MedicalResearch.com Interview with:
Marsha A. Raebel, PharmD
Kaiser Permanente Colorado’s Institute for Health Research
Medical Research: What is the background for this study? What are the main findings?
Dr. Raebel: Gout is an inflammatory arthritis that affects at least 7.5 million American adults. A hallmark of gout is high serum uric acid that can result in urate crystals being deposited in joints, causing pain and joint damage. The American College of Rheumatology (ACR) guidelines recommend lowering serum uric acid to target values in patients with gout to prevent urate crystal deposition in joints and to promote crystal dissolution. For most patients, serum uric acid levels should be reduced to < 6mg/dL and maintained below that level. Measuring serum uric acid is a necessary step when titrating urate-lowering medications using a treat to target approach, but little is known about either serum uric acid measurement practices or attainment of target serum uric acid levels outside of clinical trials. We set out to characterize uric acid measurement and target serum uric acid attainment in patients with gout in the usual ambulatory care settings of the Kaiser Permanente integrated health system in the United States.
We identified 72,803 patients newly-diagnosed with gout in three Kaiser Permanente regions; 61% had at least one serum uric acid measurement within the baseline year prior to their gout diagnosis. Over each 12 month interval after the gout diagnosis, fewer patients had a serum uric acid measured. For example, serum uric acid measurement decreased to 40% of the patients the first year after the gout diagnosis, and to 26% of patients the second year after the gout diagnosis. While median serum uric acid levels across all patients decreased from 8.0 to 6.6 mg/dL over the entire 12 years of follow-up, almost 60% of patients never achieved a serum uric acid level less than 6 mg/dL. Achievement of this target serum uric acid level was more frequent in those who had a lower serum uric acid at baseline. Less than 12% of patients achieved all follow-up serum uric acid levels in the target range.
Medical Research: What should clinicians and patients take away from your report?
Dr. Raebel: Clinicians should be aware that, although most patients had at least one serum uric acid measured at some time, regular serum uric acid assessment was infrequent. Infrequent serum uric acid assessment impedes optimal use and monitoring of urate-lowering therapy. More than half of patients did not achieve any serum uric acid value within the target range of less than 6mg/dL. Given that the majority of patients with new-onset gout never reach the target serum uric acid level, more frequent serum uric acid measurement is urged.
Specifically, patients should adhere to having serum uric acid monitored as recommended by their physician and should request that their physician periodically order laboratory serum uric acid testing for them at frequencies based on treatment guidelines. To assist in reaching serum uric acid target levels, patients should take their urate-lowering medication as prescribed by their doctor. Furthermore, they should not stop their urate-lowering therapy without having been so advised by their doctor.
Medical Research: What recommendations do you have for future research as a result of this study?
Dr. Raebel: We recommend developing interventions that support physicians and patients with gout in monitoring serum uric acid and treating to target serum uric acid levels. For example, best practice alerts could be developed and implemented in electronic health records that prompt physicians to order serum uric acid laboratory testing when more than a year has passed between measurements for any patient with gout or more frequently for patients who are not in the target range.
Abstract presented at the 2015 ACR meeting November 2015
Treating to Target in Gout: The Epidemiology of Serum Urate Measurement Among Patients with Incident Gout in Usual Care Settings in the United States
Marsha A. Raebel, PharmD (2015). Majority of Gout Patients Do Not Achieve Target Uric Acid Level