Understanding and improving the use of allopurinol in a teaching hospital

Efficacy and safety of urate-lowering therapy in people with kidney impairment: a GCAN-initiated literature review

OBJECTIVES

The aim was to evaluate the efficacy, defined as achieving target serum urate <6.0 mg/dl, and safety of urate-lowering therapies (ULTs) for people with gout and chronic kidney disease (CKD) stages 3-5.

METHODS

PubMed, The Cochrane Library and EMBASE were searched from 1 January 1959 to 31 January 2018 for studies that enrolled people with gout, who had an estimated glomerular filtration rate (eGFR) or creatinine clearance (CrCl) of <60 ml/min and exposure to allopurinol, febuxostat, probenecid, benzbromarone, lesinurad or pegloticase. All study designs other than case reports were included, except for people on dialysis, for whom we did include case reports.

RESULTS

There were 36 reports with an analysis of efficacy and/or safety based upon renal function: allopurinol (n = 12), febuxostat (n = 10), probenecid (n = 3), benzbromarone (n = 5), lesinurad (n = 5) and pegloticase (n = 1). There were 108 reports that involved people with gout and renal impairment but did not contain any analysis on efficacy and/or safety based upon renal function: allopurinol (n = 84), febuxostat (n = 14), benzbromarone (n = 1), lesinurad (n = 3) and pegloticase (n = 6). Most studies excluded people with more severe degrees of renal impairment (eGFR or CrCl of <30 ml/min). For allopurinol, in particular, there was significant variability in the dose of drug used and the efficacy in terms of urate lowering, across all levels of renal impairment.

CONCLUSION

There is a lack of evidence regarding the efficacy and/or safety of currently used ULTs according to different levels of renal function. Future studies should include patients with CKD and should report study outcomes stratified by renal function.

Partners and nurses' knowledge and representations of gout: A qualitative study

Adherence to gout treatment is poor. Partners of patients and nurses are two major communicators with gouty patients, and their perceptions of illness may affect patient behavior.

OBJECTIVE

To explore partners' and nurses' knowledge and representations of gout.

METHODS

We used a qualitative grounded approach with semi-structured face-to-face individual interviews with a purposive sample of hospital nurses working in rheumatology and internal medicine departments and patient partners. Interviews were audio-recorded and transcribed. All authors met regularly to discuss coding and data interpretation.

RESULTS

Overall, 20 nurses and 12 partners participated in the interviews. Four major themes were evidenced: knowledge gaps (gout cause was unknown, unawareness of urate-lowering therapy and the possibility to cure gout, focus in gout flare and diet); lack of information and education on gout (knowledge acquired by personal experiences, nurses complained to be insufficiently educated, partners highlighted the lack of information and that general practitioners did not have time to educate patients); gout consequences and social impacts (handicapping disease, avoid social activities like dinner with friends); attitudes towards gout flare and patient management (feeling powerless during flare, negative feelings such as being ashamed leading to postpone medical seek or unconcerned about their partner disease). Nurses regretted that they had not enough time to discuss issues with patients.

CONCLUSION

Partners and nurses' knowledge of gout is based on daily experiences. Participants were eager to learn more about gout. Nurses' education and education programs including partners may improve gout management and patient adherence to treatment.

Key barriers to gout care: a systematic review and thematic synthesis of qualitative studies

OBJECTIVES

Gout care remains highly suboptimal, contributing to an increased global disease burden. To understand barriers to gout care, our aim was to provide a systematic review and thematic synthesis of qualitative studies worldwide reporting provider and patient perspectives and experiences with management.

METHODS

We conducted a mapped search of MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and Social Sciences Citation Index databases and selected qualitative studies of provider and patient perspectives on gout management. We used thematic synthesis to combine the included studies and identify key themes across studies.

RESULTS

We included 20 studies that reported the experiences and perspectives of 480 gout patients and 120 providers spanning five different countries across three continents. We identified three predominant provider themes: knowledge gaps and management approaches; perceptions and beliefs about gout patients; and system barriers to optimal gout care (e.g. time constraints and a lack of incentives). We also identified four predominant themes among gout patients: limited gout knowledge; interactions with health-care providers; attitudes towards and experiences with taking medication; and practical barriers to long-term medication use.

CONCLUSION

Our systematic review of worldwide literature consistently identified gaps in gout knowledge among providers, which is likely to contribute to patients' lack of appropriate education about the fundamental causes of and essential treatment approaches for gout. Furthermore, system barriers among providers and day-to-day challenges of taking long-term medications among patients are considerable. These factors provide key targets to improve the widespread suboptimal gout care.