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Allopurinol Medication Adherence as a Mediator of Optimal Outcomes in Gout Management

Coburn, Brian W. PhD*†; Bendlin, Kayli A. PharmD, MEd; Sayles, Harlan MS†§; Meza, Jane PhD§; Russell, Cynthia L. PhD, RN; Mikuls, Ted R. MD, MSPH*†

JCR: Journal of Clinical Rheumatology: September 2017 - Volume 23 - Issue 6 - p 317–323
doi: 10.1097/RHU.0000000000000561
Original Articles

Background Patient and provider factors, including allopurinol medication adherence, affect gout treatment outcomes.

Objectives The aim of this study was to examine associations of patient and provider factors with optimal gout management.

Methods Linking longitudinal health and pharmacy dispensing records to questionnaire data, we assessed patient and provider factors among 612 patients with gout receiving allopurinol during a recent 1-year period. Associations of patient (medication adherence and patient activation) and provider factors (dose escalation, low-dose initiation, and anti-inflammatory prophylaxis) with serum urate (SU) goal achievement of less than 6.0 mg/dL were examined using multivariable logistic regression. Medication adherence was assessed as a mediator of these factors with goal achievement.

Results A majority of patients (63%) were adherent, whereas a minority received dose escalation (31%). Medication adherence was associated with initiation of daily allopurinol doses of 100 mg/d or less (odds ratio [OR], 1.82; 95% confidence interval [CI], 1.20–2.76). In adjusted models, adherence (OR, 2.35; 95% CI, 1.50–3.68) and dose escalation (OR, 2.48; 95% CI, 2.48–4.25) were strongly associated with SU goal attainment. Low starting allopurinol dose was positively associated with SU goal attainment (OR, 1.11; 95% CI, 1.02–1.20) indirectly through early adherence, but also had a negative direct association with SU goal attainment (OR, 0.21; 95% CI, 0.12–0.37).

Conclusions Medication adherence and low starting dose combined with dose escalation represent promising targets for future gout quality improvement efforts. Low starting dose is associated with better SU goal attainment through increased medication adherence, but may be beneficial only in settings where appropriate dose escalation is implemented.

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From the *Medicine Service, Veterans Affairs Nebraska–Western Iowa Health Care System; †Division of Rheumatology, University of Nebraska Medical Center; ‡Pharmacy Service, Veterans Affairs Nebraska–Western Iowa Health Care System; and §Department of Biostatistics, University of Nebraska Medical Center, Omaha, NE; and ∥School of Nursing and Health Studies, University of Missouri–Kansas City, Kansas City, MO.

This research was supported by a Rheumatology Research Foundation Health Professional Research Preceptorship, a University of Nebraska Medical Center Graduate Fellowship Grant, and the Nebraska Arthritis Outcomes Research Center. The funding sources had no role in the design or conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review of approval of the manuscript; or the decision to submit the manuscript for publication.

The authors declare no conflict of interest.

Correspondence: Ted R. Mikuls, MD, MSPH, Division of Rheumatology, University of Nebraska Medical Center, 986270 Nebraska Medical Center, Omaha, NE 68198. E-mail:

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