Treat to Target in Gout
Monitoring & achievement of target serum urate levels
By Jing Li & Gabriela Schmajuk, MD, MS
Why was this study done? The ACR’s 2020 guideline for the management of gout recommends using a treat-to-target (T2T) approach to lower serum urate (SU). Using the ACR’s RISE registry, we examined the use of a T2T approach among gout patients receiving long-term urate-lowering therapy who were followed longitudinally by rheumatologists.
What were the study methods? We identified patients who had at least one ICD 9/10 diagnosis code for gout during the study period (2018–2019) and who also had continuously used a urate-lowering therapy for at least 12 months. First, we assessed the proportion of patients with SU monitoring during a one-year period. Second, among patients with at least one SU measurement recorded, we evaluated the proportion of patients who achieved an of SU of <6.0 mg/dL during the measurement year. We also used multi-level logistic regression to determine independent factors associated with SU monitoring and achievement of target SU.
What were the key findings? We found 9,560 patients in the RISE registry who had gout and at least 12 months of urate-lowering therapy use. Most of them were older (mean age 67.2; standard deviation 12.7), and 74% were male. Two-thirds of the patients were identified as non-Hispanic white. We found that 56% of patients had at least one SU measurement recorded during the measurement year; among patients with at least one SU recorded, 74% had achieved the SU target. In multi-variate analyses, we found that older patients were less likely to have SU monitoring. We also found small but statistically significant deficiencies in achievement of a target SU for Hispanic patients compared with non-Hispanic white patients.
What were the main conclusions? Among patients with gout receiving long-term urate-lowering therapy and who were followed longitudinally by rheumatologists, more than half had a documented SU measurement, and among those tested, three-quarters achieved the recommended SU target.
What are the implications for patients? Patients with gout should work with their rheumatologist to adjust their medications to a target SU level of <6.0 mg/dL to minimize the risk of gout flares and joint damage.
What are the implications for clinicians? Routine monitoring of serum uric acid is the first step toward improving quality of care for all patients with gout. Quality improvement efforts should pay special attention to older patients and to Hispanic patients, who may be at increased risk for missed testing or undertreatment.
The study: Hammam N, Li J, Kay J, et al. Monitoring and achievement of target serum urate among gout patients receiving long-term urate lowering therapy in the ACR’s RISE registry. Arthritis Care Res (Hoboken). 2022 Aug 30. doi: 10.1002/acr.25009. Epub ahead of print.
Response to Biologics in Patients with JIA
Probability of response in the first 16 weeks after starting biologics
By Lily S.H. Lim, MBBS, MRCPCH, FRCPC, PhD; Armend Lokku, PhD; Sarah Ringold, MD, MSC; & Eleanor Pullenayegum, PhD
Why was this study done? In previous studies, two-thirds of patients with juvenile idiopathic arthritis (JIA) started on one biologic disease-modifying anti-rheumatic drug (bDMARD) required a switch to another bDMARD due to ineffectiveness at one year or later. We designed this study to test if response/non-response could be identified within the first 16 weeks of starting a bDMARD.
What were the study methods? We used the first 16 weeks’ data from four polyarticular JIA trials (Etanercept 2000, TREAT-JIA 2012 (Etanercept), Tocilizumab 2014, Abatacept 2008). The primary outcome examined was the pediatric-ACR (pedi-ACR) response criteria. We defined clinically significant response as ≥pedi-ACR50 (i.e., ≥50% improvement). As predictors, we tested baseline demographics and disease-associated parameters: baseline active joint count, inflammatory markers (ESR), diagnosis age, disease duration, rheumatoid factor, concomitant treatment with prednisone and methotrexate. We modeled the states’ transition rates using the inhomogeneous Markov multistate model, allowing response rates to change over time.
What were the key findings? We studied 532 JIA participants with mean disease duration of 4.1 years. Seventy percent were receiving methotrexate and 41% prednisone. By month 4, the probability of ≥pedi-ACR50 was 0.70 (absolute certainty=1.0). If ≥pedi-ACR50 was not achieved by month 1, the probability of achieving it by month 4 was 0.60. If ≥pedi-ACR50 was not achieved by month 3, the probability of achieving this by month 4 was 0.31, adjusted for concomitant treatment, age at diagnosis, disease duration, baseline rheumatoid factor and active joint counts predicted response and loss of response.
What are the main conclusions? Lack of a clinically significant response one month after starting treatment did not necessarily predict lower probability of responding by month 4. However, if a clinically significant response was still not observed by month 3, the probability of responding by month 4 was only 0.31. Baseline disease duration, positive rheumatoid factor and active joint counts predicted early treatment response.
What are the implications for patients? Our results support not waiting longer than three months after starting a bDMARD to switch medication if a patient is not showing ≥50% improvement because the probability of responding by month 4 was only 1 in 3. However, this result must be interpreted in the clinical context of each individual patient.
The study: Lim LSH, Lokku A, Pullenayegum E, Ringold S. Probability of response in the first 16 weeks after starting biologics: An analysis of juvenile idiopathic arthritis biologics trials. Arthritis Care Res (Hoboken). 2022 Aug 17. doi: 10.1002/acr.25003. Epub ahead of print.
Rehabilitation Dose in Adults with RA
Association with baseline factors & change in clinical outcomes
By Louise Thoma, PT, DPT, PhD; Elizabeth Wellsandt, PT, DPT; Kristin Wipfler, PhD; & Kaleb Michaud, PhD
Why was this study done? Rehabilitation, particularly physical therapy and occupational therapy, are recommended for adults with rheumatoid arthritis (RA). However, little information is available on how much rehabilitation is beneficial and what factors may drive rehabilitation dose (i.e., number of physical therapy or occupational therapy visits over six months). We were interested in evaluating what baseline factors were associated with the rehabilitation dose and if it was associated with change in function, pain and fatigue.
What were the study methods? We examined data from FORWARD, the National Databank for Rheumatic Diseases on 1,381 adults with RA, including self-reported rehabilitation dose, physical function, pain and fatigue. Rehabilitation dose was defined as low dose (one or two visits), medium dose (three to eight visits) and high dose (eight or more visits). We used logistic regression models to examine the association of baseline factors with rehabilitation dose and the association of rehabilitation dose with changes in clinical outcomes, adjusting for potential confounders.
What were the key findings? First, we observed that worse physical function at baseline was associated with a higher rehabilitation dose in the following six months among adults with RA who reported using rehabilitation. Pain and fatigue levels at baseline were not associated with rehabilitation dose. Second, we observed that a high rehabilitation dose was associated with improvement in physical function, pain and fatigue compared with a low rehabilitation dose. In the fully adjusted models, only the association with change in physical function persisted.
What were the main conclusions? This study supports a higher rehabilitation dose to improve physical function in adults with RA.
What are the implications for patients? Rehabilitation is useful in addressing functional limitations. For those using rehabilitation, a higher dose (eight or more visits) may result in greater improvement in physical function.
What are the implications for clinicians? This study provides support for clinicians to advocate for the use of rehabilitation to improve physical function in adults with RA.
The study: Thoma LM, Wellsandt E, Wipfler K, Michaud K. Examining rehabilitation dose in adults with rheumatoid arthritis: Association with baseline factors and change in clinical outcomes. Arthritis Care Res (Hoboken). 2022 Sep 12. Accepted author manuscript.
