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BACKGROUND: Long-term gout management is based on reducing serum urate by using urate-lowering therapy (ULT) 1, 2. A lifelong treat-to-target approach is advocated, though a ULT (taper to) stop attempt can be considered (treat-to-avoid symptoms approach) during remission. Exploring gout patients' beliefs on long-term ULT strategies during remission is important for optimising gout management. OBJECTIVE: To identify factors that influence the decision for continuation or discontinuation of ULT and to determine their relative importance according to gout patients in remission. METHODS: A mixed methods design was used. First, semi-structured interviews (substudy 1) were conducted to identify barriers and facilitators for (dis)continuation of ULT using inductive thematic analysis. Afterwards these barriers/facilitators were summarized into neutrally phrased items and used in a Maximum Difference Scaling study (MaxDiff, substudy 2) to determine their relative importance using the rescaled probability score (RPS). RESULTS: Substudies 1 and 2 included 18 and 156 patients, respectively. Substudy 1 yielded 22 items, within 10 overarching themes. Substudy 2 revealed that the perceived risk of joint damage and gout flares and that ULT use gives some assurance of ULT use were the most important items. The costs, ease of receiving ULT and its practical use were the least important items. CONCLUSION: These results can aid shared decision making and provide input for what's important to discuss with gout patients in remission, when they consider ULT discontinuation. Emphasis should be on the risk of having gout flares and joint damage, not so much on facilitating how easily medication is received.
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Objective: To describe beliefs of physicians and patients in primary and secondary care about urate-lowering therapy (ULT), to examine differences in physicians' medication beliefs and to examine the association of physicians' medication beliefs with the prescribed dosage of ULT, gout outcomes and patients' medication beliefs. Methods: We conducted a cross-sectional study among rheumatologists and general practitioners (GPs) and their patients using ULT in The Netherlands. All participants filled out the Beliefs About Medication Questionnaire (BMQ). Demographics of physicians were collected through questionnaires. Patient and disease characteristics were collected through questionnaires and electronic medical records. Differences between rheumatologists and GPs in the BMQ subscales Necessity and Concern and the necessity-concern difference (NCD) score were analysed by two-sample t-tests. Multilevel analyses were performed to examine the association of physicians' BMQ scores with the prescribed dosage of ULT, gout outcomes (number of gout flares, serum urate) and patients' BMQ scores. Results: A total of 28 rheumatologists, 443 rheumatology patients, 45 GPs and 294 GP patients were included. The mean NCD scores were 7.1 (s.d. 3.6), 4.0 (s.d. 4.0), and 4.2 (s.d. 5.0) for rheumatologists, GPs and patients, respectively. Rheumatologists scored higher on necessity beliefs [mean difference 1.4 (95% CI 0.0, 2.8)] and lower on concern beliefs [mean difference -1.7 (95% CI -2.7, -0.7)] compared with GPs. No associations between physicians' beliefs and prescribed dosage of ULT, gout outcomes or patients' beliefs were found. Conclusion: Rheumatologists had higher necessity and lower ULT concern beliefs compared with GPs and patients. Physicians' beliefs were not related to prescribed ULT dosage and patient outcomes. The role of physicians' beliefs in gout management in patients using ULT seems limited. Future qualitative research can provide more insights into physicians' views of gout management.
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OBJECTIVE: Gout and diabetes mellitus type 2 (DM) frequently co-exist. The pharmacological effects of metformin may include anti-inflammatory and urate lowering effects. The objective of this study was to test these effects in patients with gout starting uric acid lowering treatment (ULT) in secondary care. METHODS: Retrospective cohort study including patients with gout and DM starting ULT. Differences in the incidence density of gout flares, proportion of patients reaching target sUA in the first six months after starting ULT, and difference in mean allopurinol dose at sUA target were compared between users of metformin and users of other or no anti-diabetic drugs (control group). Correction for confounding was applied. RESULTS: A total of 307 patients were included, of whom 160 (52.1%) used metformin. The incidence of flares was 1.61 and 1.70 in the first six months for respectively the metformin group and control group. The incidence rate ratio for gout flares was not significant (0.95, 95% CI 0.78 to 1.14). At six months, 62.8% and 54.9% reached target sUA in the metformin and control group respectively, corrected odds ratio of 1.09 (95% CI 0.66 to 1.80). There was no difference in mean allopurinol dose at sUA target 266 mg for metformin users and 236 mg for the control group, difference 30 mg (95% CI - 4.7 to 65.5). CONCLUSIONS: In conclusion we could not confirm a clinically relevant anti-inflammatory or urate lowering effect of metformin in patients starting ULT treatment and receiving usual care flare prophylaxis.
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OBJECTIVE: Owing to lower mean uric acid excretion in women compared with men, uricosuric agents might be preferred in women over xanthine oxidase (XO) inhibitors. We therefore investigated the differences in response to two urate-lowering therapies (ULTs) with different modes of action within and between sexes. METHODS: This retrospective cohort study included patients with a clinical diagnosis of gout who started allopurinol and/or benzbromarone. The successful response to ULT, defined as reaching a serum uric acid (sUA) target of <0.36 mmol/l within 6 months after commencing ULT, was compared between allopurinol and benzbromarone in women and men. Effect modification by sex on differences in response was evaluated. RESULTS: Allopurinol was started in 255 women and 1045 men, and benzbromarone in 60 women and 205 men. After 6 months, the proportions of women reaching the sUA target were 58.4% and 66.7% for allopurinol and benzbromarone, respectively (difference, -8%; 95% CI: -22%, 5%). The respective proportions in men were 61.0% and 75.6%, respectively (difference, -15%; 95% CI: -21%, -8%). Corrected for confounding, the odds ratio (OR) of reaching the target on benzbromarone vs allopurinol within women was 0.91 (95% CI: 0.47, 1.75), and within men 1.55 (95% CI: 1.04, 2.32). Corrected for confounding, sex was not an effect modifier of the difference in allopurinol and benzbromarone response (OR, 0.59; 95% CI: 0.28, 1.24). CONCLUSION: This study did not demonstrate between-sex differences regarding the response to either a uricosuric agent or an XO inhibitor, negating different treatment choices by sex.