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Hao Y, Oon S, Nikpour M. Efficacy and safety of treat-to-target strategy studies in rheumatic diseases: A systematic review and meta-analysis. Semin Arthritis Rheum 2024; 67:152465. [PMID: 38796922 DOI: 10.1016/j.semarthrit.2024.152465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 05/06/2024] [Accepted: 05/08/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND The concept of treat-to-target (T2T), a treatment strategy in which treatment is directed to reach and maintain a defined goal such as remission or low disease activity (LDA), has been explored for several diseases including rheumatic diseases such as rheumatoid arthritis (RA). However, a comprehensive review of T2T in all rheumatic diseases has not recently been undertaken. OBJECTIVE To perform a systematic review and meta-analysis of the efficacy and safety of a T2T strategy in the management of adult patients with inflammatory rheumatic diseases. METHODS PUBMED, EMBASE and CINAHL were searched from January 1990 to December 2023 using key words related to a T2T strategy and rheumatic diseases; T2T strategy clinical trials or observational studies were included. Clinical, physical function and radiologic outcomes, cost-effectiveness, and adverse events (AEs) of the T2T strategies were investigated and a random-effect meta-analysis was conducted for the most commonly used outcomes in RA studies. RESULTS The search identified 7896 studies, of which 66 fit inclusion criteria, including 50 in RA, 3 in psoriatic arthritis (PsA), 1 in spondyloarthritis (SpA) and 12 in gout. For the studies comparing a T2T strategy with usual care (UC) in RA, 83.3% (20/24) showed a T2T strategy could achieve significantly better clinical outcomes, and the meta-analysis showed that patients treated with a T2T strategy were more likely to be in remission (pooled RR: 1.68 (1.47-1.92), p<0.001] and achieve DAS-28 response (pooled standardised mean difference (SMD): 0.47 (0.26-0.69), P<0.001] at 1 year than patients treated with UC. Sensitivity analyses showed that a T2T strategy with a predefined treatment protocol had better clinical efficacy than that without protocol. In terms of improving physical function and health-related quality of life (HRQoL), 11/19 (57.9%) studies found a T2T strategy was significantly more likely to achieve these than UC, with the meta-analysis for the mean change of HAQ score supporting this conclusion (pooled SMD: 1.48 (0.46-2.51), p=0.004). Five out of 9 studies (55.6%) demonstrated greater benefit regarding radiographic progression from a T2T strategy. In terms of cost-effectiveness and AEs, 2/2 studies found a T2T strategy was more cost-effective than UC and 8/8 studies showed no tendency for AEs to occur more often with a T2T strategy. For the studies in PsA and SpA, a T2T strategy was also demonstrated to be more effective than UC in clinical and functional benefits, but not in radiologic outcomes. All gout studies showed that sUA level could be controlled more effectively with a T2T strategy, and 2 studies revealed that the T2T strategy could inhibit erosion development or crystal deposition. CONCLUSIONS For patients with active RA, a T2T strategy has been shown in mulitple studies to increase the likelihood of achieving clinical response and improving HRQoL without increasing economic costs and AEs. Limited studies have shown clinical and functional benefits from T2T strategies in active PsA and SpA. A T2T strategy has also been found to improve clinical and radiologic outcomes in gout. T2T trials in other rheumatic diseases are lacking.
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Affiliation(s)
- Yanjie Hao
- The University of Melbourne at St Vincent's Hospital, 29 Regent Street, Fitzroy, VIC 3065, Australia
| | - Shereen Oon
- The University of Melbourne at St Vincent's Hospital, 29 Regent Street, Fitzroy, VIC 3065, Australia; Department of Rheumatology, St. Vincent's Hospital Melbourne, 35 Victoria Parade, Fitzroy, VIC 3065, Australia.
| | - Mandana Nikpour
- The University of Melbourne at St Vincent's Hospital, 29 Regent Street, Fitzroy, VIC 3065, Australia; Department of Rheumatology, St. Vincent's Hospital Melbourne, 35 Victoria Parade, Fitzroy, VIC 3065, Australia; Sydney MSK Research Flagship Centre, The University of Sydney School of Public Health, Room 132, Edward Ford Building, Fisher Road, University of Sydney, NSW 2006, Australia; Royal Prince Alfred Hospital Institute of Rheumatology and Orthopedics, 59 Missenden Rd, Camperdown NSW 2050, Australia.
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Rasmussen C, Larsen JW, Christensen HM, Larsen MB, Thomsen AM, Leishmann T, Kragh J, Nielsen GL. Optimising gout treatment: insights from a nurse-led cohort study. RMD Open 2024; 10:e004179. [PMID: 38663881 PMCID: PMC11043733 DOI: 10.1136/rmdopen-2024-004179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 04/08/2024] [Indexed: 04/28/2024] Open
Abstract
OBJECTIVES Currently, gout management, particularly urate-lowering therapy (ULT), is often suboptimal. Nurses successfully manage various diseases including gout. As gout prevalence is rising, and rheumatologists and general practitioners face shortages, a new approach is imperative. This real-life prospective cohort study evaluated the effectiveness of nurse-led care employing a treat-to-target strategy for gout management over a 2-year period. METHODS All consecutively confirmed gout patients were included. The nurse-led clinic provided a structured treatment plan with consultations, patient leaflets, telephone contacts and laboratory monitoring. After a year of nurse-led care, patients transitioned to continued care in general practice. Follow-up data were complete through registries. The primary outcome was achieving target p-urate levels (<0.36 mmol/L) at 2 years after diagnosis. Secondary outcomes included treatment continuation and achievement of target p-urate levels in specific subgroups. The results were compared with patients diagnosed in the same clinic but followed up in 'usual care'. RESULTS In the nurse-led group (n=114), 83% achieved target p-urate levels and ULT was continued by 98%. This trend persisted across various patient subgroups. Only 44% of patients in usual care achieved target p-urate and with insufficient doses of allopurinol . Nurse-led care involved an average of two visits and three telephone contacts over 336 days. The 2-year mortality rate was 15%. CONCLUSIONS Nurse-led gout care, employing a targeted approach, was associated with a very high uptake of and adherence to ULT. The encouraging results were not achieved in usual care although a direct comparison might be influenced by selection bias.
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Affiliation(s)
- Claus Rasmussen
- Department of Rheumatology, North Denmark Regional Hospital, Hjorring, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | | | - Monica Bak Larsen
- Department of Rheumatology, North Denmark Regional Hospital, Hjorring, Denmark
| | - Anna Marie Thomsen
- Department of Rheumatology, North Denmark Regional Hospital, Hjorring, Denmark
| | - Tinna Leishmann
- Department of Rheumatology, North Denmark Regional Hospital, Hjorring, Denmark
| | - Jette Kragh
- Department of Rheumatology, North Denmark Regional Hospital, Hjorring, Denmark
| | - Gunnar Lauge Nielsen
- Clinical Medicine, Aalborg Universitet, Aalborg, Denmark
- Department of Internal Medicine, Farsø Outpatient Clinic, Aalborg University Hospital, Aalborg Universitetshospital, Aalborg, Denmark
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Hu S, He S, Zhang J, Ma W, Geng H, Zhan Z, Yao X, Zhong L, Wei J, Qiu X, Jia E. Association between patient adherence and treat-to-target in gout: A cross-sectional study. Medicine (Baltimore) 2024; 103:e37228. [PMID: 38394537 DOI: 10.1097/md.0000000000037228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2024] Open
Abstract
The implementation of a treat-to-target (T2T) approach has been widely recommended for achieving optimal outcomes in gout treatment, as substantiated by a wealth of compelling evidence. However, a paucity of knowledge exists regarding the barriers hindering effective T2T management in China. This study seeks to investigate the factors contributing to treatment failure within the context of the T2T strategy. A cross-sectional, multi-center investigation was conducted, involving the completion of electronic questionnaires by outpatients undergoing urate-lowering treatment for a duration exceeding 6 months. These questionnaires encompassed demographic information, disease-related conditions, comorbid conditions, and management. The study analyzed factors associated with serum uric acid levels exceeding 360 µmol/L, poor disease control, and poor medication adherence. A total of 425 valid questionnaires were collected, representing 90.8% of the patients. The T2T implementation rate was 26.82% (n = 114). Factors linked to serum uric acid levels surpassing 360 µmol/L included moderate medication adherence (odds ratio (OR) = 2.35; 95% confidence interval (CI) 1.17-4.77; P = .016), poor medication adherence (OR = 4.63; 95% CI 2.28-9.51; P < .001), and management by general practitioners (OR = 0.60; 95% CI 0.37-0.97; P = .036). The rate of well-controlled patients was 14.35% (n = 61). Predictors of not well controlled encompassed the presence of tophi (OR = 2.48; 95% CI 1.17-5.61; P = .023), general medication adherence (OR = 2.78; 95% CI 1.28-6.05; P = .009), poor medication adherence (OR = 6.23; 95% CI 2.68-14.77; P < .001), and poor patient's perception of gout (OR = 4.07; 95% CI 1.41-13.91; P = .015). A poor medication adherence rate of 55.29% (n = 235) was observed, with lower rates of poor medication adherence associated with the use of febuxostat (OR = 0.35; 95% CI 0.14-0.83; P = .02), uric acid levels exceeding 360 µmol/L (OR = 3.05; 95% CI 1.84-5.12; P = .00), moderate patient education (OR = 2.28; 95% CI 1.29-4.15; P = .01), moderate diet control (OR = 1.98; 95% CI 1.17-3.41; P = .01), and poor diet control (OR = 3.73; 95% CI 1.26-12.83; P = .02). The rate of T2T implementation in China is notably low among patients undergoing urate-lowering treatment of gout beyond 6 months. Importantly, medication adherence demonstrates a significant association with T2T outcomes.
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Affiliation(s)
- Shasha Hu
- The Department of Rheumatology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
- Shenzhen Traditional Chinese Medicine Hospital Affiliated to Nanjing University of Chinese Medicine, Shenzhen, China
| | - Sihui He
- Shenzhen Traditional Chinese Medicine Hospital Affiliated to Nanjing University of Chinese Medicine, Shenzhen, China
| | - Jianyong Zhang
- The Department of Rheumatology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
- The Department of Rheumatology, the Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Wukai Ma
- The Department of Rheumatology, the Second Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, China
| | - Hongling Geng
- The Department of Gynecology, Guangdong Provincial Hospital of Chinese Medicine, the Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guiyang, China
| | - Zhiying Zhan
- Department of Epidemiology and Health Statistics, Fujian Provincial Key Laboratory of Environment Factors and Caner, School of Public Health, Fujian Medical University, Fuzhou, China
| | - Xueming Yao
- The Department of Rheumatology, the Second Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, China
| | - Li Zhong
- The Department of Rheumatology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
- The Department of Rheumatology, the Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Jiaxin Wei
- The Department of Rheumatology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
- The Department of Rheumatology, the Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Xia Qiu
- The Department of Rheumatology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
- The Department of Rheumatology, the Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Ertao Jia
- The Department of Rheumatology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
- The Department of Rheumatology, the Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, China
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Leonardo N, Lester S, Whittle S, Rischmueller M. Review of gout clinic in a tertiary hospital setting. Intern Med J 2020; 50:117-120. [PMID: 31943621 DOI: 10.1111/imj.14689] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 07/27/2019] [Accepted: 08/05/2019] [Indexed: 02/04/2023]
Abstract
Although updated consensus guidelines, and effective therapies, are available for management of gout, suboptimal management remains an issue. Barriers were identified and addressed as part of a dedicated, structured gout clinic. More frequent appointments resulted in a faster rate of serum urate reduction, and the clinic provided the opportunity for the education of both patients and general practitioners in the management of gout.
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Affiliation(s)
- Nieves Leonardo
- Rheumatology Department, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Susan Lester
- Rheumatology Department, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia.,Discipline of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Samuel Whittle
- Rheumatology Department, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia.,Discipline of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Maureen Rischmueller
- Rheumatology Department, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia.,Discipline of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, South Australia, Australia
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Hüzmeli C, Timucin M, Güllü M, Hüzmeli C, Öztürk K, Yetimoğlu E, Candan F. Gut Artritli Hastalarda Hiperürisemi ve Kronik Böbrek Hastalığının Prevalansı. ACTA MEDICA ALANYA 2019. [DOI: 10.30565/medalanya.505058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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