How is Gout Managed in the Real World?
Despite availability of effective therapy, ULT is greatly underutilized in gout management. On the basis of a study of commercial health insurance enrolees from the USA, the number of ULT users per 1000 gout patients was estimated to be 567 in 2009, and this number increased only slightly to 656 in 2019. Another claims-based analysis reported that less than 80% of patients with gout, including those with tophaceous gout, received prescriptions for ULT, and prescription coverage was for less than 50% of the year. Adherence is also poor at about 46%, with 54–87% of patients experiencing a gap in therapy.
Among ULT options, patients are almost exclusively prescribed allopurinol. Febuxostat's use peaked at nearly 10% of all ULT prescriptions in 2013–2014; following the CARES trial data and addition of the FDA black box warning, its use diminished. Probenecid is prescribed infrequently, accounting for less than 5% of all ULT prescriptions. Pegloticase prescriptions represent less than 0.1% and the same was true for lesinurad prior to it coming off the market.
Gout is often managed by primary care physicians. The 2017 American College of Physicians (ACP) gout management guideline differs from all Rheumatology specialty guidelines from the past decade, including ACR, European League against Rheumatism and British Society of Rheumatology.[12,46–48] Specifically, the ACP guideline does not offer clear recommendations for initiation of ULT, serum urate target levels or T2T. Although the bulk of gout care occurs in primary care, a recent study showed that having a visit with a rheumatologist reduces patients' emergency room utilization, emphasizing that there is a tremendous room for improvement of gout management outside of rheumatology.
Curr Opin Rheumatol. 2022;34(2):118-124. © 2022 Lippincott Williams & Wilkins