Aspirin-Containing Antiplatelet Therapy and In-Hospital Gout Flares in Acute Ischemic Stroke Patients with Gout and Hyperuricemia: A Retrospective New-User Cohort Study

Background: Antiplatelet selection is challenging in patients with acute ischemic stroke (AIS), gout, and hyperuricemia. We compared the risk of in-hospital gout flares between aspirin-containing regimens and clopidogrel monotherapy, and examined subsequent aspirin discontinuation during dual antiplatelet therapy (DAPT). Methods: A retrospective new-user cohort study was conducted based on electronic medical records (2019-2025). Patients were categorized into aspirin-containing therapy (aspirin monotherapy or DAPT with aspirin plus clopidogrel) and clopidogrel monotherapy groups. The primary analysis used IPTW-adjusted logistic regression. Interaction tests assessed effect modification and a Sankey diagram visualized DAPT treatment transition. Results: Among 105,890 screened patients, 457 were enrolled (234 aspirin-containing therapy, 223 clopidogrel monotherapy). In-hospital gout flares occurred in 187 (40.9%). Aspirin-containing regimens were associated with a higher flare risk (OR = 1.57, 95% CI 1.07-2.31, P = 0.022). Results were consistent in sensitivity analyses. Higher SUA (OR 1.20 per 1-mg/dL increase, 95% CI 1.03-1.40; P = 0.023) and baseline mRS ≥3 (OR 2.13, 95% CI 1.42-3.20; P < 0.001) were independently associated with in-hospital gout flares. No significant interactions were observed between antiplatelet regimens and SUA, mRS or urate-lowering therapy (ULT). Among DAPT recipients, aspirin discontinuation in patients with gout flares was 65.2%, 66.7%, and 56.0% in 2019-2021, 2022-2023, and 2024-2025, respectively, versus 47.8%, 28.6%, and 11.9% in those without flares. Conclusions: In AIS patients with gout and hyperuricemia, initiating aspirin-containing regimens was associated with a higher risk of in-hospital gout flares compared with clopidogrel monotherapy. Gout flares during DAPT were accompanied by frequent aspirin discontinuation, which may limit completion of guideline-recommended DAPT. Prospective studies are needed.