American College of Rheumatology/Association of Rheumatology Health Professionals (ACR/ARHP) 2012 Annual Meeting
November 9-14, 2012, Washington, DC
Allopurinol May Not Sufficiently Achieve Target Serum Uric Acid Levels in Patients With Gout
Inflammation and severe pain are common symptoms of gout in older adults, but over time deposits of uric acid crystals may cause joint deformity, resulting in severe disability. In nursing home residents, many of whom have renal insufficiency, serum uric acid (SUA) levels and activities of daily living (ADLs) require evaluation and resident care management. During a poster session at the ACR/ARHP meeting, Joy Higa, Takeda Pharmaceuticals, and colleagues reported the findings of a study that compared patients’ characteristics, SUA levels, and ADLs while taking allopurinol.
Between October 2010 and March 2011, the researchers conducted on-site chart reviews of 14 Hawaii-based nursing homes. The charts included patients’ serum creatinine levels, SUA levels, characteristics from the Minimum Data Set (MDS), and medication records. Patients were considered eligible for the study if they were above the age of 65 years, had been a nursing home resident for more than 30 days, and had recent SUA and ADL assessments. Residents with gout taking allopurinol (identified by the term “cases”; n=202) were compared with a control group of patients without gout who were identified by simple random sampling from the same time frame (two controls per case, n=404). A global ADL score was calculated from the most recent MDS per the Carpenter study (BMC Geriatr. 2006;6:7).
The team found that of the nursing home residents with gout, 69% had SUA levels ≥6 mg/dL despite allopurinol treatment. Age was found to be a related factor. When compared with the control group, residents with SUA levels ≥6 mg/dL were more likely to be younger than 85 years (39% vs 53%; P<.001) and more likely to be of Hawaiian ancestry (odds ratio [OR]=7.3; P<.001). Cases in this study were more likely to have coronary artery disease (OR=4.0; P<.001), diabetes (OR=3.6; P<.001), previous myocardial infarction (OR=7.3; P<.001), and charted renal failure (OR=4.9; P<.001). Body mass index was also 2.3 points higher for cases of gout versus the control group (P<.001). Gout was independently associated with a 7.26-point higher Carpenter ADL score (P<.001). Cases were also more likely to receive an opiate than the control arm (adjusted OR=8.7; P<.001).
Higa and colleagues concluded that gout is independently associated with worsened ADL scores and they should be factored into pre-admission evaluation upon entering a nursing home. Furthermore, they noted, allopurinol may not be sufficient to achieve target SUA levels, even when given at maximum renally-adjusted doses.—Kerri Fitzgerald
CAPRA-2 Trial Finds Prednisone May Improve Rheumatoid Arthritis–Associated Fatigue
For patients with rheumatoid arthritis (RA), disease-related pain and inflammation can cause fatigue and negatively impact overall quality of life. Recent studies have shown that glucocorticoid treatment and chronotherapy with delayed-release prednisone may improve patient-reported fatigue. During a poster session at the ACR/ARHP meeting, Rieke Alten, Schlosspark-Klinik, University Medicine, Germany, and colleagues analyzed the results of the CAPRA-2 trial (Circadian Administration of Prednisone in Rheumatoid Arthritis-2) and found that delayed-release prednisone may significantly reduce fatigue in RA patients.
During a 12-week, double-blind, placebo-controlled study, 350 patients with RA were randomized to receive either 5 mg delayed-release prednisone (n=231) or placebo (n=119) taken once daily at bedtime in addition to standard treatment with a disease-modifying antirheumatic drug. At the 12-week follow-up, the primary end point of the study was the proportion of patients achieving a 20% improvement in tender or swollen joints, as defined by the American College of Rheumatology criteria (ACR20). One of the secondary objectives was to observe improvement in fatigue symptoms, measured by change from baseline status on the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) questionnaire. The FACIT-F is a 13-item questionnaire that assesses the effect of fatigue on daily activity and function on a 5-point scale with a total score range of 0 to 52.
The results of their analysis showed mean baseline scores on the FACIT-F were comparable between the prednisone group and the placebo group (28.81 vs 28.73). By week 12, the difference in FACIT-F score between these two groups reached clinical significance. At week 12, the least square mean (LSM) change from baseline was significantly greater for 5 mg delayed-release prednisone than for placebo (LSM difference=2.24; 95% confidence interval, 0.76, 3.72; P=.0032). The findings were consistent with improvement in ACR20 score.
The study concluded that patients treated with 5 mg delayed-release prednisone demonstrated significant improvements in their FACIT-F scores when compared with patients receiving placebo, which indicates a reduction in fatigue and, therefore, a major improvement to quality of life for RA patients. The authors concluded, “chronotherapy with a [delayed-release] prednisone formulation improves ACR scores and provides a potential new treatment option for patients with RA that can also improve symptoms of fatigue.”—Kerri Fitzgerald