Session Title: Metabolic and Crystal Arthropathies
Session Type: Abstract Submissions (ACR)
Guidelines for initiating urate lowering therapy (ULT) in the treatment of gout recommend treatment to a target serum urate (SUA) level of ≤6mg/dl with monitoring of SUA.
We reviewed the use of ULT with allopurinol (allop) or febuxostat (febux) in a large health care system between June 2010 and April 2012. Eligible subjects were >18 years at ULT initiation, had a diagnosis of gout, and had ≥ two outpatient prescriptions for a ULT after June 1, 2010. Demographics, ULT dose, prescribing providers, diagnosis, and SUA levels were collected from our EPIC EMR using Explorys Inc. proprietary software. A study author checked agreement of data between the subjects EMR and the Explorys data in random cases within the study population. Cleveland Clinic IRB approval was obtained.
1,870 subjects were eligible for inclusion: 74.1% male, mean age 62.8 (SD 14.2). Study subjects had been prescribed allop alone (82.5%, n=1543), febux alone (5.9%, n=188), or both (11.6%, n=217). Following initiation of ULT, 68.8% of subjects (n=1286) had a repeat SUA within our health system: 56.1% within 6 months and 65.4% within 12 months of their initial prescription. After initiation of ULT, 45.9% of subjects achieved a level of ≤6mg/dl, 22.0% had levels between 6.1-7.0mg/dl, and 32.1% never had a level ≤7.0mg/dl. There were 523 subjects on allop with SUA measurements ≥7.0mg/dl, yet only 2.3% were prescribed a daily dose of >300mg. Subjects treated by a rheumatologist (60.6%) vs non-rheumatologist (42.0%) were more likely to achieve a SUA ≤6mg/dl, odds ratio 2.1 (95% CI 1.7-2.7). The starting dose of allop was <100mg (1.0%), 100mg (59.6%), 101-300mg (38.8%). For subjects prescribed allop the maximum daily dose was ≤ 100mg in 32.4% and 101-300mg in 65.0% of subjects. Maximum dose of allop was greater than 300mg in 2.7% of subjects seen by a rheumatologist and 2.6% of non-rheumatologists. The starting dose of febux was ≤ 40mg in 87.9% of subjects. Of those who did not achieve a SUA level ≤6.0mg/dl, 38.4% had ULT adjusted to a higher dose (ULT adjustment to target may not have been completed by the time of analysis). Only 11.3% of subjects started on febux had documented allop intolerance. A statistically significant difference was found in the mean creatinine level closest to the initiation of ULT (1.3 allop vs 1.5 febux p<0.001) which may indicate renal insufficiency as a perceived reason for febuxostat.
Only 45.9% of patients started on ULT achieved recommended SUA levels, only 38.4% of those not meeting target had a documented dose adjustment and > 97% of patients on allop were on < 300mg per day. This demonstrates a persistent care gap in the treatment of gouty arthritis.
R. A. Overman,
B. F. Mandell,
Novartis Pharmaceutical Corporation,
C. L. Deal,
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