JAMA Internal Medicine最新文献

{"title":"Too Much Dental Radiography-Reply.","authors":"Yehuda Zadik","doi":"10.1001/jamainternmed.2024.5048","DOIUrl":"10.1001/jamainternmed.2024.5048","url":null,"abstract":"","PeriodicalId":14714,"journal":{"name":"JAMA Internal Medicine","volume":" ","pages":"1481-1482"},"PeriodicalIF":22.5,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142465863","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Arm Position and Blood Pressure Readings: The ARMS Crossover Randomized Clinical Trial.","authors":"Hairong Liu, Di Zhao, Ahmed Sabit, Chathurangi H Pathiravasan, Junichi Ishigami, Jeanne Charleston, Edgar R Miller, Kunihiro Matsushita, Lawrence J Appel, Tammy M Brady","doi":"10.1001/jamainternmed.2024.5213","DOIUrl":"10.1001/jamainternmed.2024.5213","url":null,"abstract":"<p><strong>Importance: </strong>Guidelines for blood pressure (BP) measurement recommend arm support on a desk with the midcuff positioned at heart level. Still, nonstandard positions are used in clinical practice (eg, with arm resting on the lap or unsupported on the side).</p><p><strong>Objective: </strong>To determine the effect of different arm positions on BP readings.</p><p><strong>Design, setting, and participants: </strong>This crossover randomized clinical trial recruited adults between the ages of 18 and 80 years in Baltimore, Maryland, from August 9, 2022, to June 1, 2023.</p><p><strong>Intervention: </strong>Participants were randomly assigned to sets of triplicate BP measurements with the arm positioned in 3 ways: (1) supported on a desk (desk 1; reference), (2) hand supported on lap (lap), and (3) arm unsupported at the side (side). To account for intrinsic BP variability, all participants underwent a fourth set of BP measurements with the arm supported on a desk (desk 2).</p><p><strong>Main outcomes and measures: </strong>The primary outcomes were the difference in differences in mean systolic BP (SBP) and diastolic BP (DBP) between the reference BP (desk 1) and the 2 arm support positions (lap and side): (lap or side - desk 1) - (desk 2 - desk 1). Results were also stratified by hypertensive status, age, obesity status, and access to health care within the past year.</p><p><strong>Results: </strong>The trial enrolled 133 participants (mean [SD] age, 57 [17] years; 70 [53%] female); 48 participants (36%) had SBP of 130 mm Hg or higher, and 55 participants (41%) had a body mass index (calculated as weight in kilograms divided by height in meters squared) of 30 or higher. Lap and side positions resulted in statistically significant higher BP readings than desk positions, with the difference in differences as follows: lap, SBP Δ 3.9 (95% CI, 2.5-5.2) mm Hg and DBP Δ 4.0 (95% CI, 3.1-5.0) mm Hg; and side, SBP Δ 6.5 (95% CI, 5.1-7.9) mm Hg and DBP Δ 4.4 (95% CI, 3.4-5.4) mm Hg. The patterns were generally consistent across subgroups.</p><p><strong>Conclusion and relevance: </strong>This crossover randomized clinical trial showed that commonly used arm positions (lap or side) resulted in substantial overestimation of BP readings and may lead to misdiagnosis and overestimation of hypertension.</p><p><strong>Trial registration: </strong>ClinicalTrials.gov Identifier: NCT05372328.</p>","PeriodicalId":14714,"journal":{"name":"JAMA Internal Medicine","volume":" ","pages":"1436-1442"},"PeriodicalIF":22.5,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11459360/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142380892","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Masked Taper With Behavioral Intervention for Discontinuation of Benzodiazepine Receptor Agonists: A Randomized Clinical Trial.","authors":"Constance H Fung, Cathy Alessi, Jennifer L Martin, Karen Josephson, Lara Kierlin, Joseph M Dzierzewski, Alison A Moore, M Safwan Badr, Michelle Zeidler, Monica Kelly, Jason P Smith, Ian A Cook, Erin Der-Mcleod, Sara Ghadimi, Saadia Naeem, Lisa Partch, Andrew Guzman, Austin Grinberg, Michael Mitchell","doi":"10.1001/jamainternmed.2024.5020","DOIUrl":"10.1001/jamainternmed.2024.5020","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Importance: &lt;/strong&gt;Placebo effects are commonly observed in benzodiazepine receptor agonist hypnotic clinical trials. Clinical guidelines recommend discontinuing benzodiazepine receptor agonist hypnotics (particularly in older adults) and administering cognitive behavioral therapy for insomnia (CBTI) as first-line therapy for insomnia. It is unknown whether a novel intervention that masks the daily dose of benzodiazepine receptor agonist during tapering and augments CBTI with novel cognitive and behavioral exercises targeting placebo effect mechanisms improves benzodiazepine receptor agonist discontinuation.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Objective: &lt;/strong&gt;To compare a masked benzodiazepine receptor agonist taper plus augmented CBTI vs an unmasked taper plus standard CBTI.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Design, setting, and participants: &lt;/strong&gt;This randomized clinical trial conducted at an academic medical center and a Department of Veterans Affairs medical center included adults aged 55 years or older who had used lorazepam, alprazolam, clonazepam, temazepam, and/or zolpidem for current or prior insomnia, at doses of less than 8-mg diazepam-equivalent 2 or more nights per week for at least 3 months. Data were collected between December 2018 and November 2023. Data analyses were conducted between November 2023 and July 2024.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Interventions: &lt;/strong&gt;Masked taper plus cognitive behavioral therapy-augmented program (MTcap); standard CBTI plus supervised (unmasked) gradual taper (SGT).&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Main outcomes and measures: &lt;/strong&gt;The primary efficacy outcome was percentage achieving benzodiazepine receptor agonist discontinuation 6 months after treatment ended (6-month; intention-to-treat) measured with 7-day self-reported medication logs and for a subset, urine tests. Secondary outcomes were Insomnia Severity Index scores at 1 week posttreatment and 6 months posttreatment, percentage of participants that have discontinued benzodiazepine receptor agonist use at 1 week posttreatment, and benzodiazepine receptor agonist dose and the Dysfunctional Beliefs About Sleep-Medication subscale at 1 week and 6 months posttreatment.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;Of 338 participants who underwent in-depth screening, 188 participants (mean [SD] age, 69.8 [8.3] years, 123 male [65.4%] and 65 female [35.6%]) were randomly assigned to MTcap (n = 92) or SGT (n = 96). Compared with SGT, MTcap resulted in greater benzodiazepine receptor agonist discontinuation at 6 months (MTcap = 64 [73.4%], SGT = 52 [58.6%]; odds ratio [OR], 1.95; 95% CI 1.03-3.70; P = .04) and 1 week posttreatment (MTcap = 76 [88.4%], SGT =  62 [67.4%]; OR, 3.68; 95% CI, 1.67-8.12; P = .001) and reduced frequency of benzodiazepine receptor agonist use (nights/week) at 1 week posttreatment (-1.31; 95% CI, -2.05 to -0.57; P &lt; .001). Insomnia Severity Index improved with no significant between-group difference at follow-up (baseline to 1 week posttreatment, 1.38; P = .16; baseline to 6 months, 0.1","PeriodicalId":14714,"journal":{"name":"JAMA Internal Medicine","volume":" ","pages":"1448-1456"},"PeriodicalIF":22.5,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11459364/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142380896","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Supplemental Oxygen Use, Outcomes, and Spending in Patients With COPD in the Medicare Competitive Bidding Program.","authors":"Kevin I Duan, Emmi Obara, Edwin S Wong, Joshua M Liao, Amber K Sabbatini, Lucas M Donovan, Laura J Spece, Laura C Feemster, David H Au","doi":"10.1001/jamainternmed.2024.5738","DOIUrl":"10.1001/jamainternmed.2024.5738","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Importance: &lt;/strong&gt;The Medicare Competitive Bidding Program (CBP), a policy that reduced durable medical equipment prices, was implemented starting in 2011. Legislation introduced in 2024 aims to remove supplemental oxygen from the CBP because of concerns that recent decreases in oxygen prescribing are due to lower prices set by the CBP, which may have decreased supply and, in turn, limited oxygen access for patients with chronic lung diseases. However, low-value prescribing of oxygen is also prevalent in practice, and decreased oxygen prescription rates may not have necessarily caused harm. Little is known about the association of the CBP with patient use, outcomes, or spending.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Objective: &lt;/strong&gt;To examine the association between the 2011 and 2013 implementation of the CBP and supplemental oxygen use, clinical outcomes, and supplemental oxygen spending among patients with chronic obstructive pulmonary disease (COPD).&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Design, setting, and participants: &lt;/strong&gt;This cohort study used a difference-in-differences (DID) method to evaluate the association between implementation of the CBP and the outcomes of interest. Patients aged 65 to 100 years with COPD living in CBP areas were compared with those living in areas where the CBP was not yet or never implemented. The study included 100% fee-for-service Medicare data of beneficiaries enrolled between July 1, 2009, and December 31, 2015. The data analysis was performed between June 6, 2023, and August 16, 2024.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Exposure: &lt;/strong&gt;The 2011 and 2013 implementation cycles of the Medicare CBP.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Main outcomes and measures: &lt;/strong&gt;The primary outcomes were new prescriptions of oxygen during a 6-month period among beneficiaries with COPD and discontinuation of oxygen during a 6-month period among beneficiaries with COPD previously prescribed oxygen. Secondary outcomes included switches between oxygen types (gas, liquid, or concentrator), all-cause mortality, all-cause unplanned hospitalizations, COPD hospitalizations, and mean monthly allowed charges (total spending) over a 6-month period. The analysis was performed using the Callaway-Sant'Anna method, a dynamic DID model for policies with staggered implementation.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;Among 5 753 308 Medicare beneficiaries with COPD (mean [SD] age, 79.2 [8.4] years; 55.1% female), 25.9% received supplemental oxygen for at least one 6-month period during the study. The CBP was not associated with differential changes in new oxygen prescribing (DID estimate, -0.19 percentage points; 95% CI, -2.45 to 2.08 percentage points) or oxygen discontinuations (DID estimate, -0.77 percentage points; 95% CI, -8.15 to 6.60 percentage points). Similarly, differential changes were not observed in the secondary outcomes of oxygen switches (DID estimate, -0.04 percentage points; 95% CI, -0.44 to 0.37 percentage points), all-cause mortality (DID estimate, 0.16 percentage points; 95% CI, -7.52 t","PeriodicalId":14714,"journal":{"name":"JAMA Internal Medicine","volume":" ","pages":"1457-1465"},"PeriodicalIF":22.5,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11581493/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142500733","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Lifestyle Intervention Requirements for Novel Antiobesity Medications-Necessary Adjunct or Harmful Gatekeeper?","authors":"Ilya Golovaty, Scott Hagan","doi":"10.1001/jamainternmed.2024.6450","DOIUrl":"https://doi.org/10.1001/jamainternmed.2024.6450","url":null,"abstract":"","PeriodicalId":14714,"journal":{"name":"JAMA Internal Medicine","volume":" ","pages":""},"PeriodicalIF":22.5,"publicationDate":"2024-11-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142710215","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"As-Needed Blood Pressure Medication and Adverse Outcomes in VA Hospitals.","authors":"Muna Thalji Canales, Seonkyeong Yang, Anders Westanmo, Xinping Wang, Dexter Hadley, Areef Ishani, Rajesh Mohandas, Ronald Shorr, Weihsuan Lo-Ciganic","doi":"10.1001/jamainternmed.2024.6213","DOIUrl":"10.1001/jamainternmed.2024.6213","url":null,"abstract":"<p><strong>Importance: </strong>Asymptomatic blood pressure (BP) elevations in the hospital are commonly treated with as-needed BP medications, including recurring as-needed and 1-time administration. Veterans represent a population at risk of ischemic events from rapid lowering of BP, but the impact of as-needed BP medication use in this population is unknown.</p><p><strong>Objective: </strong>To assess the risks of acute kidney injury (AKI) and other outcomes from as-needed BP medication administration in a hospitalized veteran cohort.</p><p><strong>Design, setting, and participants: </strong>This retrospective cohort study using target trial emulation and propensity score matching included adult veterans, who were hospitalized 3 or more days in Veterans Administration hospitals between October 1, 2015, and September 30, 2020. Participants must have been hospitalized on a non-intensive care unit medical or surgical floor, must not have undergone surgery, and must have received at least 1 scheduled BP medication in the first 24 hours of admission. Participants also must have had at least 1 systolic BP more than 140 mm Hg during hospitalization. Data in this study were analyzed from April 2023 to August 2024.</p><p><strong>Main outcomes and measures: </strong>The primary outcome was time to first AKI occurrence during hospitalization. Secondary outcomes included greater than 25% reduction in systolic BP within 3 hours of as-needed BP medication administration and the composite outcome of myocardial infarction, stroke, or death during hospitalization.</p><p><strong>Results: </strong>Of the 133 760 veterans eligible for analysis (mean [SD] age, 71.2 [11.6] years), 96% were male. The mean (SD) baseline estimated glomerular filtration rate was 75.7 (22.7) mL/min/1.73m2. A total of 28 526 patients (21%) received as-needed BP medication. As-needed BP medication use was associated with an increased AKI risk (adjusted hazard ratio, 1.23 [95% CI, 1.18-1.29]) compared to nonusers. Subgroup analyses showed higher AKI risk with intravenous as-needed BP medication use (compared to oral or combined oral and intravenous routes). Secondary analyses indicated as-needed BP medication users had a 1.5-fold greater risk of rapid BP reduction (95% CI, 1.39-1.62) and 1.69-fold higher rate of the composite outcome (95% CI, 1.49-1.92) compared to nonusers.</p><p><strong>Conclusions and relevance: </strong>The results of this retrospective cohort study showed that as-needed BP medication use among veterans is associated with increased AKI risk. The risks and benefits of this type of BP medication use would best be determined through a prospective trial, and these data suggest that there is the necessary equipoise to conduct such a trial.</p>","PeriodicalId":14714,"journal":{"name":"JAMA Internal Medicine","volume":" ","pages":""},"PeriodicalIF":22.5,"publicationDate":"2024-11-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11589853/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142710185","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Attributing Racial Differences in Care to Health Plan Performance or Selection.","authors":"Jacob Wallace, Chima D Ndumele, Anthony Lollo, Danil Agafiev Macambira, Matthew Lavallee, Beniamino Green, Kate A Duchowny, J Michael McWilliams","doi":"10.1001/jamainternmed.2024.5451","DOIUrl":"10.1001/jamainternmed.2024.5451","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Importance: &lt;/strong&gt;There is increased interest in public reporting of, and linking financial incentives to, the performance of organizations on health equity metrics, but variation across organizations could reflect differences in performance or selection bias.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Objective: &lt;/strong&gt;To assess whether differences across health plans in sex- and age-adjusted racial disparities are associated with performance or selection bias.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Design, setting, and participants: &lt;/strong&gt;This cross-sectional study leveraged a natural experiment, wherein a southern US state randomly assigned much of its Medicaid population to 1 of 5 plans after shifting to managed care in 2012. Enrollee-level administrative claims and enrollment data from 2011 to 2015 were obtained for self-identified Black and White enrollees. The analyses were limited to Black and White Medicaid enrollees because they accounted for the largest percentages of the population and could be compared with greater statistical power than other groups. Data were analyzed from June 2021 to September 2024.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Exposures: &lt;/strong&gt;Plan enrollment via self-selection (observational population) vs random assignment (randomized population).&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Main outcomes and measures: &lt;/strong&gt;Annual counts of primary care visits, low-acuity emergency department visits, prescription drug fills, and total spending. For observational and randomized populations, models of each outcome were fit as a function of plan indicators, indicators for race, interactions between plan indicators and race, and age and sex. Models estimated the magnitude of racial differences within each plan and tested whether this magnitude varied across plans.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;Of 118 101 enrollees (mean [SD] age, 9.3 [7.5] years; 53.0% female; 61.4% non-Hispanic Black; and 38.6% non-Hispanic White), 70.2% were included in the randomized population, and 29.8% were included in the observational population. Within-plan differences in primary care visits, low-acuity emergency department visits, prescription drug use, and total spending between Black and White enrollees were large but did not vary substantially and were not statistically significantly different across plans in the randomized population, suggesting minimal effects of plans on racial differences in these measures. In contrast, in the observational population, racial differences varied substantially across plans (standard deviations 2-3 times greater than in the randomized population); this variation was statistically significant after adjustment for multiple testing, except for emergency department visits. Greater between-plan variation in racial differences in the observational population was only partially explained by sampling error. Stratifying by race did not bring observational estimates of plan effects meaningfully closer to randomized estimates.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions and relevance: &lt;/strong&gt;This cross-sectional s","PeriodicalId":14714,"journal":{"name":"JAMA Internal Medicine","volume":" ","pages":""},"PeriodicalIF":22.5,"publicationDate":"2024-11-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11589859/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142710189","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Semaglutide vs Tirzepatide Dosages for Weight Loss.","authors":"Matthew E Levy, Kelly M Schiabor Barrett, Elizabeth T Cirulli","doi":"10.1001/jamainternmed.2024.5768","DOIUrl":"https://doi.org/10.1001/jamainternmed.2024.5768","url":null,"abstract":"","PeriodicalId":14714,"journal":{"name":"JAMA Internal Medicine","volume":" ","pages":""},"PeriodicalIF":22.5,"publicationDate":"2024-11-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142710295","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Lifestyle Modification for Obesity Management-A Cornerstone and Not a Roadblock.","authors":"Ilana Richman, Eve Rittenberg","doi":"10.1001/jamainternmed.2024.6453","DOIUrl":"https://doi.org/10.1001/jamainternmed.2024.6453","url":null,"abstract":"","PeriodicalId":14714,"journal":{"name":"JAMA Internal Medicine","volume":" ","pages":""},"PeriodicalIF":22.5,"publicationDate":"2024-11-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142710218","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Target Serum Urate Achievement and Chronic Kidney Disease Progression in Patients With Gout and Kidney Disease.","authors":"Yilun Wang, Nicola Dalbeth, Robert Terkeltaub, Yuqing Zhang, Xiaoxiao Li, Chao Zeng, Guanghua Lei, Jie Wei","doi":"10.1001/jamainternmed.2024.6212","DOIUrl":"10.1001/jamainternmed.2024.6212","url":null,"abstract":"<p><strong>Importance: </strong>Clinicians often approach urate-lowering therapy (ULT) cautiously in patients with gout and impaired kidney function because they are concerned about the risk of progression to severe or end-stage kidney disease. However, evidence from randomized clinical trials of this association remains inconclusive.</p><p><strong>Objective: </strong>To evaluate the association between achieving target serum urate level with ULT and progression of chronic kidney disease (CKD) to severe or end-stage in patients with gout and impaired kidney function.</p><p><strong>Design, setting, and participants: </strong>This was a cohort study using the target trial emulation approach using data from a general practice database (IQVIA Medical Research Database) for 2000 to 2023. Eligible patients were 40 to 89 years old and had gout and CKD stage 3. Data analyses were performed from November 2023 to September 2024.</p><p><strong>Exposures: </strong>Lowering serum urate level to target level (<6 mg/dL) using ULT.</p><p><strong>Main outcomes and measures: </strong>Severe or end-stage kidney disease, determined by an estimated glomerular filtration rate of less than 30 mL/min/1.73 m2 on at least 2 occasions more than 90 days apart within 1 year, or at least 1 Read code (per the Refined Etiology, Anatomical Site, and Diagnosis classification) for CKD stages 4 or 5, hemodialysis, peritoneal dialysis, or kidney transplant. The prespecified noninferiority margin of the hazard ratio (HR) was set at 1.2, comparing those who achieved the target serum urate level with those who did not.</p><p><strong>Results: </strong>Among the 14 792 participants (mean [SD] age, 73.1 [9.5] years; 9215 men [62.3%] and 5577 women [37.7%]) with gout and with CKD stage 3, the 5-year risk of severe or end-stage kidney disease was 10.32% for those who achieved the target serum urate level and 12.73% for those who did not. Compared with those not achieving the target level, the adjusted 5-year risk difference and HR of severe or end-stage kidney disease for patients achieving the target serum urate level was -2.41% (95% CI, -4.61% to -0.21%) and 0.89 (95% CI, 0.80 to 0.98), respectively.</p><p><strong>Conclusions and relevance: </strong>The findings of this cohort study indicate that in patients with gout and CKD stage 3, lowering serum urate level to less than 6 mg/dL vs 6 mg/dL or greater using ULT was not associated with an increased risk of severe or end-stage kidney disease. These findings support optimizing ULT to achieve target serum urate levels when treating patients with gout and impaired kidney function.</p>","PeriodicalId":14714,"journal":{"name":"JAMA Internal Medicine","volume":" ","pages":""},"PeriodicalIF":22.5,"publicationDate":"2024-11-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11589860/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142710320","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}