Improvement in the management of gout is vital and overdue: an audit from a UK primary care medical practice

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.

Validation of gout diagnosis in electronic primary care medical records: A population-based study

OBJECTIVE

The main objective of the study was to see the concordance between the diagnosis of gout recorded in primary care electronic medical records and the ACR/EULAR 2015 classification criteria.

METHODS

A cross-sectional study was conducted using electronic medicals records in 7 primary care centres of Barcelona. Patients' data to study clinical diagnose and management was gathered from the primary care electronic medical records of the Catalonian health institute (Institut Català de la Salut, ICS) and phone interview. Patients were considered to have gout if they scored 8 or more points on the EULAR/ACR 2015 classification criteria for gout.

RESULTS

In total, 70.9% of the patients with a gout diagnosis met ACR/EULAR 2015 criteria. Adding a hyperuricemia in a blood test in the EMR increased the percentage to 78.9%. 29.8% of the gout patients were not receiving urate-lowering therapy. 62.3% of the treated patients did not achieve the target uricemia (< 6mg/dL).

CONCLUSIONS

The majority of gout patients from primary care electronic medical records fulfil ACR/EULAR gout criteria. This database can be used for observational studies. In most of the gout patients the urate target was not achieved.

Impact of pharmacist-led collaborative gout clinic on timely achievement of serum uric acid goals

Background

The concept of a pharmacist-led collaborative gout clinic is relatively new in Singapore.

Objective

This study examined the impact of this pilot shared care model on providing dose titration of urate lowering therapy, gout education and patient support to achieve target serum uric acid (sUA) levels.

Method

A retrospective pre-post study was undertaken to compare outcomes in patients who were started on either allopurinol or febuxostat in the 24 months prior to (Group A: Pre implementation) or 33 months following launch of the collaborative gout clinic (Group B: Post implementation). The collaborative gout clinic comprises of a clinical pharmacist under the supervision of a rheumatologist.

Results

Of 98 eligible subjects enrolled in our study, there were 50 patients (all prescribed allopurinol) for Group A and 48 patients for Group B (allopurinol n = 29, febuxostat n = 19). Among patients who achieved target sUA level of 360 μmol/L or less at 1 year of drug initiation with use of allopurinol, the median [interquartile range, IQR] time taken to attain target sUA was shorter in Group B than Group A (111 [82–308] days vs. 293 [265–414] days, p = 0.016). As compared to Group A, Group B had lesser patients experiencing gout flare (41.3% vs. 70.0%, p = 0.018) and more patients achieving target sUA (75.9% vs. 22.0%, p < 0.001). Mean ± [standard deviation, SD] daily allopurinol dose to achieve target sUA levels was 276 mg ± [138 mg].

Conclusion

Our results demonstrate the use of a pharmacist-led collaborative gout clinic may help to achieve better clinical outcomes in gout management.

The Singapore Experience With Uncontrolled Gout: Unmet Needs in the Management of Patients

Gout is the most common type of inflammatory arthritis, and its impact on cardiovascular health and quality of life is often underestimated. The prevalence and incidence of gout are increasing globally. Further, ischemic heart disease (IHD) and chronic kidney disease (CKD) are prevalent in gout patients. Some unmet needs for gout management include physicians' low initiation rate of urate-lowering therapy (ULT) and poor treatment adherence in patients with gout. There is also a lack of randomized controlled trials that establish safe doses of acute and long-term treatment for gout, particularly in patients with IHD and stage 4 CKD and above (including end-stage renal failure). Furthermore, there is also a lack of studies showing optimal serum uric acid (SUA) target and validated clinical outcome measures, including disease activity and remission criteria for gout tailored to treat-to-target approaches and the high cost of newer gout medications. The causal relationship between asymptomatic hyperuricemia or gout with comorbidities such as IHD and CKD has yet to be fully elucidated. There is a pressing need for collaborative international efforts to address the overall suboptimal management of gout.

Egyptian consensus on treat-to-target approach of gout: evidence-based clinical practice guidelines for the management of gout

Introduction

New therapies, management approaches, and evidence regarding the management of gout have become available over the past years. This triggered the need for an updated recommendation for gout management. Through an up-to-date consensus evidence-based clinical practice guideline for the management of gout including recommendations for management of gout flares, optimum usage of urate lowering therapy for chronic gout, as well as patient education and lifestyle guidance. A wide systematic literature review was performed, and evidence-based recommendations were extrapolated, based on 16-key questions identified according to population, intervention, comparator, and outcomes (PICO) approach. These were evaluated by a panel consisted of 17 rheumatology experts via online surveys over a 2-round Delphi process. The purpose of this study is to offer an updated, consensus-evidence-based, and in the meantime patient-focused, expert recommendations for the treat-to-target approach of gout management.

Results

Results revealed that after round 2 ended, a total of 30-recommendation items, categorized into 10 domains, were obtained. Agreement with the recommendations (rank 7–9) ranged from 90 to 100%. Consensus was reached (i.e., ≥ 75% of respondents strongly agreed or agreed) on the wording, the grade of recommendation, and level of evidence of all the 30 clinical standards identified by the scientific committee.

Conclusions

This guideline provides updated evidence-based recommendations for the prevention and treatment of acute as well as chronic gout. This guideline provides an approach for physicians and patients making decisions on the management of gout. It will also facilitate improvement and uniformity of care.

Variability in Test Interval Is Linked to Glycated Haemoglobin (HbA1c) Trajectory over Time

AIMS

We previously showed that the glycated haemoglobin (HbA1c) testing frequency links to diabetes control. Here, we examine the effect of variability in test interval, adjusted for the frequency, on change in HbA1c (ΔHbA1c). Materials & Methods. HbA1c results were collected on 83,872 people with HbA1c results at baseline and 5 years (±3 months) later and ≥6 tests during this period. We calculated the standard deviation (SD) of test interval for each individual and examined the link between deciles of SD of the test interval and ΔHbA1c level, stratified by baseline HbA1c.

RESULTS

In general, less variability in testing frequency (more consistent monitoring) was associated with better diabetes control. This was most evident with moderately raised baseline HbA1c levels (7.0-9.0% (54-75 mmol/mol)). For example, in those with a starting HbA1c of 7.0-7.5% (54-58 mmol/mol), the lowest SD decile was associated with little change in HbA1c over 5 years, while for those with the highest decile, HbA1c rose by 0.4-0.6% (4-6 mmol/mol; p < 0.0001). Multivariate analysis showed that the association was independent of the age/sex/hospital site. Subanalysis suggested that the effect was most pronounced in those aged <65 years with baseline HbA1c of 7.0-7.5% (54-58 mmol/mol). We observed a 6.7-fold variation in the proportion of people in the top-three SD deciles across general practices.

CONCLUSIONS

These findings indicate that the consistency of testing interval, not the just number of tests/year, is important in maintaining diabetes control, especially in those with moderately raised HbA1c levels. Systems to improve regularity of HbA1c testing are therefore needed, especially given the impact of COVID-19 on diabetes monitoring.

'It's just a great muddle when it comes to food': a qualitative exploration of patient decision-making around diet and gout

Objective

Our aim was to understand whether, why and how patients choose to modify their diets after developing gout.

Methods

We conducted an inductive thematic secondary analysis of qualitative data from 43 interviews and four focus groups with UK participants with gout (n = 61).

Results

Participants commonly initiated dietary changes as part of a self-management strategy for gout. Reasons for making such dietary changes included: desperation; a desire for control; and belief that it would be possible to achieve successful management through diet alone; but not weight loss. Participants who did not make changes or who reverted to previous dietary patterns did so because: they believed urate-lowering therapy was successfully managing their gout; medication allowed normal eating; they did not find ‘proof’ that diet would be an effective treatment; or the dietary advice they found was unrealistic, unmanageable or irrelevant. Dietary modification was patient led, but patients would have preferred the support of a health-care professional. Beliefs that diet could potentially explain and modify the timing of flares gave patients a sense of control over the condition. However, the belief that gout could be controlled through dietary modification appeared to be a barrier to acceptance of management with urate-lowering therapy.

Conclusions

Perceptions about gout and diet play a large role in the way patients make decisions about how to manage gout in their everyday lives. Addressing the reasons why patients explore dietary solutions, promoting the value of urate-lowering therapy and weight loss and drawing on strong evidence to communicate clearly will be crucial in improving long-term clinical management and patient experience.

Gout, Hyperuricaemia and Crystal-Associated Disease Network (G-CAN) common language definition of gout

Objective

To develop a Gout, Hyperuricaemia and Crystal-Associated Disease Network (G-CAN) common language definition of gout, with the goal of increasing public understanding and awareness, and ensure consistent and understandable messages about gout.

Methods

A G-CAN working group that included patients, physicians and nongovernmental organisation (NGO) representatives was formed to develop a common language definition of gout for use with the public, media, healthcare providers and stakeholders. A literature search and interviews with patients, healthcare workers and stakeholders informed development of the definition. Following consultation with G-CAN members and partners, the definition was endorsed by the G-CAN board.

Results

The G-CAN common language definition of gout describes the epidemiology, pathophysiology, symptoms and impact, risk factors, comorbidities, management and healthcare and workforce considerations. Detailed information is provided to support the content of the definition. After the publication of the English-language version, the definition will be available for translation into other languages by G-CAN members.

Conclusion

G-CAN has developed a concise and easily understandable statement describing gout in language that can be used in conversations with the lay public, media, NGOs, funders, healthcare providers and other stakeholders.

Quality of care in people requiring hospital admission for gout in Aotearoa New Zealand: a nationwide analysis

AIMS

To understand national trends in hospital admission for a primary diagnosis of gout in Aotearoa New Zealand over the past 10 years and the quality of care for gout received by these patients before and after the admission.

METHODS

Data from the Aotearoa New Zealand National Collections from 1 January 2007 to 31 December 2019 were analysed to determine rates of hospital admission for a primary diagnosis of gout. Admission data including cost-weight analysis, as well as quality of care data including gout-specific medication dispensing in the year prior and year after admission.

RESULTS

There were 13,721 admissions with a primary diagnosis of gout over the analysis period, with an average cost per admission in 2019 of NZD 4,301. The rate of admission per 100,000 population was highest in Pacific peoples followed by MĀori. Although dispensing of any allopurinol increased in the year after admission, rates of regular allopurinol dispensing remained low; 38.1% for admissions in 2018. Patients who were younger (especially 20-44 years), not enrolled in a primary health organisation before admission, and female had lower rate of regular allopurinol after admission.

CONCLUSION

In this nationwide study, rates of admission for gout were highest in Pacific peoples and in MĀori. Rates of regular allopurinol dispensing was low even after admission for a primary diagnosis of gout. These findings highlight the need for improvements in gout management in Aotearoa New Zealand, including in post-discharge planning from secondary care inpatient services. This article is protected by copyright. All rights reserved.

Reasons for discontinuing urate-lowering treatment in community-dwelling adults with gout: results of a primary care-based cross-sectional study

Objectives

The aim was to examine the prevalence of urate-lowering treatment (ULT) in community-dwelling adults with gout and the reasons for drug discontinuation.

Methods

Adults with gout living in the East Midlands, UK, were mailed a postal questionnaire by their general practice surgery. It enquired about demographic details, co-morbidities, number of gout flares in the previous 12 months, current ULT and the reasons for discontinuing ULT if applicable. The number (percentage), median [interquartile range (IQR)] and mean (s.d.) were used for descriptive purposes. The Mann–Whitney U test and χ² test were used for univariate analyses. STATA v.16 was used for data analysis. Statistical significance was set at P < 0.05.

Results

Data for 634 gout patients [89.3% men, mean (s.d.) age 64.77 (12.74) years)] were included. Of the respondents, 59.8% self-reported taking ULT currently, with the vast majority (95.6%) taking allopurinol. Participants self-reporting current ULT experienced fewer gout flares in the previous 12 months than those who did not self-report current ULT [median (IQR) 0 (0–2) and 1 (0–3), respectively, P < 0.05]. One hundred and seven participants (16.9%) self-reported ULT discontinuation previously. The most commonly cited reasons for this were side-effects (29.7%), being fed up with taking tablets (19.8%) and lack of benefit from treatment or ULT-induced gout flares (19.8%). Treatment being stopped by the general practitioner without a clear reason known to the participant (15.8%) was another common report.

Conclusion

This study identified patient-, physician- and treatment-related barriers to long-term ULT. These should be addressed when initiating ULT and during regular review. Further research is required to confirm these findings in other populations.

Development of a novel gout treatment patient decision aid by patient and physician: A qualitative research study

BACKGROUND

Gout treatment is not optimized globally, often due to therapeutic inertia by physicians or poor adherence to urate-lowering medications by patients. A patient decision aid (PDA) to facilitate shared decision making (SDM) in gout treatment may overcome these physician-patient barriers.

OBJECTIVE

The study explored the views of physicians and patients on a novel locally designed gout treatment PDA prototype.

DESIGN

Qualitative descriptive design was used to gather data from in-depth-interviews (IDI) and focus group discussions (FGD). Data analysis was via thematic analysis. Emergent themes shaped a revised version of the PDA.

SETTING AND PARTICIPANTS

Adult Asian patients with recent acute gout exacerbations and local Primary Care Physicians (PCP) in Singapore were purposefully chosen. 15 patients with gout and 11 PCPs participated across three IDIs and six FGDs, with the investigators exploring their views of a prototype gout treatment PDA.

RESULTS

Patients and physicians generally concurred with the content and design of the PDA prototype. However, while patients preferred fewer treatment details, the PCPs desired more information. Patients preferred the display of statistics, while PCPs felt that numbers were not relevant to patients. The latter were hesitant to include treatment options that were unavailable in primary care. Both stakeholders indicated that they would use the PDA during a consultation. PCPs would need further training in SDM, given a lack of understanding of it.

CONCLUSION AND PATIENT CONTRIBUTION

Patients will be the prime users of the PDA. While their views differed partially from the physicians, both have jointly developed the novel gout treatment PDA.

Interventions to improve uptake of urate-lowering therapy in patients with gout: a systematic review

BACKGROUND

Gout treatment is suboptimal despite available therapy, with low levels of initiation and persistence of urate-lowering therapy (ULT) in many patients.

AIM

To identify all interventions that have attempted to improve the uptake of ULT and analyse the clinical outcomes.

DESIGN & SETTING

A systematic review of international articles published in English.

METHOD

A systematic search was conducted through MEDLINE, Embase, CINAHL Plus, and Scopus databases to identify all studies on relevant interventions for gout. Interventions were included if they aimed to address patient adherence with serum urate (SU) level as an outcome. This included patient education, practitioner monitoring, medication titration, SU monitoring, and ongoing patient engagement and follow-up. Follow-up studies to original interventions and those with only an abstract available were included.

RESULTS

Twenty articles met the inclusion criteria, describing outcomes of 18 interventions conducted in primary care settings: six nurse-led, five pharmacist-led, and seven multidisciplinary, multifaceted interventions. Improvement in SU levels was observed in all interventions. Nurse-led interventions were effective at empowering patients as they addressed illness perceptions and provided education, advice, and telephone follow-up. Pharmacist-led interventions primarily aimed to monitor patients, alter medication dosage, and provide automated telephone follow-up. Various multifaceted programmes involving a range of providers resulted in increased sustained use of urate-lowering medication.

CONCLUSION

A nurse-led approach focusing on patient understanding about gout is the most effective in achieving improved patient adherence, and lowered SU levels among patients. An intervention should include patient education and follow-up components.

[Gout and Its Management in Clinical Practice]

Gout and Its Management in Clinical Practice Abstract. Resolution of an acute attack is usually the prime objective in routine clinical management of gout. Crystal identification in synovial fluid by polarised light microscopy is considered the diagnostic gold standard. Imaging procedures such as high-resolution ultrasonography are also useful. Non-steroidal anti-inflammatory drugs, steroids and colchicine (not approved in Switzerland, available from pharmacies) are used to treat an acute gout attack. Just as important as the diagnosis and treatment of an acute attack is the long-term management of hyperuricaemia in order to prevent further gout attacks as well as possible renal, cardiac or metabolic complications. Therefore, patients with a confirmed diagnosis of gout should, apart from non-pharmacologic interventions, receive hypouricaemic therapy with a target uric acid level of <360 µmol/l (<6 mg/dl). Drugs of first choice are xanthine oxidase inhibitors. Achievement of the therapeutic objective should be periodically reviewed, adjusting therapy as necessary.

Epidemiology of Depression and Anxiety in Gout: A Systematic Review and Metaanalysis

OBJECTIVE

To conduct a systematic review of depression and anxiety among patients with gout that specifically evaluates the prevalence, incidence, determinants, and effects of these mental health comorbidities.

METHODS

We conducted a literature search in Medline, Embase, Cochrane Database of Systematic Reviews, CINAHL, and PsycINFO using indexed terms and key words to identify studies reporting on depression/anxiety in patients with gout. This review included full-text articles published in English that reported on patients with gout, evaluated depression/anxiety using a routinely reported measure, and provided estimates or sufficient data on the prevalence, incidence, determinants, or effects of depression/anxiety. Metaanalyses were conducted using random effects models.

RESULTS

Twenty of 901 articles identified through the search strategy met our inclusion criteria. All 20 studies evaluated depression, while only 10 assessed anxiety (50%). Metaanalyses suggest a positive association between mental health disorders and gout, as resultant pooled OR were 1.29 (95% CI 1.07-1.56) for depression and 1.29 (95% CI 0.96-1.73) for anxiety. Findings from four studies reporting on the incidence of depression in patients with gout resulted in a pooled HR of 1.17 (95% CI 1.01-1.36). Significant determinants of depression included number of tophi, frequency of flares, and oligo/polyarticular gout.

CONCLUSION

Our systematic review suggests that depression and anxiety are significantly associated with gout, highlighting the need for future research to focus on the onset of mental disorders after gout diagnosis. We also identify potential targets for intervention.

eHealth-supported decentralized multi-disciplinary care for gout involving rheumatology, pharmacy, and dietetics: proof-of-concept study

OBJECTIVE

To conduct quantitative and qualitative evaluation of an electronic health (eHealth)-supported decentralized multi-disciplinary care model for gout involving rheumatologists, pharmacist, and dietitian.

METHODS

We conducted a 12-month proof-of-concept study. Gout patients with ≥ 1 flare in the past year and serum urate (SUA) ≥ 360 μmol/L within the previous 2 months were followed by participating community rheumatologists on an as-needed basis, received monthly telephone consults with a pharmacist, and one telephone consult with a dietitian. Healthcare professionals were not co-located but had shared access to the rheumatologists' electronic medical records (EMR) for remote communication and collaboration. In quantitative evaluation, the primary outcome was the proportion of patients with SUA < 360 μmol/L at 12 months. In qualitative evaluation, we conducted semi-structured interviews with a subset of patients and applied constructivist grounded theory to gather patients' perspectives.

RESULTS

Overall, 35 gout patients (86% males, mean age 60.9 ± 14.9 years) participated. At 12 months, 72% of patients achieved target SUA < 360 μmol/L. Qualitative analysis of interviews with a subset of 12 patients resulted in two themes: (1) experiences with receiving care, including categories of improved knowledge about gout, receiving personalized support, and knowing someone cares, and (2) practical considerations, including categories of optimizing timing of care and coordination and accessibility.

CONCLUSION

Our multi-method study shows that a decentralized, multi-disciplinary care for gout involving rheumatology, pharmacy, and dietetics with shared EMR access led to gout patients achieving target SUA. It was well-received by patients who perceived better education about gout and personalized care.Key Points• We demonstrated the feasibility and impact of an eHealth-supported, decentralized collaborative care model for gout involving rheumatology, pharmacy, and dietetics• Although prior multi-disciplinary models of care for gout have been reported, the novelty of our model is that healthcare providers are not co-located, lending to potential efficiencies and outreach to patients in rural areas.

Variation in methods, results and reporting in electronic health record-based studies evaluating routine care in gout: A systematic review

OBJECTIVE

To perform a systematic review examining the variation in methods, results, reporting and risk of bias in electronic health record (EHR)-based studies evaluating management of a common musculoskeletal disease, gout.

METHODS

Two reviewers systematically searched MEDLINE, Scopus, Web of Science, CINAHL, PubMed, EMBASE and Google Scholar for all EHR-based studies published by February 2019 investigating gout pharmacological treatment. Information was extracted on study design, eligibility criteria, definitions, medication usage, effectiveness and safety data, comprehensiveness of reporting (RECORD), and Cochrane risk of bias (registered PROSPERO CRD42017065195).

RESULTS

We screened 5,603 titles/abstracts, 613 full-texts and selected 75 studies including 1.9M gout patients. Gout diagnosis was defined in 26 ways across the studies, most commonly using a single diagnostic code (n = 31, 41.3%). 48.4% did not specify a disease-free period before 'incident' diagnosis. Medication use was suboptimal and varied with disease definition while results regarding effectiveness and safety were broadly similar across studies despite variability in inclusion criteria. Comprehensiveness of reporting was variable, ranging from 73% (55/75) appropriately discussing the limitations of EHR data use, to 5% (4/75) reporting on key data cleaning steps. Risk of bias was generally low.

CONCLUSION

The wide variation in case definitions and medication-related analysis among EHR-based studies has implications for reported medication use. This is amplified by variable reporting comprehensiveness and the limited consideration of EHR-relevant biases (e.g. data adequacy) in study assessment tools. We recommend accounting for these biases and performing a sensitivity analysis on case definitions, and suggest changes to assessment tools to foster this.

Rising Incidence of Acute Hospital Admissions due to Gout

Objective.

To describe trends in acute hospital admissions due to gout in England, with rheumatoid arthritis (RA) as a comparator, alongside prescribing trends for common gout medications.

Methods.

An ecological study was performed using UK National Health Service (NHS) Digital Hospital Episode Statistics data to calculate the incidence of unplanned admissions with primary diagnoses of gout or RA in adults in England between April 2006 and March 2017. NHS Digital Community Prescription data for allopurinol, febuxostat, and colchicine were considered over a similar period.

Results.

The incidence of unplanned gout admissions increased by 58.4% over the study period, from 7.9 admissions per 100,000 population in 2006/07 to 12.5 admissions per 100,000 population in 2016/17 (p < 0.0001). Gout admissions increased as a proportion of all hospital admissions, and accounted for 349,768 bed-days cumulatively. Unplanned RA admissions halved over the study period, from 8.6 admissions per 100,000 population in 2006/07 to 4.3 admissions per 100,000 population in 2016/17 (p < 0.0001). Community prescriptions dispensed for allopurinol and colchicine have increased by 71.4% and 165.6%, respectively, since 2006 (p < 0.0001). Febuxostat prescriptions have increased 20-fold since 2010 (p < 0.0001), when prescription data became available.

Conclusion.

Acute gout admissions in England increased between 2006 and 2017, accompanied by increasing prescription of gout therapies. Acute admissions due to RA halved over the same time period. These data call for aggressive target-driven therapy for this highly treatable disease.

Venous thromboembolism in patients with gout and the impact of hospital admission, disease duration and urate-lowering therapy

BACKGROUND

Systemic inflammatory diseases have been associated with increased risk of venous thromboembolism. We aimed to quantify the risk of venous thromboembolism in patients with gout, the most common inflammatory arthritis, and to assess how disease duration, hospital admission and urate-lowering therapy affect this risk.

METHODS

We used data from the population-representative, England-based Clinical Practice Research Datalink linked to Hospital Episode Statistics, to identify incident gout cases between 1998 and 2017. We matched cases individually to 1 control without gout on age, gender, general practice and follow-up time. We calculated absolute and relative risks of venous thromboembolism, stratified by age, gender and hospital admission. Among those with gout, we assessed the risk of venous thromboembolism by exposure to urate-lowering therapy.

RESULTS

We identified 62 234 patients with incident gout matched to 62 234 controls. Gout was associated with higher risk of venous thromboembolism compared with controls (absolute rate 37.3 [95% confidence interval (CI) 35.5-39.3] v. 27.0 [95% CI 25.5-28.9] per 10 000 person-years, adjusted hazard ratio [HR] 1.25, 95% CI 1.15-1.35). The excess risk in patients with gout, which was sustained up to a decade after diagnosis, was present during the time outside hospital stay (adjusted HR 1.30, 95% CI 1.18-1.42), but not during it (adjusted HR 1.01, 95% CI 0.83-1.24). The risk of venous thromboembolism was similar among patients prescribed versus not prescribed urate-lowering therapy (incidence rate ratio 1.04, 95% CI 0.89-1.23).

INTERPRETATION

Gout was associated with higher risk of venous thromboembolism, particularly when the patient was not in hospital and regardless of exposure to urate-lowering therapy. Although the observed excess risk may not be sufficient to warrant preventive intervention, clinical vigilance may be required when caring for these patients.

Adherence and Outcomes with Urate-Lowering Therapy: A Site-Randomized Trial

PURPOSE

The purpose of this study was to test a pharmacist-led intervention to improve gout treatment adherence and outcomes.

METHODS

We conducted a site-randomized trial (n=1463 patients) comparing a 1-year, pharmacist-led intervention to usual care in patients with gout initiating allopurinol. The intervention was delivered primarily through automated telephone technology. Co-primary outcomes were the proportion of patients adherent (proportion of days covered ≥0.8) and achieving a serum urate <6.0 mg/dl at 1 year. Outcomes were reassessed at year 2.

RESULTS

Patients who underwent intervention were more likely than patients of usual care to be adherent (50% vs 37%; odds ratio [OR] 1.68; 95% confidence interval [CI] 1.30, 2.17) and reach serum urate goal (30% vs 15%; OR 2.37; 95% CI 1.83, 3.05). In the second year (1 year after the intervention ended), differences were attenuated, remaining significant for urate goal but not for adherence. The intervention was associated with a 6%-16% lower gout flare rate during year 2, but the differences did not reach statistical significance.

CONCLUSIONS

A pharmacist-led intervention incorporating automated telephone technology improved adherence and serum urate goal in patients with gout initiating allopurinol. Although this light-touch, low-tech intervention was efficacious, additional efforts are needed to enhance patient engagement in gout management and ultimately to improve outcomes.

Treatment Options for Gout

BACKGROUND

1-2% of adults in Germany suffer from gout. Gout is one of the few rheumatological diseases that can be cured. It arises through the deposition of uric acid crystals in joints as a result of hyperuricemia. Painful redness and swelling of the affected joints are typical findings. Multiple pertinent guidelines and treatment recommendations have been published, but there is reason to believe that patients with gout are not always treated accordingly.

METHODS

This review is based on relevant publications from the years 2000-2016 that were retrieved by a selective search in the Cochrane and PubMed databases.

RESULTS

In a person with normal renal function, asymptomatic hyperuricemia is not an indication for treatment to lower the serum uric acid level. The drugs of first choice for acute gouty arthritis are nonsteroidal antiinflammatory drugs (NSAID), corticosteroids, and colchicine. Treatment with xanthine oxidase inhibitors (XOI) or uricosuric drugs is indicated for patients with a recurrent or severe course; the target uric acid value is <6 mg/dL. Long-term treatment should be initiated only after resolution of the acute attack. For patients with refractory gout, lesinurad (approved in February 2016) in combination with XOI is a new treatment option that can be considered. Comprehensive patient education and counseling is an important component of the treatment of patients with gout. Regular laboratory follow-up is necessary as well.

CONCLUSION

The prevalence of gout is rising around the world. Patients with gout could benefit greatly from consistent implementation of the existing treatment guidelines and recommendations. In the future, controlled trials should be conducted to determine the best time to start treatment and the optimal target level for the serum uric acid concentration in terms of a risk/benefit analysis.

Risk of chronic kidney disease in patients with gout and the impact of urate lowering therapy: a population-based cohort study

Background

An association between gout and renal disease is well-recognised but few studies have examined whether gout is a risk factor for subsequent chronic kidney disease (CKD). Additionally, the impact of urate-lowering therapy (ULT) on development of CKD in gout is unclear. The objective of this study was to quantify the risk of CKD stage ≥ 3 in people with gout and the impact of ULT.

Methods

This was a retrospective cohort study using data from the Clinical Practice Research Datalink (CPRD). Patients with incident gout were identified from general practice medical records between 1998 and 2016 and randomly matched 1:1 to patients without a diagnosis of gout based on age, gender, available follow-up time and practice. Primary outcome was development of CKD stage ≥ 3 based on estimated glomerular filtration rate (eGFR) or recorded diagnosis. Absolute rates (ARs) and adjusted hazard ratios (HRs) were calculated using Cox regression models. Risk of developing CKD was assessed among those prescribed ULT within 1 and 3 years of gout diagnosis.

Results

Patients with incident gout (n = 41,446) were matched to patients without gout. Development of CKD stage ≥ 3 was greater in the exposed group than in the unexposed group (AR 28.6 versus 15.8 per 10,000 person-years). Gout was associated with an increased risk of incident CKD (adjusted HR 1.78 95% CI 1.70 to 1.85). Those exposed to ULT had a greater risk of incident CKD, but following adjustment this was attenuated to non-significance in all analyses (except on 3-year analysis of women (adjusted HR 1.31 95% CI 1.09 to 1.59)).

Conclusions

This study has demonstrated gout to be a risk factor for incident CKD stage ≥ 3. Further research examining the mechanisms by which gout may increase risk of CKD and whether optimal use of ULT can reduce the risk or progression of CKD in gout is suggested.

Electronic supplementary material

The online version of this article (10.1186/s13075-018-1746-1) contains supplementary material, which is available to authorized users.

Implication of nurse intervention on engagement with urate-lowering drugs: A qualitative study of participants in a RCT of nurse led care

OBJECTIVES

To explore patient perception of the role of a nurse-led complex package of care in facilitating engagement with urate-lowering therapies (ULTs) in the management of gout.

METHODS

Thirty people who had participated in a randomised controlled trial investigating the effect of a nurse-led complex package of care for gout, were purposively sampled and interviewed between 18-26 months after the end of the trial. Interviews were recorded, transcribed and analysed using a modified grounded-theory approach. Data were managed using Nvivo. STATA v15 was used to describe summary statistics.

RESULTS

Participants described their views and experiences of engaging with a nurse-led intervention designed to provide holistic assessment, individualised patient education, and involvement in shared decision-making for the long-term management of gout. The analysis revealed key themes in how nurse-led intervention facilitated engagement with ULT, namely by proving improved knowledge and understanding of gout and its treatment, involvement of patients in decision-making about treatment, and increased confidence about benefits from treatment. However, some treatment uncertainty and concern remained and one participant free of gout flares discontinued ULT, while another halved the dose after the end of the trial.

CONCLUSIONS

This study reports data on patient experience of engaging with ULT to manage gout after receiving nurse-led care. It demonstrates that shared decision-making and the joint efforts of fully informed practitioners and patients persuades patients to engage with ULTs, and that experiencing the benefits of curative treatment motivates them to maintain adherence.

How patients with gout become engaged in disease management: a constructivist grounded theory study

Background

Prior qualitative research on gout has focused primarily on barriers to disease management. Our objective was to use patients’ perspectives to construct an explanatory framework to understand how patients become engaged in the management of their gout.

Methods

We recruited a sample of individuals with gout who were participating in a proof-of-concept study of an eHealth-supported collaborative care model for gout involving rheumatology, pharmacy, and dietetics. Semistructured interviews were used. We analyzed transcripts using principles of constructivist grounded theory involving initial coding, focused coding and categorizing, and theoretical coding.

Results

Twelve participants with gout (ten males, two females; mean age, 66.5 ± 13.3 years) were interviewed. The analysis resulted in the construction of three themes as well as a framework describing the dynamically linked themes on (1) processing the diagnosis and management of gout, (2) supporting management of gout, and (3) interfering with management of gout. In this framework, patients with gout transition between each theme in the process of becoming engaged in the management of their gout and may represent potential opportunities for healthcare intervention.

Conclusions

Findings derived from this study show that becoming engaged in gout management is a dynamic process whereby patients with gout experience factors that interfere with gout management, process their disease and its management, and develop the practical and perceptual skills necessary to manage their gout. By understanding this process, healthcare providers can identify points to adapt care delivery and thereby improve health outcomes.

Management of gout by UK rheumatologists: a British Society for Rheumatology national audit

Objectives

To assess the concordance of gout management by UK rheumatologists with evidence-based best-practice recommendations.

Methods

Data were collected on patients newly referred to UK rheumatology out-patient departments over an 8-week period. Baseline data included demographics, method of diagnosis, clinical features, comorbidities, urate-lowering therapy (ULT), prophylaxis and blood tests. Twelve months later, the most recent serum uric acid level was collected. Management was compared with audit standards derived from the 2006 EULAR recommendations, 2007 British Society for Rheumatology/British Health Professionals in Rheumatology guideline and the National Institute for Health and Care Excellence febuxostat technology appraisal.

Results

Data were collected for 434 patients from 91 rheumatology departments (mean age 59.8 years, 82% male). Diagnosis was crystal-proven in 13%. Of 106 taking a diuretic, this was reduced/stopped in 29%. ULT was continued/initiated in 76% of those with one or more indication for ULT. One hundred and fifty-eight patients started allopurinol: the starting dose was most commonly 100 mg daily (82%); in those with estimated glomerular filtration rate <60 ml/min the highest starting dose was 100 mg daily. Of 199 who started ULT, prophylaxis was co-prescribed for 94%. Fifty patients started a uricosuric or febuxostat: 84% had taken allopurinol previously. Of 44 commenced on febuxostat, 18% had a history of heart disease. By 12 months, serum uric acid levels ⩽360 and <300 μmol/l were achieved by 45 and 25%, respectively.

Conclusion

Gout management by UK rheumatologists concords well with guidelines for most audit standards. However, fewer than half of patients achieved a target serum uric level over 12 months. Rheumatologists should help ensure that ULT is optimized to achieve target serum uric acid levels to benefit patients.

Education and non-pharmacological approaches for gout

The objectives of this review are as follows: to highlight the gaps in patient and physician knowledge of gout and how this might impede optimal disease management; to provide recommended core knowledge points that should be conveyed to people with gout; and to review non-pharmacological interventions that can be used in gout management. MeSH terms were used to identify eligible studies examining patients' and health-care professionals' knowledge about gout and its management. A narrative review of non-pharmacological management of gout is provided. Many health-care professionals have significant gaps in their knowledge about gout that have the potential to impede optimal management. Likewise, people with gout and the general population lack knowledge about causes, consequences and treatment of this condition. Full explanation about gout, including the potential benefits of urate-lowering treatment (ULT), motivates people with gout to want to start such treatment, and there is evidence, albeit limited, that educational interventions can improve uptake and adherence to ULT. Additionally, several non-pharmacological approaches, such as rest and topical ice application for acute attacks, avoidance of risk factors that can trigger acute attacks, and dietary interventions that may reduce gout attack frequency (e.g. cherry or cherry juice extract, skimmed milk powder or omega-3 fatty acid intake) or lower serum uric acid (e.g. vitamin C), can be used as adjuncts to ULT. There is a pressing need to educate health-care professionals, people with gout and society at large to remove the negative stereotypes associated with gout, which serve as barriers to optimal gout management, and to perceive gout as a significant medical condition. Moreover, there is a paucity of high-quality trial evidence on whether certain simple individual dietary and lifestyle factors can reduce the risk of recurrent gout attacks, and further studies are required in this field.

Physiology of Hyperuricemia and Urate-Lowering Treatments

Gout is the most common form of inflammatory arthritis and is a multifactorial disease typically characterized by hyperuricemia and monosodium urate crystal deposition predominantly in, but not limited to, the joints and the urinary tract. The prevalence of gout and hyperuricemia has increased in developed countries over the past two decades and research into the area has become progressively more active. We review the current field of knowledge with emphasis on active areas of hyperuricemia research including the underlying physiology, genetics and epidemiology, with a focus on studies which suggest association of hyperuricemia with common comorbidities including cardiovascular disease, renal insufficiency, metabolic syndrome and diabetes. Finally, we discuss current therapies and emerging drug discovery efforts aimed at delivering an optimized clinical treatment strategy.

Exploring current and potential roles of Australian community pharmacists in gout management: a qualitative study

Background

Gout is an increasingly prevalent form of inflammatory arthritis. Although effective treatments for gout exist, current management is suboptimal due to low medication adherence rates and treatments that are non-concordant with guidelines. Medications are the mainstay and most effective form of gout management. Thus, there is potential for community pharmacists to play an important primary health care role in gout management, however their current role and their potential to improve management of gout treatment is currently unclear. The purpose of the study is to explore the views of Australian pharmacists on their roles in gout management and to identify factors influencing their involvement in gout management.

Methods

A convenience sample of community pharmacists were invited to participate using a snowballing recruitment strategy. Semi-structured, face-to-face interviews were conducted with 15 pharmacists of varying age, gender and pharmacy experience. Interviews focused on pharmacists’ experiences of managing gout, interactions with people living with gout and their perceived roles and responsibilities in gout management. Interviews were transcribed verbatim and independently analysed by two reviewers to identify themes.

Results

The main role of pharmacists reported in gout management was providing patient education. The greatest facilitator to pharmacists involvement in gout management was identified to be pharmacists’ good understanding of gout and its management. Barriers to pharmacists involvement were identified to be difficulties in monitoring adherence to gout medications, low priority given to gout in the pharmacy compared to other chronic health conditions, and lack of specific training and/or continuing education in gout prevention and management.

Conclusions

Pharmacists can expand their primary health care role in gout management, particularly in the area of ongoing provision of education to people living with gout and in monitoring medication adherence in patients. However, a number of barriers need to be overcome including difficulties in monitoring patient adherence to medications, ensuring a higher priority is given to chronic gout management and providing continuing training to community pharmacists about gout. Implications for pharmacist practice include initiating conversations about medication adherence and education when dispensing medications and undertaking continuing education in gout.

Work disability in gout: a population-based case-control study

OBJECTIVES

To examine the extent and cost of work disability among patients with gout compared with matched population controls and to analyse predictors of work disability.

METHODS

A regional cohort study using data from Swedish national and regional registries from January 2000 through December 2012, including 4571 patients with gout of working age, with a first recorded diagnosis of gout in the years 2003-2009 and 22 482 population controls, matched by age, sex and place of residence. Differences in baseline characteristics (educational level, income, previous employment and comorbidities) and the number of work-loss days (absenteeism) due to sick leave and disability pension for 3 years after identification were calculated. Predictors for new-onset work absenteeism (>90 days/year) in a subset were determined by conditional logistic regression.

RESULTS

Patients with gout (median age 53 years) had significantly more comorbidities, lower income and lower level of education than matched controls. The average work absentee rate during the 3-year follow-up period was higher among patients with gout than controls, 22% and 14%, respectively (P<0.0001). New-onset absenteeism was in multivariate analyses significantly predicted by gout (OR 1.47; 95% CI 1.23 to 1.75). Other variables independently related to new-onset absenteeism were education ≤12 years, previous unemployment and history of sick leave, in addition to several comorbidities (renal disease, cardiovascular disease, alcohol abuse and obesity).

CONCLUSIONS

Gout is associated with substantially higher work absenteeism and costs for society due to productivity loss, after adjusting for associated comorbidities and socioeconomic differences. Whether more intensive treatment of gout is cost-effective needs to be addressed in future studies.

Burden of gout in the Nordic region, 1990-2015: findings from the Global Burden of Disease Study 2015

OBJECTIVE

To explore the burden of gout in the Nordic region, with a population around 27 million in 2015 distributed across six countries.

METHOD

We used the findings of the 2015 Global Burden of Diseases study to report prevalence and disability associated with gout in the Nordic region.

RESULTS

From 1990 to 2015, the number of prevalent gout cases rose by 30% to 252 967 [95% uncertainty interval (UI) 223 478‒287 288] in the Nordic region. In 2015, gout contributed to 7982 (95% UI 5431‒10 800) years lived with disability (YLDs) in the region, an increase of 29% (95% UI 24‒35%) from 1990. While the crude YLD rate of gout increased by 12.9% (95% UI 7.8‒18.1%) between 1990 and 2015, the age-standardized YLD rate remained stable. Gout was ranked as the 63rd leading cause of total YLDs in the region in 2015, with the highest rank in men aged 55-59 years (38th leading cause of YLDs). The corresponding rank at the global level was 94. Of 195 countries studied, four Nordic countries [Greenland (2nd), Iceland (12th), Finland (14th), and Sweden (15th)] were among the top 15 countries with the highest age-standardized YLD rate of gout.

CONCLUSION

The burden of gout is rising in the Nordic region. Gout's contribution to the total burden of diseases in the region is more significant than the global average. Expected increases in gout burden owing to population growth and ageing call for stronger preventive and therapeutic strategies for gout management in Nordic countries.

Improvement in Diagnosis and Treat-to-Target Management of Hyperuricemia in Gout: Results from the GEMA-2 Transversal Study on Practice

INTRODUCTION

The objective of the study was to evaluate changes regarding main European League Against Rheumatism (EULAR) recommendations on diagnosis and treatment of gout compared to a previous assessment.

METHODS

The GEMA-2 (Gout Evaluation and MAnagement) is a transversal assessment of practice for gout by rheumatologists. Main outcome variables were improvement of the previous GEMA assessment regarding the rate of crystal-proven diagnosis and that reaching therapeutic serum urate target below 6 mg/dl at last visit. Other management variables (prophylaxis, treatment of flares, lifestyle change advice) were also evaluated along with general characteristics. The sample was powered to include at least 483 patients for up to 50% change.

RESULTS

Data on management of 506 patients were retrieved from 38 out of 41 rheumatology units that participated in the previous GEMA audit. Crystal-proved diagnosis rate increased from 26% to 32% (31% improvement) and was higher in gout-dedicated practices; ultrasonography contributed to diagnosis in less than 1% of cases. Therapeutic serum urate at last visit improved from 41% to 64% of all patients (66% of patients on urate-lowering medications), in any case over 50% improvement from the previous assessment. The use of any urate-lowering medication available was not prescribed as per label dosing in patients who failed to achieve target serum urate. Clinical inertia to increase doses of either allopurinol or febuxostat was still present in clinical practice.

CONCLUSION

Over 50% improvement in targeting therapeutic serum urate has been observed, but clinical inertia is still present. Diagnosis is still mostly clinically based, ultrasonography not being commonly contributive.

FUNDING

Menarini España.

Poorly controlled gout: who is doing poorly?

Gout, an inflammatory arthritis caused by the deposition of monosodium urate crystals, is commonly seen in primary care and specialist clinics. In recent years, there has been a resurgence of interest in gout due to advances in therapies and the understanding of pathophysiology, with new guidelines being published by international bodies. However, there is still a gap between the goals of treatment and actual day-to-day practice. Barriers that result in poorly controlled gout include patient factors such as lack of understanding of the disease, stigma and nonadherence to treatment, as well as physician factors such as knowledge gaps, inadequate use of allopurinol and lack of ownership of the disease. The medical profession needs to do more to bridge the gap through physician and patient education, identification of treatment targets with appropriate use of drugs, and dissemination of guidelines.

Quality of care in gout: a clinical audit on treating to the target with urate lowering therapy in real-world gout patients

The current paper aimed to describe the quality of care for gout patients by showing the clinical outcomes achieved in two patient cohorts in which differing targeted urate lowering therapy (ULT) treatment approaches were employed, both aiming to reach the European League Against Rheumatism recommended serum urate (sUA) targets. A retrospective medical chart review study was conducted. Data from the medical records of gout patients from two clinical centers in The Netherlands, both applying targeted ULT treatments (albeit using different approaches), were reviewed. Patients in cohort A were given a combination of xanthine oxidase inhibitors with uricosurics if treatment with allopurinol monotherapy failed to reach sUA target levels, whereas patients in cohort B were treated with sequential monotherapy. Data on patient characteristics and clinical outcomes were collected. A total of 177 patient dossiers were included: 99 from cohort A and 78 from cohort B. The great majority (n = 146, 82.5%) of the patients in both cohorts had a current sUA level <360 µmol/L. In addition, more than half (n = 104, 58.8%) of the patients met the stringent sUA target level of <300 µmol/L. The largest reductions in mean sUA levels were observed for patients who were treated with combination therapy. This clinical audit of two cohorts of gout patients provides initial—yet promising—results regarding the proportion of real-world gout patients in whom recommended that sUA target levels can be achieved, and demonstrates the added value that a targeted treatment approach may have in reaching these goals.

Long-term persistence and adherence on urate-lowering treatment can be maintained in primary care-5-year follow-up of a proof-of-concept study

Objectives

To evaluate the persistence and adherence on urate-lowering treatment (ULT) in primary care 5 years after an initial nurse-led treatment of gout.

Methods

One hundred gout patients initiated on up-titrated ULT between March and July 2010 were sent a questionnaire that elicited information on current ULT, reasons for discontinuation of ULT if applicable, medication adherence and generic and disease-specific quality-of-life measures in 2015. They were invited for one visit at which height and weight were measured and blood was collected for serum uric acid measurement.

Results

Seventy-five patients, mean age 68.13 years ( s . d . 10.07) and disease duration 19.44 years ( s . d . 13), returned completed questionnaires. The 5-year persistence on ULT was 90.7% (95% CI 81.4, 91.6) and 85.3% of responders self-reported taking ULT ⩾6 days/week. Of the 65 patients who attended the study visit, the mean serum uric acid was 292.8 μmol/l ( s . d . 97.2).

Conclusion

An initial treatment that includes individualized patient education and involvement in treatment decisions results in excellent adherence and persistence on ULT >4 years after the responsibility of treatment is taken over by the patient's general practitioner, suggesting that this model of gout management should be widely adopted.

Gout in primary care: Can we improve patient outcomes?

In the United Kingdom, gout represents one of the most common inflammatory arthropathies predominantly managed in the primary care setting. Gout is a red flag indicator for cardiovascular disease and comorbidity. Despite this, there are no incentivised treatment protocols and suboptimal management in the primary care setting is common. A computer based retrospective search at a large inner city GP practice between January 2014-December 2014 inclusive, identified 115 patients with gout. Baseline measurements revealed multiple gout related consultations, poor medication compliance, high uric acid levels and deficiencies in uric acid monitoring.

A series of improvement cycles were conducted. A telephone questionnaire conducted in January 2015, identified that patient education was suboptimal. The following improvement cycles aimed to educate patients, improve uric acid monitoring and support medication compliance. It was ultimately hoped that these measures would reduce gout flares and GP practice attendance. The improvement cycles contributed towards reduction in uric acid levels from 0.37 to 0.3 (p=0.14), 20% reduction in patients experiencing one or more gout flares and 77% reduction in GP related consultations between March 2015-March 2016 compared to baseline. The proportion of patients fully compliant with taking their urate lowering therapies improved from 63% to 91% (p=0.0001).

A follow up series of PDSA cycles were performed between July-December 2016. The purpose of these cycles was to assess the sustainability of the improved medication compliance demonstrated by the improvement cycles. Three months following the completion of the improvement cycles, full medication compliance dropped from 91% to 70% (p=0.0001). The introduction of a paper calendar saw sustained and maintained improvement in medication compliance to 100% (p=0.0001) at the end of the study period. The improvement and PDSA cycles have demonstrated that simple interventions can be a sustainable way of improving disease control and patient outcomes.

Monitoring of Urate-Lowering Therapy Among US Veterans Following the 2012 American College of Rheumatology Guidelines for Management of Gout

BACKGROUND

With the prevalence of and hospitalizations for gout increasing, optimizing care for patients with gout is imperative. The 2012 American College of Rheumatology gout guidelines emphasize that timely monitoring is key to achieving serum urate (SUA) goals. Few studies have examined this metric following the 2012 update, and to our knowledge, none have examined a veteran population.

OBJECTIVE

To evaluate adherence to urate-lowering therapy (ULT) monitoring guidelines in a veteran population.

METHODS

This is a single-center, multisite, retrospective chart review of US veterans receiving ULT for gout within the VA (Veterans Affairs) Tennessee Valley Healthcare System from January 1, 2013, to June 30, 2015. The primary end point was percentage of patients with a SUA within 6 months of initial xanthine oxidase inhibitor prescription. Secondary end points included percentage of patients with SUA <6 mg/dL and percentage of patients with uptitration following SUA above goal.

RESULTS

A total of 601 patients met inclusion criteria for the study; after application of exclusion criteria, 505 were analyzed. Of these, 295 patients (58%) did not have a SUA drawn within 6 months, and 162 patients (32%) reached the end of the study period without SUA measured. Of 226 patients with SUA above goal on initial check, 64 (28%) had timely dose adjustment, whereas 143 patients (63%) had no adjustment. A total of 161 patients (32%) had a SUA at goal within the study period.

CONCLUSIONS

Rates of ULT monitoring at a major VA medical center were suboptimal, and improved adherence to guideline recommendations is needed.

Gout

Gout is a chronic disease of deposition of monosodium urate crystals, which form in the presence of increased urate concentrations. Although environmental factors contribute to hyperuricaemia, renal and gut excretion of urate is central to regulation of serum urate, and genetic factors are important. Activation of the NLRP3 inflammasome and release of interleukin 1β have key roles in initiation of acute gout flares. A "treat to target serum urate" approach is essential for effective gout management; long-term lowering of serum urate to less than 360 μmol/L leads to crystal dissolution and ultimately to suppression of flares. An allopurinol dose-escalation strategy is frequently effective for achieving treatment targets, and several new urate-lowering drugs are also available. Worldwide, rates of initiation and continuation of urate-lowering therapy are very low, and, consequently, achievement of serum urate targets is infrequent. Strategies to improve quality of gout care are needed.

Rationale and design of the randomized evaluation of an Ambulatory Care Pharmacist-Led Intervention to Optimize Urate Lowering Pathways (RAmP-UP) Study

BACKGROUND

Despite the availability of effective therapies, most gout patients achieve suboptimal treatment outcomes. Current best practices suggest gradual dose-escalation of urate lowering therapy and serial serum urate (sUA) measurement to achieve sUA<6.0mg/dl. However, this strategy is not routinely used. Here we present the study design rationale and development for a pharmacist-led intervention to promote sUA goal attainment.

METHODS

To overcome barriers in achieving optimal outcomes, we planned and implemented the Randomized Evaluation of an Ambulatory Care Pharmacist-Led Intervention to Optimize Urate Lowering Pathways (RAmP-UP) study. This is a large pragmatic cluster-randomized trial designed to assess a highly automated, pharmacist-led intervention to optimize allopurinol treatment in gout. Ambulatory clinics (n=101) from a large health system were randomized to deliver either the pharmacist-led intervention or usual care to gout patients over the age of 18years newly initiating allopurinol. All participants received educational materials and could opt-out of the study. For intervention sites, pharmacists conducted outreach primarily via an automated telephone interactive voice recognition system. The outreach, guided by a gout care algorithm developed for this study, systematically promoted adherence assessment, facilitated sUA testing, provided education, and adjusted allopurinol dosing. The primary study outcomes are achievement of sUA<6.0mg/dl and treatment adherence determined after one year. With follow-up ongoing, study results will be reported subsequently.

CONCLUSION

Ambulatory care pharmacists and automated calling technology represent potentially important, underutilized resources for improving health outcomes for gout patients.

A joint effort over a period of time: factors affecting use of urate-lowering therapy for long-term treatment of gout

Background

Although international guidelines encourage urate lowering therapy (ULT) for people who have more than two attacks of gout, only 30 % of patients are prescribed it and only 40 % of those adhere to the treatment. The aim was to explore reasons for this through an exploration of patient experience and understanding of ULT treatment for gout.

Methods

A qualitative study was conducted throughout the United Kingdom. Narrative and semi-structured video-recorded interviews and thematic analysis were used.

Results

Participants talked about their views and experiences of treatment, and the factors that affected their use of ULT. The analysis revealed five main themes: 1) knowledge and understanding of gout and its treatment; 2) resistance to taking medication; 3) uncertainty about when to start ULT; 4) experiences of using ULT; and 5) desire for information and monitoring.

Conclusion

Patients’ understanding and experiences of gout and ULT are complex and it is important for clinicians to be aware of these when working with patients. It is also important for clinicians to know that patients’ perceptions and behaviour are not fixed, but can change over time, with changes to their condition, with dialogue and increased understanding. Patients want this interaction with their clinicians, through “a joint effort over a period of time”.

General practitioners' perspectives on the management of gout: a qualitative study

BACKGROUND

Many quantitative studies globally have identified suboptimal management of gout.

PURPOSE

To explore management of gout from the perspective of general practitioners (GPs), while identifying the barriers and possible strategies for improvement.

STUDY DESIGN

This descriptive qualitative study used semistructured interviews with 14 purposely selected GPs from four separate general practices in Townsville. The questions focused on management strategies, practicalities in managing gout, barriers and possible strategies to improve management.

RESULTS

Indomethacin was commonly reported to be used in acute gout with progression to allopurinol after the acute stage had subsided. There were differences with the initial allopurinol dose and follow-up periods. GPs reported lack of patient adherence to allopurinol and lifestyle modifications, mainly due to lack of education. Most suggested the need for allied health input and improved patient education.

CONCLUSIONS

Tailor-made plan in terms of education and lifestyle advice could help adherence to gout management.

Management of gout in the real world: current practice versus guideline recommendations

OBJECTIVES

Gout is a chronic, extremely painful disease that is potentially curable when treated effectively. Unfortunately approximately one-half of patients with gout are inadequately controlled.

METHODS

We surveyed 315 primary care physicians in the United States and Europe to investigate current practice in the real world, as distinct from recommendations in guidelines.

RESULTS

Our survey on 1657 patients found that regular testing of serum uric acid, in conformity with the guidelines, was conducted by approximately 50% of physicians. Advice to patients on diet and lifestyle was less well implemented, and identification of overweight/obese patients was inconsistent.

CONCLUSION

Improvements in practice by physicians would include comprehensive assessment of the patient, adoption of regular monitoring during treatment, and the provision of patient education on adherence and lifestyle.