Optimizing adherence to allopurinol for gout: patients' perspectives

Psychometric evaluation of the Adherence to Refills and Medications Scale (ARMS) in Australians living with gout

This study aimed to examine psychometric properties of the Adherence to Refills and Medications Scale (ARMS) in people with gout. We conducted exploratory factor analysis (EFA) and tested internal consistency (ordinal and Cronbach's alpha coefficients) and agreement (intraclass correlation coefficient (2,1)) in ARMS scores across three timepoints (baseline, 6, and 12 months) in 487 people with gout. The Kruskal-Wallis test, Spearman's rank, Kendall's tau-b correlations, and logistic regression were used to examine the criterion-related validity of the ARMS and factors associated with the ARMS. EFA suggested a one-factor structure, explaining 43.2% of total variance. High internal consistency (ordinal alpha = 0.902 at baseline) and moderate agreement in ARMS scores over time (ICCs > 0.5; p < 0.001) were observed. Lower ARMS scores (indicating better adherence) predicted achieving target serum urate (OR, 0.89; 95% CI, 0.83-0.95; p < 0.001), but not urate-lowering therapy (ULT) adherence (Proportion of Days Covered (PDC) ≥ 80%) (OR, 0.93; 95% CI, 0.81-1.05; p = 0.261). Negative correlations between ARMS and PDC were not statistically significant (Kendall's tau-b, r =  - 0.126, p = 0.078; Spearman's rho =  - 0.173, p < 0.073). Differences in median ARMS scores (IQR) of 16 (14-20), 13 (12-15), and 17.5 (15-21) in three groups of participants who reported (1) not taking ULT, (2) taking ULT and adherent, and (3) taking ULT but not adherent, respectively, were statistically significant (p < 0.001). Age was the only patient factor independently associated with optimal adherence (ARMS score = 12) (OR, 1.91; 95% CI, 1.50-2.43; p < 0.001). The ARMS is a reliable and valid measure of medication adherence behaviours in people with gout, justifying its use in gout medication adherence research.

Leveraging Habits to Improve Adherence to Gout Medications: A Qualitative Study

OBJECTIVE

This study investigates patients' medication-taking routines and the feasibility of harnessing habit formation through context cues and rewards to improve medication adherence.

METHODS

Semistructured qualitative interviews with patients with gout from an urban health care system were conducted to explore typical medication-taking behavior, experiences using electronic pill bottles, barriers to adherence, existing context cues, and potential cues and rewards for habit-forming behavior. Medication-taking patterns were recorded for six weeks using electronic pill bottles before interviews to inform discussion. Transcribed interviews were analyzed to generate themes using codes developed by the study team, with representative quotations selected as illustrations.

RESULTS

We conducted interviews with 15 individuals (mean age 60.6 [SD 20.3] years, three women [20%], and nine White patients [60%]). Pill bottle-recorded adherence to urate-lowering therapy (ULT) was high (mean 0.91 [SD 0.10]), and one patient was experiencing an active gout flare. Five key themes emerged: (1) reasons for nonadherence, (2) internal and external motivations for adherence, (3) structured routines around taking medications, (4) rewards for good medication adherence, and (5) the role of pill cap technology in medication-taking.

CONCLUSION

The importance of a predictable, structured routine in which participants could incorporate their medication-taking behavior emerged as a key factor that promoted consistent adherence. Further, identifying context cues and reminders seemed to promote incorporation of medication-taking into routines. Therefore, habit-based interventions that use context cues to establish routines around medication-taking may be a feasible strategy to improve adherence in patients with chronic conditions such as gout.

Patient-Led Urate Self-Monitoring to Improve Clinical Outcomes in People With Gout: A Feasibility Study

OBJECTIVE

Self-monitored point-of-care urate-measuring devices are an underexplored strategy to improve adherence to urate-lowering therapy and clinical outcomes in gout. This study observed patient-led urate self-monitoring practice and assessed its influence on allopurinol adherence, urate control, and health-related quality of life.

METHODS

People with gout (n = 31) and prescribed allopurinol self-monitored their urate concentrations (HumaSens2.0plus) at baseline and thereafter monthly for 12 months (3 months per quarter). Adherence to allopurinol was measured using medication event monitoring technology (Medication Event Monitoring System cap). Time spent below the target urate concentration (<0.36 mmol/L) was determined. Health-related quality of life was measured using a survey (EuroQoL EQ-5D-5L). Gout flares were recorded. Two-tailed Spearman correlation and the Wilcoxon matched-pairs signed-rank test (P < 0.05) were used for statistical comparisons.

RESULTS

Most participants were male (94%) and had urate concentrations below the target (74%) at baseline. Overall, seven participants demonstrated repeated periods of "missed doses" (two or fewer allopurinol doses missed consecutively) and "drug holidays" (three or more missed doses). Most participants (94%) persisted with allopurinol. Time spent within the target urate concentration increased 1.3-fold (from 79% to 100%; P = 0.346), and the incidence of gout flares decreased 1.6-fold (from 8 to 5; P = 0.25) in the final quarter compared to that in the first quarter of the study. Health-related quality of life was reduced for participants reporting at least one gout flare (median utility values 0.9309 vs 0.9563, P = 0.04).

CONCLUSION

Patient-led urate self-monitoring may support the maintenance of allopurinol adherence and improve urate control, thus reducing the incidence of gout flares. Further research on patient-led urate self-monitoring in a randomized controlled study is warranted.

Perspective of Dutch Patients with Gout on Continuation or Discontinuation of Urate-Lowering Therapy During Remission: A Mixed-Methods Study

OBJECTIVE

Long-term gout management is based on reducing serum urate by using urate-lowering therapy (ULT). A lifelong treat-to-target approach is advocated, although a ULT (taper to) stop attempt can be considered (treat-to-avoid symptoms approach) during remission. Exploring the beliefs of patients with gout on long-term ULT strategies during remission is important for optimizing gout management. We aimed to identify factors that influence the decision for continuation or discontinuation of ULT and to determine their relative importance according to patients with gout in remission.

METHODS

A mixed-methods design was used. First, semistructured interviews (substudy 1) were conducted to identify barriers and facilitators for the (dis)continuation of ULT using inductive thematic analysis. Afterwards, these barriers/facilitators were summarized into neutrally phrased items and used in a maximum difference scaling study (substudy 2) to determine their relative importance using the rescaled probability score.

RESULTS

Substudies 1 and 2 included 18 and 156 patients, respectively. Substudy 1 yielded 22 items within 10 overarching themes. Substudy 2 revealed that the perceived risk of joint damage and gout flares and that ULT use gives some assurance were the most important items. The costs, ease of receiving ULT, and its practical use were the least important items.

CONCLUSION

These results can aid shared decision-making and provide input for what is important to discuss with patients with gout in remission when they consider ULT discontinuation. The emphasis should be on the risk of having gout flares and joint damage, not so much on facilitating how easily medication is received.

The experiences and perspectives of people with gout on urate self-monitoring

INTRODUCTION

Gout management remains suboptimal despite safe and effective urate-lowering therapy. Self-monitoring of urate may improve gout management, however, the acceptability of urate self-monitoring by people with gout is unknown. The aim of this study was to explore the experiences of urate self-monitoring in people with gout.

METHODS

Semistructured interviews were conducted with people taking urate-lowering therapy (N = 30) in a 12-month trial of urate self-monitoring in rural and urban Australia. Interviews covered the experience of monitoring and its effect on gout self-management. Deidentified transcripts were analysed thematically.

RESULTS

Participants valued the ability to self-monitor and gain more understanding of urate control compared with the annual monitoring ordered by their doctors. Participants indicated that self-monitoring at home was easy, convenient and informed gout self-management behaviours such as dietary modifications, hydration, exercise and medication routines. Many participants self-monitored to understand urate concentration changes in response to feeling a gout flare was imminent or whether their behaviours, for example, alcohol intake, increased the risk of a gout flare. Urate concentrations were shared with doctors mainly when they were above target to seek management support, and this led to allopurinol dose increases in some cases.

CONCLUSION

Urate self-monitoring was viewed by people with gout as convenient and useful for independent management of gout. They believed self-monitoring achieved better gout control with a less restricted lifestyle. Urate data was shared with doctors at the patient's discretion and helped inform clinical decisions, such as allopurinol dose changes. Further research on implementing urate self-monitoring in routine care would enable an evaluation of its impact on medication adherence and clinical outcomes, as well as inform gout management guidelines.

PATIENT OR PUBLIC CONTRIBUTION

One person with gout, who was not a participant, was involved in the study design by providing feedback and pilot testing the semistructured interview guide. In response to their feedback, subsequent modifications to the interview guide were made to improve the understandability of the questions from a patient perspective. No additional questions were suggested.

A content analysis of medication adherence material in patient educational resources about gout

Objective

This study aimed to investigate how medication adherence is addressed in online gout resources in six countries. We investigated how often adherence was referred to, the strategies suggested to improve patient adherence, and the types of nonadherence that were targeted. We also examined the readability of the adherence material.

Methods

A content analysis was conducted on 151 online gout resources from medical and health organisations in six predominantly English-speaking countries. Two reviewers coded the content of the websites into categories (kappa 0.80). The analysis involved coding the resources for reasons for nonadherence, and adherence-promoting strategies. Flesch-Kincaid Reading Ease scores and word count were also computed.

Results

Out of 151 websites examined, 77 websites discussed medication adherence (51%), with intentional nonadherence being more prevalent than unintentional nonadherence. 67 websites targeted different types of nonadherence, including drug-specific concerns (50%), misconceptions of gout curability and the necessity of medication (16%), forgetfulness (16%), and other practical challenges (5%). Strategies to promote adherence were found in one-third of the websites, with medication education being the most prevalent strategy (17%), followed by healthcare provider engagement (13%) and memory aid strategies (6%). On average, about 11% of the words (89.27, SD = 76.35) in the entire document were focused on adherence. Difficult reading comprehension was found in one-fifth of adherence-related websites.

Conclusion

Findings reveal limited medication adherence coverage and narrow strategies in online gout resources. Improved adherence portrayal is needed for effective gout management through comprehensive strategies and clear, understandable information.

Can Smartphone Notifications Help With Gout Management? A Feasibility Study

OBJECTIVE

This feasibility study aimed to assess the acceptability of using smartphone notifications to modify the medication beliefs of people with gout. We evaluated the feasibility and acceptability of a smartphone application using the Technology Acceptance Model. We explored adherence rate differences and outcomes between the intervention and control groups.

METHODS

Fifty-two patients with gout who were prescribed allopurinol were randomly assigned to either active control (n = 24) or intervention group (n = 28). Over 3 months, both groups used the study app on their smartphones. The active control group received notifications about general health advice, whereas the intervention group received adherence-targeted notifications. The feasibility and acceptability of the smartphone app was measured through semistructured interviews. Adherence rate was assessed through serum urate levels and missed doses at 3 timepoints: baseline, 3 months (post intervention), and 6 months (follow-up).

RESULTS

The smartphone app demonstrated high feasibility, with strong participant retention and compliance. The participants expressed high levels of satisfaction with the app's user-friendliness and content, highlighting its acceptability. Both groups showed a significant reduction in missed doses over time (P < 0.05), but no significant differences in serum urate levels were found between the groups. Patients who received adherence-targeted notifications reported finding it more convenient to take allopurinol and expressed higher overall treatment satisfaction throughout the study.

CONCLUSION

Adherence-targeted notifications have the potential to be an effective and scalable approach to supporting medication adherence in patients with gout. Further research is needed with larger samples to refine the components of the intervention and explore its optimal implementation.

The British Journal of Clinical Pharmacology: The first 50 years

The British Journal of Clinical Pharmacology celebrates its 50th anniversary of publication in 2023. Here four previous Editors-in-Chief and the current Editor reflect on the Journal's history and the changes that have occurred during that time.