Comparative effectiveness studies in gout seem to be reflecting current clinical practice by comparing poor management with inadequate management, two experts from New Zealand say.

Writing in Nature Reviews Rheumatology  Nicola Dalbeth and Lisa Stamp say a recently published study (reported here by the limbic in May) assessing the effectiveness of two different urate-lowering drugs demonstrates that the message of ‘treat to serum urate’ target has failed to penetrate into real-world clinical practice.

Although the study  found a higher proportion of patients achieved target serum urate concentrations with febuxostat compared with patients treated with allopurinol it painted “a troubling picture of real-world gout management,” they said.

For instance almost half of the patients did not file a prescription for either drug during the study period, less than a quarter had one or more serum urate measurements, and the number of treatment naive patients reaching a treatment target of <6mg/dl was low (56.9% for febuxostat and 44.8% for allopurinol).

But a particularly striking finding was that low doses of both drugs were used in routine clinical care. The vast majority of patients treated with febuxostat received the lowest dose available and only 2.9% of patients taking allopurinol received doses above 300mg a day.

In order to convincingly demonstrate the comparative effectiveness of febuxostat a pragmatic randomised trial of febuxostat and allopurinol, with both drugs titrated according to a target serum urate level and with careful examination of efficacy, safety and health economics in a real world setting is needed, Dalbeth and Stamp say.

“At present, comparative effectiveness studies in gout seem to be comparing poor management with inadequate management,” they wrote in the News & Views section of the journal.

Rheumatologists needed to work closer with GPs to address barriers to optimum care…”Effective treatment is available, and people with gout deserve better,” they concluded.