title: A world of hurt: failure to achieve treatment goals in patients with gout requires a paradigm shift.
abstract: BACKGROUND
  Gout continues to be underdiagnosed and poorly managed despite the potential for cure. US and European management guidelines recommend treating to target serum urate (sUA) levels of <6 mg/dL (or <5 mg/dL to durably improve severe symptoms), with use of regular sUA monitoring, but studies suggest relatively poor adherence to these recommendations. This study investigates the real-world state of gout management in the United States by describing the characteristics of a large patient population treated in primary care and rheumatology settings.
  
  
  METHODS
  A retrospective chart audit, conducted among 124 primary care physicians and 125 rheumatologists, included 1245 patients with gout. Physicians completed structured case report forms capturing 12 months of sUA laboratory values, flare counts, comorbidities, types and doses of treatment, treatment duration, diagnosis date, physician specialty and socio-demographic factors. Focusing on the xanthine oxidase inhibitors (n = 858), descriptive statistics and multivariate models characterized relationships between patient characteristics, disease control, and treatment.
  
  
  RESULTS
  Only 83 (11%) patients achieved disease control, defined as a 12-month average sUA ≤6 mg/dL, no flares, and no tophi. Patients with greatest disease severity (defined as sUA >6 mg/dL, ≥2 flares per year, and tophi) were more likely to have kidney disease and other comorbidities. In a multivariate model, predictors of more severe gout were rheumatologist (vs primary care) management, febuxostat (vs allopurinol) use and presence of comorbid conditions.
  
  
  CONCLUSIONS
  Our findings confirm the inadequacy of gout management in the real-world setting. Regular monitoring, including sUA measurement as recommended in guidelines, is important to assess gout control. Our analyses also demonstrate that patients with more severe gout are more likely to have comorbid conditions, be treated by a specialist and use newer therapies.
authors.affiliation: a Department of Internal Medicine , University of Michigan , Ann Arbor , MI , USA.
authors.forename: Puja
authors.initials: P
authors.lastname: Khanna
authors.affiliation: a Department of Internal Medicine , University of Michigan , Ann Arbor , MI , USA.
authors.forename: Dinesh
authors.initials: D
authors.lastname: Khanna
authors.affiliation: b Research & Development, Ardea Biosciences, Inc. , San Diego , CA , USA.
authors.forename: Chris
authors.initials: C
authors.lastname: Storgard
authors.affiliation: c Medical Affairs, Ardea Biosciences, Inc. , San Diego , CA , USA.
authors.forename: Scott
authors.initials: S
authors.lastname: Baumgartner
authors.affiliation: d Health Outcomes, Ardea Biosciences, Inc. , San Diego , CA , USA.
authors.forename: Robert
authors.initials: R
authors.lastname: Morlock
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015415:Biomarkers / Q000097:blood; D054869:Clinical Audit; D005260:Female; D006073:Gout / Q000097:blood / Q000175:diagnosis / Q000188:drug therapy*; D006074:Gout Suppressants / Q000627:therapeutic use*; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011320:Primary Health Care; D012189:Retrospective Studies; D012219:Rheumatology; D016896:Treatment Outcome; D014481:United States; D014527:Uric Acid / Q000097:blood*
chemical_list: D015415:Biomarkers; D006074:Gout Suppressants; D014527:Uric Acid
keywords: Allopurinol; Febuxostat; Flares; Gout; Serum urate; Tophi