Treat-to-Target in Gout and Cardiovascular Outcomes Save

A 5 year JAMA study shows that a treat-to-target (serum urate < 6 mg/dL) study finds that effective urate-lowering treatment (ULT) results in a significantly reduced cardiovascular risk in patients with gout. 

These findinds are significant knowing that: a) the majority of ULT prescribers do not follow serum urate levels and do not achieve SUA < 6 mg/dl (the target); b) the majority of rheumatologists fail to achieve T2T goals; and c) American College of Physician guidelines on gout fail to require regular monitoring of SUA or a T2T strategy.

Using primary care data from the Clinical Practice Research Datalink Aurum, a new-user target emulation cohort study linked gout outcomes, ULT use to one year hospitalization and mortality outcomes. Adults with gout, and a pretreatment serum urate (SUA) > 6 mg/dL,  who started a newly prescribed ULT were enrollled. The primary outcome was first major adverse cardiovascular event (MACE) within 5 years of first ULT prescription. Gout flare was the positive control outcome. 

A total of 109 504 gout patients were included  (mean age 63 years, 78% male, mean disease duration 2.5 years) and 27% were included in the T2T ULT arm. Compared to those NOT on ULT, gout patients in the T2T ULT arm had: 

• Higher 5-year survival (weighted survival difference, 1.0%; 95% CI, 0.5%-1.6%)
• Lower risk of major adverse cardiovascular events (HR, 0.91; 95% CI, 0.89-0.92
• T2T achieving SUA < 5 mg/dL had a larger risk reduction (HR, 0.77; 95% CI, 0.72-0.81)
• T2T ULT patients had had fewer gout flares 

These associations were greater for gout patietns with a high and very high cardiovascular risk than those with moderate risk.

No differences were observed for negative control outcomes (no flare gout patients).

ULT therapy achieving serum urate levels (lower than 6 mg/dL) within 12 months was associated with a lower 5-year risk of major adverse cardiovascular events and fewer gout flares.