4 year time period. Subjects were followed for a mean (SD) of 13.4 (8.5) years. The majority of patients were male (73.4%) and the mean age (SD) at gout onset was 59.2.0 (17.8).  Isolated podagra was the most common form of joint involvement at disease onset (74.7%) and the mean (SD) serum uric acid level was 8.1 (1.6) mg/dl. 111 patients (70.3%) developed at least 1 subsequent flare, with a total of 381 subsequent flares during the entire follow-up period. Patients with the highest risk of subsequent flares had an initial joint involvement other than first MTP joint (odds ratio 1.5, 95% CI 1.1, 2.2) and a high serum uric acid level at baseline (OR 1.35, 95% CI 1.2, 1.5). Age, gender, BMI, alcohol consumption, lipid levels and starting uric acid lowering therapy 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 a initial diagnosis of gout, with a 20-year cumulative incidence of more than 80 percent. Joint involvement other than the first MTP1 joint and the serum uric acid level were significant predictors of subsequent flare risk and should be taken into account when deciding on the timing of starting uric acid lowering therapy.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/the-risk-of-subsequent-attacks-in-patients-with-incident-gout-a-population-based-study/