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    <recommendedItem id="20100101_19_411"
                     title="Older Women with Gout at Risk of MI (CME/CE)"
                     score="0.01"
                     href="http://www.medpagetoday.com/Cardiology/MyocardialInfarction/tb/18319?impressionId=1265792346454"
                     
      &lt;p&gt;Elderly women with gout are at increased risk of acute myocardial infarction (MI), even more so than men with this painful arthritis, a population-based study found.&lt;/p&gt;
&lt;p&gt;After adjusting for age, comorbidities such as hypertension and diabetes, and prescription drug use, the relative risk of MI among women ages 65 and older was 1.39 (95% CI 1.20 to 1.61), according to Mary A. De Vera of the Arthritis Research Centre of Canada in Vancouver, and colleagues.&lt;/p&gt;
&lt;p&gt;In comparison, the multivariate relative risk among men was 1.11 (95% CI 0.99 to 1.23, &lt;em&gt;P&lt;/em&gt;=0.003 for interaction), the researchers reported online in the &lt;em&gt;Annals of the Rheumatic Diseases&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Men with gout are known to be at higher risk for coronary heart disease and acute MI, but corresponding data for women were sparse.&lt;/p&gt;
&lt;p&gt;So De Vera and colleagues conducted a cohort study using the British Columbia Linked Health Database, comparing the incidence rates of MI between 9,642 patients with gout and 48,210 matched controls with no history of ischemic heart disease.&lt;/p&gt;
&lt;p&gt;A total of 3,890 of the cases were women, as were 19,450 of the controls.&lt;/p&gt;
&lt;p&gt;The gout incidence rate in women ages 65 to 85 years was 2.5 per 1,000 person-years, and 2.9 per 1,000 person-years in those ages 85 and higher.&lt;/p&gt;
&lt;p&gt;The rates in men of the corresponding ages were 5.7 and 6.5 per 1,000 person-years.&lt;/p&gt;
&lt;p&gt;Hospital records indicated that the incidence rates of acute MI among women and men were 6.7 and 10.7 per 1,000 person-years, respectively.&lt;/p&gt;
&lt;p&gt;During a median of seven years&apos; follow-up there were 3,268 incident cases of MI, including 996 in women.&lt;/p&gt;
&lt;p&gt;In unadjusted analysis, the relative risk of acute MI among women with gout was 1.67 (95% CI 1.45 to 1.93), while that for men with gout was 1.19 (95% CI 1.07 to 1.32).&lt;/p&gt;
&lt;p&gt;Multivariate analysis determined that the relative risk for nonfatal MI in women was 1.41 (95% CI 1.19 to 1.67), while that in men was 1.11 (95% CI 0.98 to 1.25, &lt;em&gt;P&lt;/em&gt;=0.005 for interaction).&lt;/p&gt;
&lt;p&gt;The gender difference did not show up in fatal events, however. The relative risk for fatal MI was 1.33 in women (95% CI 0.99 to 1.78) and 1.10 in men (95% CI 0.88 to 1.38, &lt;em&gt;P&lt;/em&gt;=0.30 for interaction).&lt;/p&gt;
&lt;p&gt;Overall, there was a 39% increased risk for MI among women with gout, an association that was independent of age, comorbidities, and use of prescription drugs including nonsteroidal anti-inflammatories, diuretics, statins, anticoagulants, and aspirin.&lt;/p&gt;
&lt;p&gt;The association was significantly stronger than for men, according to the researchers.&lt;/p&gt;
&lt;p&gt;These gender differences may relate to serum uric acid levels and metabolism. Levels in men are about 1 mg/dL higher, although levels do rise in women at menopause.&lt;/p&gt;
&lt;p&gt;&quot;Thus, the relative physiological impact of having gout or a certain level of hyperuricemia may be stronger among women than men,&quot; the authors wrote.&lt;/p&gt;
&lt;p&gt;Possible mechanisms for the contribution of hyperuricemia to cardiovascular disease include vascular smooth muscle cell proliferation and inflammation, as well as platelet adhesiveness and aggregation.&lt;/p&gt;
&lt;p&gt;&quot;Inflammation associated with gout may also have a role in potential mechanisms, including promotion of atherogenesis and thrombogenesis, similar to other inflammatory arthritides associated with cardiovascular disease,&quot; the investigators noted.&lt;/p&gt;
&lt;p&gt;A strength of the study was its population-based design, which makes its findings generalizable. Limitations include the potential for misclassification of diagnosis because of the use of diagnostic codes, and the inability to adjust for lifestyle factors such as smoking.&lt;/p&gt;
&lt;p&gt;Nonetheless, according to the investigators, &quot;These findings provide support for the aggressive management of cardiovascular risk factors for male and female patients with gout.&quot;&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was partly funded by the National Institute of Health.&lt;/p&gt;&lt;p&gt;The authors have received support from the Canadian Arthritis Network/The Arthritis Society, and one disclosed receiving research funding and honoraria from TAP Pharmaceuticals and Savient.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_19_3498"
                     title="ASN: Febuxostat Works in Gout Patients with Renal Impairment (CME/CE)"
                     score="-0.005"
                     href="http://www.medpagetoday.com/MeetingCoverage/ASN/tb/16742?impressionId=1265792346454"
                     
      &lt;p&gt;SAN DIEGO  --  In patients with gout and preexisting mild to moderate renal impairment, febuxostat (Uloric) is more effective and as safe as allopurinol, the gold standard gout treatment, researchers found.&lt;/p&gt;
&lt;p&gt;In these patients, two doses of febuxostat  --  40 and 80 mg  --  were both more effective at lowering serum urate to less than 6 mg/dL than allopurinol through six months of treatment, Andrew Whelton, MD, of Johns Hopkins, reported at the American Society of Nephrology meeting here.&lt;/p&gt;
&lt;p&gt;Rates of adverse events were similar in all three groups, regardless of renal function.&lt;/p&gt;
&lt;p&gt;Although the 80-mg dose of febuxostat was more effective than allopurinol in the overall patient population, including those with normal renal function, Whelton said it still would probably not become the primary gout treatment.&lt;/p&gt;
&lt;p&gt;&quot;Allopurinol still remains the gold standard to use generally,&quot; he said. &quot;But in those with preexisting renal impairment, [febuxostat] is very useful, it is highly effective, and it is as safe as allopurinol.&quot;&lt;/p&gt;
&lt;p&gt;In patients with renal impairment, febuxostat has an advantage because it is processed primarily by the liver, and not the kidneys, as allopurinol is, Whelton said. Allopurinol is used in these patients but at a lower dose than usual in those with moderate impairment (200 versus 300 mg).&lt;/p&gt;
&lt;p&gt;His study findings show that the dose of febuxostat does not need to be adjusted on the basis of renal function, he said.&lt;/p&gt;
&lt;p&gt;Febuxostat was approved by the FDA in February for the chronic management of gout. (See &lt;a href=&quot;http://www.medpagetoday.com/ProductAlert/Prescriptions/12902&quot; mce_href=&quot;http://www.medpagetoday.com/ProductAlert/Prescriptions/12902&quot; target=&quot;_blank&quot;&gt;FDA Okays New Treatment for Gout-Related Hyperuricemia&lt;/a&gt;)&lt;/p&gt;
&lt;p&gt;The Phase III CONFIRMS trial, which showed that the 80-mg dose was superior to both the 40-mg dose of febuxostat and allopurinol for lowering serum urate to less than 6 mg/dL (67% versus 45% and 42%,&lt;em&gt; P&lt;/em&gt;&amp;lt;0.001 for both), provided some of the evidence used for approval.&lt;/p&gt;
&lt;p&gt;Whelton and his colleagues wanted to analyze the findings stratified by renal function, because impairment is common in patients with gout.&lt;/p&gt;
&lt;p&gt;At baseline, the mean serum urate level in the 2,269 patients included in the trial was 9.6 mg/dL.&lt;/p&gt;
&lt;p&gt;About two-thirds (65%) had mild or moderate renal impairment.&lt;/p&gt;
&lt;p&gt;As in the overall analysis, in the subgroups of patients with normal renal function, mild impairment, or moderate impairment, the 80-mg dose of febuxostat was superior to both the 40-mg dose and allopurinol, and there was no significant difference between the low dose of febuxostat and allopurinol.&lt;/p&gt;
&lt;p&gt;When those with mild and moderate renal impairment were analyzed as a single group, however, both the high dose (72%, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001) and the low dose (50%, &lt;em&gt;P&lt;/em&gt;=0.021) of febuxostat were superior to allopurinol (42%) in terms of the number of patients who achieved the target serum urate level.&lt;/p&gt;
&lt;p&gt;Adverse event rates were similar across treatment groups and across levels of renal function. The most frequent were upper respiratory tract infections, liver function test abnormalities, and diarrhea.&lt;/p&gt;
&lt;p&gt;There were five deaths, one in each febuxostat group and three in the allopurinol group.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was supported by Takeda Global Research &amp;amp; Development Center.&lt;/p&gt;&lt;p&gt;Whelton reported serving as a consultant to Takeda Global Research &amp;amp; Development Center.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_19_3336"
                     title="ACR: Skim Milk Might Prevent Gout (CME/CE)"
                     score="-0.006"
                     href="http://www.medpagetoday.com/MeetingCoverage/ACR/tb/16533?impressionId=1265792346454"
                     
      &lt;p&gt;PHILADELPHIA  --  Drinking fat-free milk may reduce men&apos;s risk of gout, researchers suggested at the American College of Rheumatology meeting here.&lt;/p&gt;
&lt;p&gt;Their crossover study indicated that all forms of fat-free milk reduced serum uric acid levels which  --  when at an elevated level  --  increase the risk of gout.&lt;/p&gt;
&lt;p&gt;&quot;This study has shown that skim milk can significantly reduce the serum uric acid concentration in the short term,&quot; said Nicola Dalbeth, MD, of the University of Auckland in New Zealand.&lt;/p&gt;
&lt;p&gt;Dalbeth and her colleagues asked the 16 healthy men who volunteered to participate in the study to drink soy milk and three forms of fat-free milk, each containing 80 grams of protein.&lt;/p&gt;
&lt;p&gt;The researchers collected samples of serum and urine immediately before each participant drank one of the beverages and then hourly over a three-hour period.&lt;/p&gt;
&lt;p&gt;When the men in the study drank soy milk they experienced about a 10% increase in serum uric acid levels.&lt;/p&gt;
&lt;p&gt;On the other hand, when they drank the various fat-free milk products, serum uric acid levels fell in a linear fashion, resulting in a 10% decrease in serum uric acid levels.&lt;/p&gt;
&lt;p&gt;The difference between the two types of milk was significant (&lt;em&gt;P&lt;/em&gt;&amp;lt;.0001), Dalbeth said.&lt;/p&gt;
&lt;p&gt;&quot;The results suggest that increasing the amount of skim milk in the diet may help with preventing the development of gout and also assist with treatment for those with the disease,&quot; she said. &quot;We are now continuing this work by studying the longer-term effects of milk in people with gout.&quot;&lt;/p&gt;
&lt;p&gt;&quot;It is important that this study be performed in people with gout,&quot; said Daniel Lewis, MD, a rheumatologist in private practice and co-director of the Deakin University Integrative Health Research Unit in Melbourne, Australia.&lt;/p&gt;
&lt;p&gt;He said that people with gout have problems in removing uric acid from the body so the results seen in healthy individuals may not be generalizable to those who suffer from gout. &quot;We will have to see what impact skim milk has on individuals with gout to determine if the milk has potential in preventing flares of the disease.&quot;&lt;/p&gt;
&lt;p&gt;Treatments are already available to prevent or control the arthritis associated with gout, but managing the disorder can be difficult, and treatment plans often have to be tailored individually, Lewis said.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;No corporate funding for the study was reported.&lt;/p&gt;&lt;p&gt;Dalbeth disclosed financial relationships with Fonterra Research Centre, Abbott Laboratories, and Roche.&lt;/p&gt;&lt;p&gt;Lewis had no financial disclosures.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_19_3384"
                     title="ACR: Pump Up the Allopurinol to Prevent Gout (CME/CE)"
                     score="-0.006"
                     href="http://www.medpagetoday.com/MeetingCoverage/ACR/tb/16589?impressionId=1265792346454"
                     
      &lt;p&gt;PHILADELPHIA  --  Going beyond the recommended dosing of allopurinol (Zyloprim) to treat patients with gout may help prevent recurrence safely, researchers contended here.&lt;/p&gt;
&lt;p&gt;&quot;While allopurinol is the mainstay of treatment, physicians have concerns about increasing the dose above recommended guidelines particularly in patients with impaired kidney function, &quot;said Lisa Stamp, MD, PhD, of the University of Otago in Christchurch, New Zealand.&lt;/p&gt;
&lt;p&gt;&quot;This has led to poor control of gout which causes significant pain, impacts on quality of life, and can lead to permanent joint damage,&quot; she said at the annual meeting of the American College of Rheumatology.&lt;/p&gt;
&lt;p&gt;Stamp argued instead for a &quot;treat-to-target&quot; approach for urate lowering therapy.&lt;/p&gt;
&lt;p&gt;She said using sufficient allopurinol to keep serum urate to less than 6 mg/dL may be a better strategy than persisting with doses perceived to be safe but which are inadequate to achieve the goals of treatment.&lt;/p&gt;
&lt;p&gt;She explained that recommendations for allopurinol use are tied partly to kidney function. But these conservative doses may fail to achieve adequate serum uric acid reduction, she said.&lt;/p&gt;
&lt;p&gt;Stamp and colleagues recruited 90 people with gout who were on a stable dose of allopurinol for at least one month. The average age of the participants was 58.3; 87.8% were male. At the initial visit, 52 participants had serum uric acid levels greater than 6 mg/dL, the critical level above which gout is more likely to occur.&lt;/p&gt;
&lt;p&gt;For 45 participants their dose of allopurinol was increased anywhere from 50 to 400 milligrams above the recommended range. Of these, three developed rashes and discontinued the drug or went back to a lower dose, and six failed to attend follow-up appointments or developed intervening medical problems unrelated to gout.&lt;/p&gt;
&lt;p&gt;Of the 36 patients who completed the 12-month study, 86% saw a drop in serum urate levels to 6 mg/dL or less.&lt;/p&gt;
&lt;p&gt;&quot;There was no increase in toxicity with higher doses of allopurinol in this cohort, including those with renal impairment,&quot; Stamp said. Three patients on high-dose allopurinol had rashes.&lt;/p&gt;
&lt;p&gt;Baseline doses of allopurinol were about 35% higher in patients co-treated with furosemide (248 mg/day versus 180 mg/day in patients not given furosemide), Stamp reported.&lt;/p&gt;
&lt;p&gt;But similar proportions of patients achieved the 6-mg/dL urate target whether they were on furosemide of not (72% versus 89%, &lt;em&gt;P&lt;/em&gt;=0.24).&lt;/p&gt;
&lt;p&gt;Increasing the dose of allopurinol above the recommended levels could help reduce gout attacks, agreed Eric Matteson, MD, of the Mayo Clinic in Rochester, Minn.&lt;/p&gt;
&lt;p&gt;&quot;The key message in this study is that in those patients who can tolerate the 300 mg dose of allopurinol, the dose can be safely pushed higher,&quot; Matteson said. &quot;We may be far too conservative in treating these patients to prevent gout.&quot;&lt;/p&gt;
&lt;p&gt;He noted, though, that 10% to 20% of people who are prescribed allopurinol cannot tolerate the drug because of adverse side effects.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;No corporate funding for the study was reported.&lt;/p&gt;&lt;p&gt;Stamp reported a relationship with Wyeth.&lt;/p&gt;&lt;p&gt;Matteson disclosed financial relationships with Amgen, Wyeth, UCB, Genentech, and Pfizer.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_19_3475"
                     title="ASN: HCV Changes Dialysis Treatment Needs (CME/CE)"
                     score="-0.006"
                     href="http://www.medpagetoday.com/MeetingCoverage/ASN/tb/16712?impressionId=1265792346454"
                     
      &lt;p&gt;SAN DIEGO  --  Patients on dialysis need less epoetin to treat their anemia if they are infected with hepatitis C (HCV), a researcher reported here.&lt;/p&gt;
&lt;p&gt;HCV-positive patients also needed a lower dose of IV iron than their noninfected counterparts, even though they had similar hemoglobin levels, according to David Goodkin, MD, of the Arbor Research Collaborative for Health in Ann Arbor, Mich.&lt;/p&gt;
&lt;p&gt;This is a &quot;surprising, unusual finding,&quot; Goodkin said at the American Society of Nephrology meeting, because most inflammatory diseases, which interfere with the signal the bone marrow sends to make more red blood cells, would result in the need for a higher dose of epoetin.&lt;/p&gt;
&lt;p&gt;&quot;We speculate that it may be that this viral infection is actually stimulating the liver to make this hormone erythropoietin,&quot; Goodkin said, although he admitted that he doesn&apos;t know why the virus would activate the erythropoietin-producing cells.&lt;/p&gt;
&lt;p&gt;He said the finding would probably not affect clinical practice because patients on dialysis have their epoetin doses adjusted regularly anyway.&lt;/p&gt;
&lt;p&gt;&quot;The doctors are still going to follow the hemoglobin level and adjust the EPO dose,&quot; Goodkin said. &quot;This is just a clue that if it&apos;s hepatitis C-positive, they&apos;ll need less EPO, on average, than people who are hepatitis C-negative.&quot;&lt;/p&gt;
&lt;p&gt;Goodkin said he decided to investigate after he saw the results of a small case-control study from 2008, involving 66 patients, showing that those on dialysis who were infected with HCV needed significantly lower doses of erythropoietin (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.01). There was also a trend toward lower IV iron requirements (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.07).&lt;/p&gt;
&lt;p&gt;To explore the issue on a larger scale, he turned to the prospective Dialysis Outcomes and Practice Patterns Study (DOPPS).&lt;/p&gt;
&lt;p&gt;The current analysis included 36,245 patients in 12 countries who were on hemodialysis, 7.8% of whom were positive for HCV.&lt;/p&gt;
&lt;p&gt;After adjusting for age, sex, race, years of hemodialysis, country, and 14 comorbidities, he and his colleagues found that the weekly epoetin dose was significantly lower in the HCV-positive patients (7,737 versus 8,210 Units, &lt;em&gt;P&lt;/em&gt;=0.02).&lt;/p&gt;
&lt;p&gt;IV iron dose was also significantly lower in the infected patients (89.2 versus 96.4 mg/month, &lt;em&gt;P&lt;/em&gt;=0.02).&lt;/p&gt;
&lt;p&gt;Hemoglobin concentration was not significantly different in the two groups (&lt;em&gt;P&lt;/em&gt;=0.46).&lt;/p&gt;
&lt;p&gt;The odds ratios for not receiving epoetin or IV iron therapy among HCV-positive patients were 1.15 (&lt;em&gt;P&lt;/em&gt;=0.002) and 1.19 (&lt;em&gt;P&lt;/em&gt;=0.0002), respectively.&lt;/p&gt;
&lt;p&gt;Hepatitis B infection, on the other hand, offered no advantage.&lt;/p&gt;
&lt;p&gt;In addition to the unexpected effect of HCV infection on the epoetin dose, another surprising finding was that only seven infected patients in the study received antiviral treatment, including interferon.&lt;/p&gt;
&lt;p&gt;Goodkin speculated that clinicians might have been sparing the patients the adverse effects of antiviral therapy because most HCV-positive patients do not develop cirrhosis and liver failure, and patients on dialysis, many of whom are older, have a limited lifespan.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;DOPPS is funded by Amgen, Kyowa Hakko Kirin, and Genzyme.&lt;/p&gt;&lt;p&gt;Goodkin reported relationships with Affymax, AMAG Pharmaceuticals, Amgen, FibroGen, Keryx, Seattle Life Sciences, Xenon Pharmaceuticals, and Urodynamix Technologies.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
</recommendedContent>