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Treat‐to‐Target in Gout Management? Comment on the Article by FitzGerald et al

2019 (Figure 1A). After market entry in quarter 1 of 2009, febuxostat use gradually increased and peaked at 10% of all ULT use between quarter 2 of 2013 and quarter 4 of 2014. Over the past 2 years, with FDA safety announcements, CARES trial data, and the added boxed warning, febuxostat use decreased to 6% of all ULT use in quarter 4 of 2019. Probenecid use was uncommon, ranging from 5% in quarter 1 of 2009 to 1% in quarter 4 of 2019. Both lesinurad and pegloticase use were <0.1% of all ULT use (data not shown). Similar trends were observed when we evaluated the number of individual ULT users per 1,000 gout patients over time (Figure 1B). The number of ULT users per 1,000 gout patients increased modestly from 567 in quarter 1 of 2009 to 656 in quarter 4 of 2019. In our study of commercial health insurance enrollees from the US, allopurinol accounted for nearly 90% of all ULT use between 2009 and 2019. Use of febuxostat peaked in 2013–2014, but it appeared to trend downward by 30–40% in recent years, presumably due to safety concerns. Maintaining serum urate levels <6 mg/ dl is the key to successful management of gout (2), yet we observed suboptimal utilization of ULT as a class, similar to findings in other investigations (1). These results highlight a need for addressing the treatment gap in gout with appropriate ULT prescribing and monitoring. Limitations of the current study include limited generalizability to other health plans and no adjustment for patients’ comorbidities, which may drive treatment choice. In summary, we observed that use of febuxostat decreased substantially in the US following the emergence of cardiovascular safety concerns. While the decrease in febuxostat use was accompanied by a compensatory increase in allopurinol use, the proportion of gout patients not being treated with a ULT remained high throughout the study period. Supported by internal funding from the Division of Pharmacoepidemiology and Pharmacoeconomics at the Brigham and Women’s Hospital. Dr. Neogi’s work was supported by the NIH (grant K24-AR-070892). Dr. Kim has received research support paid to the Brigham and Women’s Hospital from Pfizer, AbbVie, Roche, and Bristol Myers Squibb. Dr. Desai has received research support paid to the Brigham and Women’s Hospital from Novartis, Bayer, and Vertex. No other disclosures relevant to this letter were reported.