In a large cohort of older patients with gout who started urate-lowering therapy (ULT), researchers observed a decrease in the rate in major adverse cardiovascular events (MACE) with a treat-to-target (TTT) strategy compared with ULT alone, regardless of medication adherence. Using Medicare claims data (2007-2016) linked with EHRs from two healthcare provider networks, researchers identified patients newly diagnosed with gout who initiated allopurinol or febuxostat. They emulated a hypothetical target trial that compared the risk for MACE (ie, myocardial infarction, stroke, or cardiovascular mortality) in patients with gout receiving seven TTT strategies. Three aspects of TTT were considered in identifying different treatment strategies that were compared: 1) continuation of ULT, 2) regular serum-urate (SU) monitoring, and 3) timely modification of ULT if SU was greater than 6 mg/dL. They applied “cloning” methods to avoid immortal time bias and performed inverse probability (IP) weighted analysis to account for both baseline and time-varying confounding. The study team identified 4,402 patients with a diagnosis of gout who had initiated either allopurinol or febuxostat (mean age, 76.9; 60% male). For 11,514.83 person-years (PY) under “Initiate ULT” strategy, the incidence rate (IR) of MACE was greater than 3.53 per 100 PY (95% CI, 3.20-3.89). Compared to this “Initiate ULT” strategy (no specification beyond ULT initiation), the “initiate and continue ULT + SU monitoring every 6 months” strategy was associated with decreased risk for MACE (RR, 0.81). Similarly, a “Initiate, continue, and titrate ULT to SU” strategy had a RR of 0.86. When comparison was made to the “Initiate and continue ULT” strategy, the risk for MACE was similar across five strategies.
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