• Eric Jutkowitz, Hyon K Choi, Laura T Pizzi, and Karen M Kuntz.
• Ann. Intern. Med. 2014 Nov 4; 161 (9): 617-26.

BackgroundGout is the most common inflammatory arthritis in the United States.ObjectiveTo evaluate the cost-effectiveness of urate-lowering treatment strategies for the management of gout.DesignMarkov model.Data SourcesPublished literature and expert opinion.Target PopulationPatients for whom allopurinol or febuxostat is a suitable initial urate-lowering treatment.Time HorizonLifetime.PerspectiveHealth care payer.Intervention5 urate-lowering treatment strategies were evaluated: no treatment; allopurinol- or febuxostat-only therapy; allopurinol-febuxostat sequential therapy; and febuxostat-allopurinol sequential therapy. Two dosing scenarios were investigated: fixed dose (80 mg of febuxostat daily, 0.80 success rate; 300 mg of allopurinol daily, 0.39 success rate) and dose escalation (≤120 mg of febuxostat daily, 0.82 success rate; ≤800 mg of allopurinol daily, 0.78 success rate).Outcome MeasuresDiscounted costs, discounted quality-adjusted life-years, and incremental cost-effectiveness ratios.Results Of Base Case AnalysisIn both dosing scenarios, allopurinol-only therapy was cost-saving. Dose-escalation allopurinol-febuxostat sequential therapy was more costly but more effective than dose-escalation allopurinol therapy, with an incremental cost-effectiveness ratio of $39 400 per quality-adjusted life-year.Results Of Sensitivity AnalysisThe relative rankings of treatments did not change. Our results were relatively sensitive to several potential variations of model assumptions; however, the cost-effectiveness ratios of dose escalation with allopurinol-febuxostat sequential therapy remained lower than the willingness-to-pay threshold of $109 000 per quality-adjusted life-year.LimitationLong-term outcome data for patients with gout, including medication adherence, are limited.ConclusionAllopurinol single therapy is cost-saving compared with no treatment. Dose-escalation allopurinol-febuxostat sequential therapy is cost-effective compared with accepted willingness-to-pay thresholds.Primary Funding SourceAgency for Healthcare Research and Quality.

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