Kazuki Yoshida, ScD: Gout Treatment Strategies Regarding Cardiovascular Outcomes

Rheumatology Network interviewed Kazuki Yoshida, MD, MPH, ScD, to discuss his upcoming ACR presentation entitled, “Comparative Safety of Gout "Treat-to-target" and "Usual Care" Treatment Strategies on Cardiovascular Outcomes Using Observational Data: Causal Inference Approach.” Yoshida is an Associate Epidemiologist and Instructor in Medicine at Brigham and Women's Hospital. We discuss why rheumatology societies advocate for a treat-to-target approach, concerns about cardiovascular safety, and future research in this field.

Below is a preview of our conversation:

Rheumatology Network: What first sparked your team's interest in examining treat to target strategies versus usual care?

Kazuki Yoshida, MD, MPH, ScD: In gout treatment, the main state of chronic management is urate-lowering therapy with medications such as allopurinol and febuxostat. In previous studies, there have been some concerns about cardiovascular safety issues with these medications. One study finding potential safety concerns and another study finding the allopurinol group has a slightly higher rate of cardiovascular disease. So, there was some concerns about the cardiovascular safety there. The interest we had is that whether treat-to-target approach which requires intensive use of medications, such as allopurinol and febuxostat, whether we have cardiovascular or safety concerns with intensive therapy with these medication compared to less intensive therapy. That was our motivation for the study.

RN: Why do rheumatology societies advocate treat-to-target serum urate strategies for patients with gout?

KY: Well, that's an important point. The reason for that is coming from some biological reasoning as gout itself is an inflammatory arthritis coming from crystal positions induced by hyperuricemia high level of serum urate in the blood. So, if he can lower the blood level of serum urate to a low level, then the crystal positions in the joints can resolve over time, thereby reducing the future risks of gout flares or inflammation attacks. So that's why intensive lowering of serum urate is advocated by rheumatology societies.

RN: Can you tell me a bit about your study design?

KY: Most importantly, this is an observational study using real world data from 2 health care centers in the United States, namely the Brigham and Women's Hospital and Massachusetts General Hospital. We used a data from Medicare as well as our EHR system to a construct a cohort of 4402 gout patients We studied the US safety and cardiovascular safety of treatment strategy within this observational cohort,

RN: What were the findings of your study?

KY: So, the analysis here is that we are comparing different levels of treatment strategies, some strategies that are more relaxed versus more intensive. And there are 2 main comparisons we did that compared that more intensive treatment strategies to what we called usual care, which was essentially what was most efficient in this 1 cohort in this study. In this comparison, 2 of our comparisons gave a somewhat productive cardiovascular event rate. In the poster you will see our treatment strategy, which is initiate, continue, and titrate urate lowering therapy to when serum urate is measured.

This is a strategy we examined gave a variety of weight ratio of 0.86, a slightly reduced risk of cardiovascular event rate. Another major comparison we is a comparison of more intensive treatment strategies to a simpler treatment strategy. In this comparison, most of the more intensive treatment strategies gave a similar rate of cardiovascular events. So, it's very similar rate of cardiovascular disease, no increase or decrease compared to this comparison strategy to initiate and continue during therapy.

RN: Is there anything else you'd like our audience to know before we wrap up?

KY: Just as a as any other observational study, our studies have certain limitations. These findings should be further confirmed in future randomized control trials.