Effectiveness of healthcare educational and behavioral interventions to improve gout outcomes: a systematic review and meta-analysis.
Ramsubeik Karishma,Ramrattan Laurie Ann,Kaeley Gurjit S,Singh Jasvinder A
Therapeutic advances in musculoskeletal disease
Background:We aimed to systematically review the effectiveness of healthcare behavioral and education interventions for gout patients on clinical outcomes. Methods:We searched multiple databases to identify trials or observational studies of educational or behavioral interventions in gout. Risk of bias was assessed with the Cochrane tool for randomized control trials (RCTs) and the Newcastle-Ottawa Scale for observational studies. We estimated odds ratios (ORs) for categorical and standardized mean difference (SMD) for continuous measures using a random-effects model. Results:Overall, eight (five RCTs and three observational) studies met the inclusion criteria and examined pharmacist-led interventions ( = 3), nurse-led interventions ( = 3) and primary care provider interventions ( = 2). Compared with the control intervention (usual care in most cases), a higher proportion of those in the educational/behavioral intervention arm achieved serum urate (SU) levels <6 mg/dl, 47.2% 23.8%, the OR was 4.86 [95% confidence interval (CI), 1.48, 15.97; 4 RCTs] with moderate quality evidence. Compared with the control intervention, a higher proportion of those in the educational/behavioral intervention arm were adherent to allopurinol, achieved at least a 2 mg/dl decrease in SU, achieved an SU < 5 mg/dl, had a reduction in the presence of tophi at 2 years, had improved quality of life as assessed with SF-36 physical component scores, had a higher knowledge about gout and higher patient satisfaction (moderate-low quality evidence). Conclusion:Educational and behavioral interventions can improve gout outcomes in the short-intermediate term. Randomized trials are needed to assess its impact on long-term gout outcomes.
Nurse-led care is preferred over GP-led care of gout and improves gout outcomes: results of Nottingham Gout Treatment Trial follow-up study.
Fuller Amy,Jenkins Wendy,Doherty Michael,Abhishek Abhishek
Rheumatology (Oxford, England)
OBJECTIVES:To explore patient satisfaction, gout knowledge, medication adherence and flares among participants receiving nurse-led or general practitioner (GP)-led care of gout in the Nottingham Gout Treatment Trial phase-II (NGTT-II). METHODS:A total of 438 participants of NGTT-II were sent a questionnaire enquiring about gout knowledge, satisfaction with health-care practitioner, urate-lowering treatment being undertaken, and gout flares ⩾1 year after their final visit. Nurse-led care participants were asked about their preference for receiving gout treatment from either a GP or a nurse. RESULTS:Completed questionnaires were returned by 82% of participants. Participants previously receiving nurse-led care reported greater satisfaction with health-care practitioner (P < 0.001), had better gout knowledge (P = 0.02), were more likely to be taking urate-lowering treatment [adjusted relative risk (95% CI) 1.19 (1.09, 1.30)], and self-reported fewer flares in the previous 12 months [median (inter-quartile range) 0 (0-0) vs 1 (0-3), P < 0.001] than those receiving GP-led care. Of participants receiving nurse-led care, 41-63% indicated preference for receiving gout treatment from a nurse, while only 5-20% indicated preference for receiving treatment from GPs. CONCLUSION:The results of this study favour nurse-led care, involving individualized patient education and engagement and a treat-to-target strategy, in terms of patient acceptability, long-term adherence, and flares. Further research is required to evaluate the feasibility of implementing such a model of care in clinical practice.
Better outcomes for patients with gout.
Day Richard,Nguyen Amy,Graham Garry,Aung Eindra,Coleshill Mathew,Stocker Sophie
Gout is increasing in prevalence despite effective pharmacotherapies. Barriers to effective management are largely educational deficiencies. Sufferers, usually men, need to understand more about gout, especially that maintaining serum urate below 0.36 mmol/L will eliminate recurrent attacks. Also, of great importance is appreciating that sub-optimal adherence to urate-lowering therapy (ULT) will result in a return of attacks. Prescribers also need to understand that acute attacks are likely to occur in the first few months of urate-lowering therapy (ULT), but these can be mitigated by commencing with a dose of ULT reflective of renal function and escalating the dose slowly, every 2-5 weeks until target serum urate is achieved. Prophylaxis against acute attacks over the initial 6 months period of ULT can be enhanced further with concomitant colchicine or nonsteroidal anti-inflammatory drugs (NSAIDs).Gout is largely managed in primary care. Rates of adherence to ULT are 50% or less, worse than most other chronic illnesses. Efforts at educating primary care physicians to, firstly, manage gout effectively and, secondly, to educate their gout patients sufficiently have not been successful. Allied health practitioners, such as nurses, working with prescribers in primary care settings and given the mandate to educate and manage patients with gout, have been spectacularly effective. However, this approach is resource intensive. 'Personalised' eHealth interventions show promise as an alternative strategy, notably in improving adherence to ULT.Numerous applications for smart phones (apps) are now available to assist people with chronic health conditions. Their design needs to accommodate the barriers and enablers perceived by patients to maintaining adherence to prescribed therapies. Personalised feedback of serum urate may represent an important enabler of adherence to ULT in the case of gout.Harnessing mobile apps to support patients managing their chronic illnesses represents an important opportunity to enhance health outcomes. Rigorous, patient-centred and driven development is critical. These tools also require careful evaluation for effectiveness.
Designing a Strategy Trial for the Management of Gout: The Use of a Modified Delphi Panel.
Solomon Daniel H,Weissman Joel S,Choi Hyon,Atlas Steven J,Berardinelli Cesar,Dedier Julien,Fischer Michael A,Fitzgerald John,Hinteregger Erica,Johnsen Brianne,Marini Diana D,McLean Robert,Murray Fred,Neogi Tuhina,Oertel Lynn B,Pillinger Michael H,Riggs Kevin R,Saag Ken,Suh Dong,Watkins James,Barry Michael J
ACR open rheumatology
OBJECTIVE:Disagreement exists between rheumatology and primary care societies regarding gout management. This paper describes a formal process for gathering input from stakeholders in the planning of a trial to compare gout management strategies. METHODS:We recruited patients, nurses, physician assistants, primary care clinicians, and rheumatologists to participate in a modified Delphi panel (mDP) to provide input on design of a trial focused on optimal management for primary care patients with gout. The 16 panelists received a plain-language briefing document that discussed the rationale for the trial, key clinical issues in gout, and aspects of trial design. The panelists also received information and considerations on nine voting questions (VQs), judged to be the key design questions. Cognitive interviews with panelists ensured that the VQs were understood by the range of panelists involved in the mDP. Panelists were asked to score all VQs from 1 (definitely no) to 9 (definitely yes). Two voting rounds were conducted-round 1 by email and round 2 by video conference. RESULTS:The VQs were modified through the cognitive interviews. The round 1 voting resulted in consensus on eight items, with consensus defined as median voting score in the same tercile (1-3, 4-6 or 7-9). Re-voting at the meeting (round 2) reached consensus on the remaining item. CONCLUSION:An mDP with various stakeholders facilitated consensus on the design of a trial of different management strategies for chronic gout. This method may be useful for designing trials of clinical questions with substantial disagreement across stakeholders.
What Is the Evidence for Treat-to-Target Serum Urate in Gout?
Bursill David,Dalbeth Nicola
Current rheumatology reports
PURPOSE OF REVIEW:Most current clinical guidelines for gout management advocate a treat-to-target serum urate approach, although notable differences exist. Serum urate is a rational target for gout treatment given the central role of urate in disease causality, its association with key outcomes and its practicality of use in clinical practice. This review analyses the evidence for this strategy in gout. RECENT FINDINGS:Recent studies have confirmed the efficacy of urate-lowering therapy in achieving serum urate targets, both in trials using fixed doses and those applying a treat-to-target strategy. In a limited number of long-term studies (> 12-month duration), interventions that incorporate a treat-to-target serum urate approach have been shown to promote regression of tophi, reduce the frequency of gout flares and improve MRI-detected synovitis. A strong case can be made for a treat-to-target serum urate strategy in gout, supported by existing knowledge of disease pathophysiology, outcomes from urate-lowering therapy studies and emerging results of randomised strategy trials of sufficient duration.
Patient and provider barriers to effective management of gout in general practice: a qualitative study.
Spencer Karen,Carr Alison,Doherty Michael
Annals of the rheumatic diseases
OBJECTIVES:To explore patient and provider illness perceptions and barriers to effective management of gout in general practice. DESIGN AND SETTING:A qualitative study involving semistructured face-to-face interviews with patients and health professionals from 25 Nottinghamshire general practices and one central National Health Service hospital. PARTICIPANTS:Twenty gout sufferers and 18 health professionals (six general practitioners, five hospital physicians, seven practice nurses). RESULTS:A number of key themes emerged suggesting that several factors impact on patients' access to recommended treatments. The main barriers were patient experiences and lay beliefs of their condition which affected seeking advice and adherence to treatment. There was universal lack of knowledge and understanding of the causes and consequences of gout and that it can be treated effectively by lifestyle change and use of urate lowering therapy (ULT). All participants associated gout with negative stereotypical images portrayed in Victorian cartoons. Many viewed it as self-inflicted or part of ageing and only focused on managing acute attacks rather than treating the underlying cause. The main provider barriers that emerged related to health professionals' lack of knowledge of gout and management guidelines, reflected in the suboptimal information they gave patients and their reluctance to offer ULT as a 'curative' long-term management strategy. CONCLUSION:There are widespread misconceptions and lack of knowledge among both patients and health professionals concerning the nature of gout and its recommended management, which leads to suboptimal care of the most common inflammatory joint disease and the only one for which we have 'curative' treatment.
Management of complex gout in clinical practice: Update on therapeutic approaches.
Narang Ravi K,Dalbeth Nicola
Best practice & research. Clinical rheumatology
Increasing therapeutic options are available for gout management. Anti-inflammatory agents are used in the acute management of gout flares, and interleukin-1 inhibitors are effective for those unable to take conventional anti-inflammatory treatments. Lowering of serum urate remains the cornerstone of effective long-term management. Allopurinol is the first-line urate-lowering therapy, and a gradual dose-escalation strategy to serum urate target is recommended. Febuxostat and lesinurad have been approved more recently. In a large cardiovascular outcomes trial, higher all-cause and cardiovascular mortality was observed with febuxostat than with allopurinol. Lesinurad should be co-prescribed with a xanthine oxidase inhibitor, and close monitoring of kidney function is required. Evidence for non-pharmacological management is limited, but personalised lifestyle modification may reduce associated cardiovascular risk. In this review, we discuss current principles in the gout management paradigm, consider strategies for managing complex, clinical scenarios, and review emerging therapies.
Cost-effectiveness of sequential urate lowering therapies for the management of gout in Singapore.
Pruis Sil-Ling,Jeon Yunjoo Karris,Pearce Fiona,Thong Bernard Yu-Hor,Aziz Mohamed Ismail Abdul
Journal of medical economics
Allopurinol is the most common urate lowering therapy (ULT) used to treat gout but may cause life-threatening severe cutaneous adverse reactions (SCAR) in a small number of patients. Risk of SCAR is increased for patients with the HLA-B*58:01 genotype. When alternative ULT is required, febuxostat or probenecid are recommended. The aim of this study was to conduct a cost-utility analysis of sequential ULT treatment strategies for gout, including strategies with and without HLA-B*58:01 genotyping prior to treatment initiation, with a view to inform optimal gout management in Singapore. A Markov model was developed from the Singapore healthcare payer perspective. Reflecting local practice, 12 different treatment strategies containing at least one ULT (allopurinol, febuxostat, probenecid) were evaluated in adults with gout. Response rates (SUA < 6mg/dL) were derived from an in-house network meta-analysis and from published literature. Incremental cost-effectiveness ratios (ICERs) were calculated over a 30-year time horizon, with costs and benefits discounted at 3% per annum. Sensitivity analyses were conducted to explore uncertainties. Sequential treatment of allopurinol 300 mg/day-allopurinol 600 mg/day-probenecid ("standard of care") was cost-effective compared to no ULT, with an ICER of SGD1,584/QALY. Allopurinol300-allopurinol600-probenecid-febuxostat sequence compared to allopurinol300-allopurinol600-probenecid had an ICER of SGD11,400/QALY. All other treatment strategies were dominated by preceding strategies. Treatment strategies incorporating HLA-B*58:01 genotyping before ULT use were dominated by the corresponding non-genotyping strategy. Current standard of care (allopurinol300-allopurinol 600-probenecid) for gout is cost-effective compared with no ULT in the local context. Febuxostat is unlikely to be cost-effective in Singapore at current prices unless it is used last-line.
"What say ye gout experts?" a content analysis of questions about gout posted on the social news website Reddit.
Derksen Christina,Serlachius Anna,Petrie Keith J,Dalbeth Nicola
BMC musculoskeletal disorders
BACKGROUND:Social media is increasingly used by patients to source information for managing chronic disease. The aim of this study was to understand patient information needs about gout by a content analysis of questions posted on the social news website Reddit. METHODS:We analysed questions posted onto the 'Gout sufferers unite' subreddit site. Two reviewers coded questions into categories (inter-reviewer kappa 0.70), with discordant coding resolved by a third reviewer. Data were analysed by calculating the frequency of questions within the categories. Where relevant, categories were further separated into sub-categories to allow organisation and interpretation of the data. RESULTS:We analysed 359 questions in 287 posts by 213 individuals. A wide range of questions arose. The single most common category related to uncertainty of diagnosis (22.3% questions), with questions about disease management common. Information-seeking about medications was generally cautious, with questions about side-effects, risk of flares after starting urate-lowering therapy, and decision to start urate-lowering therapy. Community users experiencing flares posted questions about flare management, including medications, sometimes in real-time. Dietary management questions included the effectiveness of dietary changes as a management strategy, choice of alcoholic beverage, and weight loss strategies. Questions about serum urate levels were rare (2.8% questions). CONCLUSIONS:Questions about gout posted on the subreddit site most often related to uncertainty about symptoms and disease management strategies, with infrequent questions about serum urate testing, results or targets. These findings may inform development of strategies to address the information needs of people with gout.
Comparative Study of Real-Life Management Strategies in Gout: Data From Two Protocolized Gout Clinics.
Te Kampe R,van Durme C,Janssen M,van Eijk-Hustings Y,Boonen A,Jansen T L
Arthritis care & research
OBJECTIVE:To compare outcomes of 2 gout clinics that implemented different treatment strategies. METHODS:Patients newly diagnosed with gout and a follow-up of 9-15 months were included. Co-primary outcomes were the proportion of patients reaching a serum uric acid (UA) ≤0.36 mmoles/liter and free of flares. Secondary outcomes were the proportion of patients requiring treatment intensification and experiencing adverse events. One clinic adopted a strict serum UA (≤0.30 mmoles/liter target) strategy, with early addition of a uricosuric to allopurinol, and the other clinic adopted a patient-centered (PC) strategy emphasizing a shared decision based on serum UA and patient satisfaction with gout control. Independent t-tests or chi-square tests were used to test differences in outcomes, and logistic regressions were used to adjust the effect of the treatment center on outcomes for confounders. RESULTS:In total, 126 and 86 patients had a follow-up mean ± SD of 11.3 ± 1.8 versus 11.1 ± 1.9 months. In the UA strategy, 105 of 126 patients (83%) compared to 63 of 86 (74%) in the PC strategy (P = 0.10) reached the threshold of ≤0.36 mmoles/liter; and 58 of 126 (46%) versus 31 of 86 (36%) were free of flares (P = 0.15). In the UA strategy, 76 of 126 patients (60%) were on allopurinol monotherapy compared to 63 of 86 (73%) in the PC strategy (P = 0.05), yet the number of adverse events was not different (n = 25 [20%] versus n = 20 [23%]; P = 0.55). Adjusting for confounders did not substantially change these associations. CONCLUSION:A strict UA strategy resulted in a nonsignificantly higher proportion of patients reaching a serum UA ≤0.36 mmoles/liter and being free of flares. This result was accomplished with significantly more therapy intensification. The small sample size plays a role in the significance of results.
2020 American College of Rheumatology Guideline for the Management of Gout.
FitzGerald John D,Dalbeth Nicola,Mikuls Ted,Brignardello-Petersen Romina,Guyatt Gordon,Abeles Aryeh M,Gelber Allan C,Harrold Leslie R,Khanna Dinesh,King Charles,Levy Gerald,Libbey Caryn,Mount David,Pillinger Michael H,Rosenthal Ann,Singh Jasvinder A,Sims James Edward,Smith Benjamin J,Wenger Neil S,Bae Sangmee Sharon,Danve Abhijeet,Khanna Puja P,Kim Seoyoung C,Lenert Aleksander,Poon Samuel,Qasim Anila,Sehra Shiv T,Sharma Tarun Sudhir Kumar,Toprover Michael,Turgunbaev Marat,Zeng Linan,Zhang Mary Ann,Turner Amy S,Neogi Tuhina
Arthritis care & research
OBJECTIVE:To provide guidance for the management of gout, including indications for and optimal use of urate-lowering therapy (ULT), treatment of gout flares, and lifestyle and other medication recommendations. METHODS:Fifty-seven population, intervention, comparator, and outcomes questions were developed, followed by a systematic literature review, including network meta-analyses with ratings of the available evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, and patient input. A group consensus process was used to compose the final recommendations and grade their strength as strong or conditional. RESULTS:Forty-two recommendations (including 16 strong recommendations) were generated. Strong recommendations included initiation of ULT for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares; allopurinol as the preferred first-line ULT, including for those with moderate-to-severe chronic kidney disease (CKD; stage >3); using a low starting dose of allopurinol (≤100 mg/day, and lower in CKD) or febuxostat (<40 mg/day); and a treat-to-target management strategy with ULT dose titration guided by serial serum urate (SU) measurements, with an SU target of <6 mg/dl. When initiating ULT, concomitant antiinflammatory prophylaxis therapy for a duration of at least 3-6 months was strongly recommended. For management of gout flares, colchicine, nonsteroidal antiinflammatory drugs, or glucocorticoids (oral, intraarticular, or intramuscular) were strongly recommended. CONCLUSION:Using GRADE methodology and informed by a consensus process based on evidence from the current literature and patient preferences, this guideline provides direction for clinicians and patients making decisions on the management of gout.
[Treat to target in gouty arthritis].
Gout is a crystal-induced, metabolically determined inflammatory rheumatic disease with increasing prevalence. In clinical practice, gout causes frequent diagnostic as well as therapeutic problems. The golden diagnostic standard is crystalographic analysis and evidence of monosodium urate crystals in the polarization microscope; if this is not available, the diagnosis can be established through a combination of clinical, laboratory and imaging techniques. The acute gouty attack must be treated by quick administration of anti-inflammatory medicines, with available alternatives being nonsteroidal antirheumatic drugs (NSA), colchicine and glucocorticoids. When the attack subsides, hypouricemic therapy is initiated which should combine the regimen and diet measures and pharmacological treatment. Recommendations for the treatment of gout were published by the EULAR and the Czech Society for Rheumatology. Recently a new strategy appeared known as Treat to target - T2T. This principle has been successfully used in the treatment of rheumatiod arthritis and spondyloarthritis. The publication is structured as four overarching principles and nine Recommendations. The recommendations emphasize long-term maintenance of serum levels of uric acid below 360 μmol/l as the basic gout-related target in all patients, and below 300 μmol/l for patients with tophies. It is recommended to administer prophylactic small doses of colchicine for at least 3-6 months on the commencement of hypouricemic therapy. The Recommendations further emphasize the need for regular monitoring of comorbidities and the kidney function. A separate recommendation is concerned with necessary education of patients and their motivation toward compliance with regimen measures and increased physical activity.Key words: colchicine - gouty arthritis - treat to target principle.
Treat to Target in Axial Spondyloarthritis: What Are the Issues?
Danve Abhijeet,Deodhar Atul
Current rheumatology reports
PURPOSE OF THE REVIEW:Treat to Target (T2T) strategy has been widely used in the management of chronic medical conditions, such as hypertension, diabetes, and hypothyroidism, as well as rheumatic diseases, such as rheumatoid arthritis and gout. The purpose of this review is to discuss the importance, feasibility, and challenges in adopting the T2T strategy for the management of axial spondyloarthritis (axSpA). RECENT FINDINGS:In 2014, a panel of international experts published recommendations for T2T in axSpA. Recent Tight Control of Inflammation in Early Psoriatic Arthritis (TICOPA) trial demonstrated efficacy of T2T in the management of the psoriatic arthritis. However, there are several issues in the adoption of T2T in axSpA. They include lack of evidence of the impact of aggressive management on clinical and radiographic outcomes in axSpA and unavailability of a definite target for the treatment, as well as limited therapeutic options. In this review, we discuss the intricacies of the T2T strategy in axSpA. We need more clinical evidence in the form of randomized clinical studies to assess the impact of T2T on outcomes in axSpA. We also need a definite target which is useful in the routine clinical practice, as well as for clinical trials.
Treat-to-target in axial spondyloarthritis: gold standard or fools' gold?
Machado Pedro M,Deodhar Atul
Current opinion in rheumatology
PURPOSE OF REVIEW:Treat-to-target (T2T) is an emerging management strategy in axial spondyloarthritis (axSpA). The concept was originally based on evidence from other chronic conditions, such as hypertension, diabetes and hypothyroidism, as well as some rheumatic diseases, such as rheumatoid arthritis and gout. The purpose of this review is to discuss the arguments against and in favour of adopting a T2T strategy in the management of axSpA. RECENT FINDINGS:International groups have recommended a T2T strategy in axSpA. Inactive disease according to the Ankylosing Spondylitis Disease Activity Score (ASDAS) has been suggested as a potential target. Achievement of ASDAS inactive disease has been associated with less progression of radiographic damage in several studies. Evidence for the benefit of a T2T approach has been published in psoriatic arthritis, a form of spondyloarthritis. SUMMARY:Observational evidence suggests that a T2T approach might be beneficial in axSpA. However, data from a prospective randomized study proving the efficacy of a T2T strategy compared to routine care are still lacking. Moreover, the cost-effectiveness of such strategy in clinical practice also needs to be tested. The target will need to be useful and feasible in both clinical practice and clinical trials.
Treat-to-Target urate-lowering therapy in primary gout patients: A real-world retrospective study at a dedicated gout clinic in China.
Bai Xue-Shan,Wang Ming,Zhao Xiao-Dong,Cui Ling-Ling,He Yu-Wei,Wang Can,Li Xin-De,Qu Xiao-Jie,Sun Ming-Shu,Li Chang-Gui
Technology and health care : official journal of the European Society for Engineering and Medicine
BACKGROUND:Gout is the most common inflammatory arthritis affecting 1.1% of the population in mainland China with a higher prevalence in coastal areas. OBJECTIVE:The purpose of the study was to investigate the clinical outcomes following urate-lowering therapy (ULT) in a real-world group study of primary gout patients in China. METHODS:Electronic medical records of all the gout patients (n= 1588) that visited the Clinical Medical Center of Gout of the Affiliated Hospital of Qingdao University from September 2016 to February 2018 were analyzed in this study. The patients were treated with a standard treat-to-target (T2T) ULT strategy according to the 2016 EULAR Guidelines. Clinical data were collected in the first visit and one-month (defined as the baseline of ULT), 7-month, and 13-month follow-ups were completed. RESULTS:Amongst the patients in the study, 92.70% accepted ULT and 82.93% completed ULT for 3 months, 63.54% for 6 months, and 40.49% (n= 643) for 12 months. Further analysis of the 643 patients included the following data: the sUA level reduced at month 7 and reduced further at month 13. The gout flares, patient global pain visual analogue score, and health assessment questionnaire score improved at month 7 but did not improve further at month 13, and the index tophus size did not.
Chronic gout: Barriers to effective management.
Rogenmoser Sylvie,Arnold Mark H
Australian journal of general practice
BACKGROUND:Gout is one of the most common inflammatory arthropathies, and the pathogenesis is well understood. In Australia, most patients with chronic tophaceous gout (CTG) are treated by general practitioners (GPs). Urate-lowering therapy, if adhered to continuously, can suppress the disease, reduce the likelihood of flares and prevent long-term complications such as disfiguring tophi and joint damage. Many rheumatology societies recommend a treat-to-target (T2T) approach, lowering serum urate to 0.35 mmol/L or below with urate lowering therapy. OBJECTIVE:The aim of this article is to discuss inconsistencies in treatment guidelines, identify patient and physician barriers to optimal gout care, explain why a T2T approach is appropriate and make a series of recommendations that are practical for GPs. DISCUSSION:Despite an in-depth understanding of this controllable disease and the availability of simple, safe treatments, chronic gout remains poorly managed. The development of Australian gout guidelines that are easily implemented by GPs is vital and overdue.
Treat to target in gout.
Perez-Ruiz Fernando,Moreno-Lledó Aitana,Urionagüena Irati,Dickson Alastair J
Rheumatology (Oxford, England)
The treat-to-target (T2T) approach has been successfully implemented in a number of diseases. T2T has been proposed for rheumatic diseases such as RA, spondyloarthritis, lupus, and recently for gout. The level of evidence for such approaches differs from one condition to the other (moderate to high for hyperlipidaemia, for example). Practice is based on the best available evidence at any time, and in absence of good evidence for T2T in gout, some suggest a conservative only-treat-symptoms approach. Evidence suggests that not treating gout to target in the long term is overall associated with worsening outcomes, such as flares, tophi and structural damage, which is associated to loss of quality of life and mortality. Different targets have been proposed for hyperuricaemia in gout; lower than 6 mg/dl (0.36 mmol/l) for all patients, at least <5 mg/dl (0.30 mmol/l) for patients with severe-polyarticular or tophaceous-gout.
Global patterns of treat-to-serum urate target care for gout: Systematic review and meta-analysis.
Son Chang-Nam,Stewart Sarah,Su Isabel,Mihov Borislav,Gamble Gregory,Dalbeth Nicola
Seminars in arthritis and rheumatism
BACKGROUND:International rheumatology guidelines advocate a treat to serum urate target (T2T) approach for gout management. While individual studies have reported regional and national-level gout management, global patterns in gout care have not been synthesized. This study aimed to systematically review and meta-analyze global T2T care for patients with gout. METHODS:Electronic databases were searched for studies reporting medication and serum urate testing in patients with gout. Meta-analyses were conducted to determine the pooled proportion of patients with gout achieving pre-specified T2T indicators. RESULTS:Sixty-seven papers were included from North America (n = 31 studies), Europe (n = 22), Oceania (n = 7), Asia (n = 6), and reporting data from multiple continents (n = 1). The global pooled percentages (95% confidence interval (CI)) of patients with gout achieving T2T indicators were: 52% (45%, 59%) on urate lowering therapy (ULT), 50% (40%, 61%) on ULT receiving regular uninterrupted ULT, 53% (40%, 65%) on ULT having any serum urate testing, and 34% (28%, 41%) on ULT achieving a serum urate target. CONCLUSION:Outside North America and Europe, there are relatively few studies about T2T care for gout management. However, available data demonstrate that a minority of people with gout receive T2T care worldwide. For those prescribed ULT, there are low rates of continuous therapy, serum urate testing, and achievement of serum urate target.
Gout in a rheumatology clinic: results of EULAR/ACR guidelines-compliant treatment.
Scandinavian journal of rheumatology
OBJECTIVE:Surveys of treatment results of gout in primary care have shown that less than 25% of patients reach the recommended treatment target (serum urate < 0.36 mmol/l). The aim of this study was to measure the results of a specialized European League Against Rheumatism/American College of Rheumatology (EULAR/ACR) guidelines-based treatment of gout in a rheumatology clinic. METHOD:Data from consecutive new crystal-proven gout patients were analysed in a prospective observational study. RESULTS:The study included 100 patients: 88 males aged 62.1 ± 13.1 years (mean ± sd) and 12 females aged 74.1 ± 6.9 years. Disease duration was 8.6 ± 6.9 years, and the disease pattern was monoarticular, oligoarticular, polyarticular, and tophaceous in 18, 37, 25, and 20 patients, respectively. Overall, 42% had tried urate-lowering treatment (ULT) ever and 15% were on ULT at entry. ULT was initiated or intensified in a treat-to-target (T2T) approach in 93 patients, with flare prophylactic colchicine treatment in 90 patients. T2T was successfully reached in 85 patients after 4.7 ± 3.9 months and 82 patients reached a state of well-controlled disease (T2T reached for 3 months and no flares or anti-inflammatory treatment for 1 month) after 10.4 ± 5.6 months. Ten patients did not reach T2T owing to low compliance and five patients did not reach T2T owing to adverse effects or nephropathy. CONCLUSION:EULAR/ACR guidelines-compliant treatment in a rheumatology clinic with verified diagnosis, patient education, T2T with ULT, and flare prophylaxis led to successful treatment results in 85% of patients.
A treat-to-target approach for gout confers renoprotective effect in patients with chronic kidney disease stage 3.
Novella-Navarro Marta,Cabrera-Alarcon Jose Luis,Diaz-Torne Cesar,Aramburu-Muñoz Francisco,Janta Iustina,Ortega de la O Maria Carmen,Prada-Ojeda Alejandro,Sala-Icardo Luis,Urruticoechea-Arana Ana,García de la Peña Lefebvre Paloma,Calvo-Aranda Enrique
The aim of this study was to assess changes in the estimated glomerular filtration rate (eGFR) in gouty patients with chronic kidney disease (CKD) using a "treat-to-target" (T2T) approach in gout. This multicenter observational retrospective study included patients diagnosed with gout and CKD stage 3 taking xanthine oxidase inhibitors (XOIs) (allopurinol or febuxostat) for at least 12 months. All patients were treated using a T2T strategy according to national gout guidelines to achieve the target levels of serum uric acid (sUA; < 5-6 mg/dl) within 6 months of the first visit. The primary outcome was to assess changes in eGFR. The effects of independent variables were analyzed over eGFR in a linear mixed-effects (LME) model. Fifty patients with gout and CKD stage 3 treated with XOIs with a T2T strategy for 12 months were included. Eighty-two percent of the patients achieved the sUA target during the study period. The improvement seen in eGFR was higher during the first 6 months, showing a median increase of 7.54 ml/min/m (SE = 1.25) and trending towards stability over 12 months. For every 1 mg/dl of decrease in sUA, an improvement of 1.5 ml/min/m in eGFR was observed (coefficient ± SE: - 1.58 ± 0.26) (p < 0.001) with no differences between type and dosage of XOIs treatment, colchicine administration, age, sex, and smoking status. A reduction in sUA levels using a T2T approach with XOIs at an optimal dose is possible and could help conserve and improve renal function in gouty patients with CKD stage 3.
Treat-to-target (T2T) of serum urate (SUA) in gout: a clinical audit in real-world gout patients.
Teh C L,Cheong Y K,Wan S A,Ling G R
Treat-to-target (T2T) for gout has been established recently to improve its management, which has been reported to be sub-optimal with significant gaps between the goals of treatment and day-to-day clinical practice. T2T recommended a goal of serum urate (SUA) target of <360 μmoI/L in all patients with gout and <300 μmoI/L in patients with tophaceous or severe gout. T2T strategy was applied in the management of gout patients in two Rheumatology clinics from 1 January 2016 onwards. We performed a clinical audit to assess T2T of SUA in gout patients and to identify causes for failure to achieve target SUA among them. There were a total of 304 patients for our analysis. They were of multi-ethnic origin with male predominance (88.8%). They had a mean age of 57.7+13.7 years and mean disease duration of 10.1+8.7 years. The most common comorbidities were hypertension (76.2%), dyslipidemia (52.5%) and diabetes mellitus (DM) (27.4%). Our patients' body mass indexes showed that 47.7% were obese while 34.2% were overweight. Up to 62.4% of our patients had tophi and 42.6% had joint deformities. Only 34.9% of patients achieved target SUA. Nonadherence (52.3%) was the main reason identified for failure to achieve target SUA. The independent predictors for failure to achieve target SUA were nonadherence (HR=7.84, p=0.000) and presence of tophi (HR=1.95, p=0.001).
Using serum urate as a validated surrogate end point for flares in patients with gout: protocol for a systematic review and meta-regression analysis.
Morillon Melanie B,Stamp Lisa,Taylor William,Fransen Jaap,Dalbeth Nicola,Singh Jasvinder A,Christensen Robin,Lassere Marissa
INTRODUCTION:Gout is the most common inflammatory arthritis in men over 40 years of age. Long-term urate-lowering therapy is considered a key strategy for effective gout management. The primary outcome measure for efficacy in clinical trials of urate-lowering therapy is serum urate levels, effectively acting as a surrogate for patient-centred outcomes such as frequency of gout attacks or pain. Yet it is not clearly demonstrated that the strength of the relationship between serum urate and clinically relevant outcomes is sufficiently strong for serum urate to be considered an adequate surrogate. Our objective is to investigate the strength of the relationship between changes in serum urate in randomised controlled trials and changes in clinically relevant outcomes according to the 'Biomarker-Surrogacy Evaluation Schema version 3' (BSES3), documenting the validity of selected instruments by applying the 'OMERACT Filter 2.0'. METHODS AND ANALYSIS:A systematic review described in terms of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines will identify all relevant studies. Standardised data elements will be extracted from each study by 2 independent reviewers and disagreements are resolved by discussion. The data will be analysed by meta-regression of the between-arm differences in the change in serum urate level (independent variable) from baseline to 3 months (or 6 and 12 months if 3-month values are not available) against flare rate, tophus size and number and pain at the final study visit (dependent variables). ETHICS AND DISSEMINATION:This study will not require specific ethics approval since it is based on analysis of published (aggregated) data. The intended audience will include healthcare researchers, policymakers and clinicians. Results of the study will be disseminated by peer-reviewed publications. TRIAL REGISTRATION NUMBER:CRD42016026991.
Diagnosis of Acute Gout: A Clinical Practice Guideline From the American College of Physicians.
Qaseem Amir,McLean Robert M,Starkey Melissa,Forciea Mary Ann, ,Denberg Thomas D,Barry Michael J,Boyd Cynthia,Chow R Dobbin,Fitterman Nick,Humphrey Linda L,Kansagara Devan,Manaker Scott,Vijan Sandeep,Wilt Timothy J
Annals of internal medicine
Description:The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on the diagnosis of gout. Methods:This guideline is based on a systematic review of published studies on gout diagnosis, identified using several databases, from database inception to February 2016. Evaluated outcomes included the accuracy of the test results; intermediate outcomes (results of laboratory and radiographic tests, such as serum urate and synovial fluid crystal analysis and radiographic or ultrasonography changes); clinical decision making (additional testing and pharmacologic or dietary management); short-term clinical (patient-centered) outcomes, such as pain and joint swelling and tenderness; and adverse effects of the tests. This guideline grades the evidence and recommendations by using the ACP grading system, which is based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method. Target Audience and Patient Population:The target audience for this guideline includes all clinicians, and the target patient population includes adults with joint inflammation suspected to be gout. Recommendation:ACP recommends that clinicians use synovial fluid analysis when clinical judgment indicates that diagnostic testing is necessary in patients with possible acute gout. (Grade: weak recommendation, low-quality evidence).
Improvement in Diagnosis and Treat-to-Target Management of Hyperuricemia in Gout: Results from the GEMA-2 Transversal Study on Practice.
Perez Ruiz Fernando,Sanchez-Piedra Carlos A,Sanchez-Costa Jesus T,Andrés Mariano,Diaz-Torne Cesar,Jimenez-Palop Mercedes,De Miguel Eugenio,Moragues Carmen,Sivera Francisca
Rheumatology and therapy
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.
A Pharmacist-Staffed, Virtual Gout Management Clinic for Achieving Target Serum Uric Acid Levels: A Randomized Clinical Trial.
Goldfien Robert,Pressman Alice,Jacobson Alice,Ng Michele,Avins Andrew
The Permanente journal
CONTEXT:Relatively few patients with gout receive appropriate treatment. OBJECTIVE:To determine whether a pharmacist-staffed gout management program is more effective than usual care in achieving target serum uric acid (sUA) levels in gout patients. DESIGN:A parallel-group, randomized controlled trial of a pharmacist-staffed, telephone-based program for managing hyperuricemia vs usual care. Trial duration was 26 weeks. MAIN OUTCOME MEASURES:Primary outcome measure was achieving sUA levels at or below 6 mg/dL at the 26-week visit. Secondary outcome was mean change in sUA levels in the control and intervention groups. Participants were adults with recurrent gout and sUA levels above 6.0 mg/dL. Participants were randomly assigned to management by a clinical pharmacist following protocol or to monitoring of sUA levels but management of their gout by their usual treating physician. RESULTS:Of 102 patients who met eligibility criteria, 77 subjects obtained a baseline sUA measurement and were entered into the trial. Among 37 participants in the intervention group, 13 (35%) had sUA levels at or below 6.0 mg/dL at 26 weeks, compared with 5 (13%) of 40 participants in the control group (risk ratio = 2.8, 95% confidence interval [CI] = 1.1 to 7.1, p = 0.03). The mean change in sUA levels among controls was +0.1 mg/dL compared with -1.5 mg/dL in the intervention group (sUA difference = -1.6, 95% CI = -0.9 to -2.4, p < 0.001). CONCLUSIONS:A structured pharmacist-staffed program was more effective than usual care for achieving target sUA levels. These results suggest a structured program could greatly improve gout management.
Pilot study of a multidisciplinary gout patient education and monitoring program.
Fields Theodore R,Rifaat Adam,Yee Arthur M F,Ashany Dalit,Kim Katherine,Tobin Matthew,Oliva Nicole,Fields Kara,Richey Monica,Kasturi Shanthini,Batterman Adena
Seminars in arthritis and rheumatism
OBJECTIVE:Gout patient self-management knowledge and adherence to treatment regimens are poor. Our objective was to assess the feasibility and acceptability of a multidisciplinary team-based pilot program for the education and monitoring of gout patients. METHODS:Subjects completed a gout self-management knowledge exam, along with gout flare history and compliance questionnaires, at enrollment and at 6 and 12 months. Each exam was followed by a nursing educational intervention via a structured gout curriculum. Structured monthly follow-up calls from pharmacists emphasized adherence to management programs. Primary outcomes were subject and provider program evaluation questionnaires at 6 and 12 months, program retention rate and success in reaching patients via monthly calls. RESULTS:Overall, 40/45 subjects remained in the study at 12 months. At 12 months, on a scale of 1 (most) to 5 (least), ratings of 3 or better were given by 84.6% of subjects evaluating the usefulness of the overall program in understanding and managing their gout, 81.0% of subjects evaluating the helpfulness of the nursing education program, and 50.0% of subjects evaluating the helpfulness of the calls from the pharmacists. Knowledge exam questions that were most frequently answered incorrectly on repeat testing concerned bridge therapy, the possibility of being flare-free, and the genetic component of gout. CONCLUSIONS:Our multidisciplinary program of gout patient education and monitoring demonstrates feasibility and acceptability. We identified variability in patient preference for components of the program and persistent patient knowledge gaps.
eHealth-supported decentralized multi-disciplinary care for gout involving rheumatology, pharmacy, and dietetics: proof-of-concept study.
Howren Alyssa,Tsao Nicole W,Choi Hyon K,Shojania Kam,Kydd Alison,Friesen Russell,Avina-Zubieta J Antonio,De Vera Mary A
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.
Effectiveness of an electronic patient-centred self-management tool for gout sufferers: a cluster randomised controlled trial protocol.
Day Richard O,Frensham Lauren J,Nguyen Amy D,Baysari Melissa T,Aung Eindra,Lau Annie Y S,Zwar Nicholas,Reath Jennifer,Laba Tracey,Li Ling,McLachlan Andrew,Runciman William B,Buchbinder Rachelle,Clay-Williams Robyn,Coiera Enrico,Braithwaite Jeffrey,McNeil H Patrick,Hunter David J,Pile Kevin D,Portek Ian,WIlliams Kenneth Mapson,Westbrook Johanna I
INTRODUCTION:Gout is increasing despite effective therapies to lower serum urate concentrations to 0.36 mmol/L or less, which, if sustained, significantly reduces acute attacks of gout. Adherence to urate-lowering therapy (ULT) is poor, with rates of less than 50% 1 year after initiation of ULT. Attempts to increase adherence in gout patients have been disappointing. We aim to evaluate the effectiveness of use of a personal, self-management, 'smartphone' application (app) to achieve target serum urate concentrations in people with gout. We hypothesise that personalised feedback of serum urate concentrations will improve adherence to ULT. METHODS AND ANALYSIS:Setting and designPrimary care. A prospective, cluster randomised (by general practitioner (GP) practices), controlled trial. PARTICIPANTS:GP practices will be randomised to either intervention or control clusters with their patients allocated to the same cluster. INTERVENTION:The intervention group will have access to the Healthy.me app tailored for the self-management of gout. The control group patients will have access to the same app modified to remove all functions except the Gout Attack Diary. PRIMARY AND SECONDARY OUTCOMES:The proportion of patients whose serum urate concentrations are less than or equal to 0.36 mmol/L after 6 months. Secondary outcomes will be proportions of patients achieving target urate concentrations at 12 months, ULT adherence rates, serum urate concentrations at 6 and 12 months, rates of attacks of gout, quality of life estimations and process and economic evaluations. The study is designed to detect a ≥30% improvement in the intervention group above the expected 50% achievement of target serum urate at 6 months in the control group: power 0.80, significance level 0.05, assumed 'dropout' rate 20%. ETHICS AND DISSEMINATION:This study has been approved by the University of New South Wales Human Research Ethics Committee. Study findings will be disseminated in international conferences and peer-reviewed journal. TRIAL REGISTRATION NUMBER:ACTRN12616000455460.
Change gout: how to deal with this "silently-developing killer" in everyday clinical practice.
Scirè Carlo Alberto,Rossi Cristina,Punzi Leonardo,Genderini Augusto,Borghi Claudio,Grassi Walter
Current medical research and opinion
BACKGROUND:Despite being regarded as an easily-treatable disease, gout diagnosis and management can be challenging. REVIEW:This review discusses current issues in gout management and proposes some potential solutions. Gout diagnosis should be reached as early as possible and often requires specific tests, such as synovial fluid analysis or imaging techniques that are not available in most centers, leaving healthcare professionals to rely only on clinical presentations and their experience. In addition, gout management requires the evaluation of multiple aspects, such as monitoring of serum uric acid (sUA) level (which should be reduced to <6 mg/dL) to ensure adherence and efficacy of treatment, evaluation of patient's risk profile and comorbidities, and continuous assessments to manage clinical manifestations. An important premise in gout management is non-pharmacological intervention; however, pharmacological urate-lowering therapy is crucial for an optimal control of the disease. Available options include xanthine-oxidase inhibitors (XOI), targeting uric acid overproduction, and uricosuric agents which target the predominant cause of hyperuricemia (under-excretion). Among these, lesinurad is the novel uricosuric agent to be used in combination with XOI in patients with gout not adequately controlled with XOI alone, which can further contribute to the control of hyperuricemia in gout. CONCLUSIONS:Multidisciplinary management is crucial for the diagnosis and treatment of gout, in order to ensure treatment continuity and improve management. This review, therefore, advises that educational activities for General Practitioners and specialists should be implemented to help raise awareness on gout diagnosis, monitoring, and treatment.
Palm-Sized Uric Acid Test Lab Powered by Smartphone for Proactive Gout Management.
Fu Yusheng,Yan Minghong,Yang Huan,Ma Xing,Guo Jinhong
IEEE transactions on biomedical circuits and systems
A simple and convenient photochemical system based on a smartphone-powered photochemical dongle and disposable photochemical test strips was proposed in this paper. The components of the system were only connected with each other in a simple hot-plug way, but provided a convenient function of biological sample detection. The photochemical dongle working as a highly rigorous reflectance spectral analyzer was used to evaluate the uric acid levels of the fingertip whole blood with the participation of the photochemical test strip for the point of care, which showed good agreement (linear regression coefficient of 0.99338) as compared to the results from the specific and bulky biochemical analyzer in the clinical test. Furthermore, combined with the widespread smartphone and well-developed Internet, the photochemical dongle could provide a flexible and portable platform for the evaluation and treatment of chronic diseases, such as gout, and it is promising to be applied in the remote chronic disease management.
Development and evaluation of a self-management application for patients with gout.
Kang Seung Gum,Lee Eun Nam
Japan journal of nursing science : JJNS
AIM:The present study aimed to develop a self-management application for patients with gout and determine the clinical feasibility of the application. METHODS:A self-management application (GoutCare) was developed from July 1, 2016, to October 30, 2016, by reflecting on the key elements of Fisher & Fisher's information-motivation-behavioral skills model. In order to determine the clinical feasibility of the application, a non-equivalent, control group, pre-test-posttest study was conducted among patients with gout who visited a university hospital from January to April 2017. Twenty-seven subjects in the experimental group used the smartphone allocation for 8 weeks, and 29 subjects in the control group were provided a leaflet with information on gout self-management. Knowledge of gout, self-management attitude, perceived social support, self-efficacy, self-management performance, and health-related quality of life before and after the intervention were measured using a structured questionnaire. RESULTS:The self-management application (GoutCare) developed for patients with gout was found to be effective in improving the knowledge of gout, self-management attitude, perceived social support, self-efficacy, self-management performance, and physical health-related quality of life. CONCLUSION:In conclusion, the application contributed to improving the self-management performance and health-related quality of life in the patients with gout. Therefore, this application can be used as a nursing intervention program for promoting self-management in patients with gout.
How patients with gout become engaged in disease management: a constructivist grounded theory study.
Howren Alyssa,Cox Susan M,Shojania Kam,Rai Sharan K,Choi Hyon K,De Vera Mary A
Arthritis research & therapy
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.
A User-Centred Approach to Designing an eTool for Gout Management.
Fernon Anna,Nguyen Amy,Baysari Melissa,Day Richard
Studies in health technology and informatics
INTRODUCTION:Gout is a chronic inflammatory arthritis with increasing prevalence in Australia and rates of non-adherence to therapy higher than for any other chronic disease. Electronic health interventions can increase adherence to treatment for many chronic diseases. This study set out to involve end-user patients in the design of a gout self-management eTool. METHODS:Four semi-structured focus group sessions were held in July and August 2015 with 13 patients with gout (age range 39-79 years). Focus groups involved group discussions of potential eTool features and critiquing disease self-management websites and applications. Focus group sessions were audio-taped, transcribed and analysed by two independent researchers to identify useful eTool features and patient perspectives of using technology to manage their health. FINDINGS:Participants were open to using a supportive gout self-management eTool and identified a number of potentially helpful features, including educational material, serum uric acid monitoring and medication reminder alerts. DISCUSSION:Focus groups with patients with gout revealed a number of features that should be included in a gout self-management eTool. These results will inform the design and implementation of an eTool for patients with gout and may be broadly applicable to teams designing eTools for other chronic diseases.
mHealth App Patient Testing and Review of Educational Materials Designed for Self-Management of Gout Patients: Descriptive Qualitative Studies.
Nguyen Amy D,Frensham Lauren J,Wong Michael Xc,Meslin Sylvain Mm,Martin Paige,Lau Annie Ys,Baysari Melissa T,Day Richard O
JMIR mHealth and uHealth
BACKGROUND:Gout is a form of chronic arthritis caused by elevated serum uric acid (SUA) and culminates in painful gout attacks. Although effective uric acid-lowering therapies exist, adherence is low. This is partly due to the lack of support for patients to self-manage their disease. Mobile health apps have been used in the self-management of chronic conditions. However, not all are developed with patients, limiting their effectiveness. OBJECTIVE:The objective of our study was to collect feedback from gout patients to design an effective gout self-management app. METHODS:Two descriptive qualitative studies were conducted. In Study 1, researchers developed a short educational video and written materials about gout management, designed to be embedded into an app; 6 interviews and 1 focus group were held with gout patients to gather feedback on these materials. Usability testing in Study 2 involved additional gout patients using a pilot version of Healthy.me Gout, a gout self-management app, for 2 weeks. Following the trial, patients participated in an interview about their experiences using the app. RESULTS:Patients viewed the gout educational material positively, appreciating the combined use of video, text, and images. Patients were receptive to using a mobile app to self-manage their gout. Feedback about Healthy.me Gout was generally positive with patients reporting that the tracking and diary features were most useful. Patients also provided suggestions for improving the app and educational materials. CONCLUSIONS:These studies involved patients in the development of a gout self-management app. Patients provided insight to improve the app's presentation and usability and general lessons on useful features for chronic disease apps. Gout patients enjoyed tracking their SUA concentrations and gout attack triggers. These capabilities can be translated into self-management apps for chronic diseases that require monitoring of pathological values, medication adherence, or symptoms. Future health app design should integrate patient input and be developed iteratively to address concerns identified by patients.
Implication of nurse intervention on engagement with urate-lowering drugs: A qualitative study of participants in a RCT of nurse led care.
Latif Zahira P,Nakafero Georgina,Jenkins Wendy,Doherty Michael,Abhishek Abhishek
Joint bone spine
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.
Why better treatment of gout is needed.
So Alexander K
Clinical and experimental rheumatology
The treatment of gout is thought to be simple, but in reality we are confronted regularly with patients who do not adhere to treatment and patients who have other medical conditions that render the choice of therapy difficult. A treat-to-target approach is essential in order to manage hyperuricaemia effectively and this, combined with a better use of existing treatments, offers the best way forward.
Gout Self-Management in African American Veterans: A Qualitative Exploration of Challenges and Solutions From Patients' Perspectives.
Singh Jasvinder A,Herbey Ivan,Bharat Aseem,Dinnella Janet E,Pullman-Mooar Sally,Eisen Seth,Ivankova Nataliya
Arthritis care & research
OBJECTIVE:To explore gout self-management and associated challenges and solutions in African Americans. METHODS:We conducted semistructured interviews with 35 African American veterans with gout, who received health care at Birmingham or Philadelphia Veterans Affairs (VA) medical centers, had filled urate-lowering therapy (ULT; most commonly allopurinol) for at least 6 months, and had a ULT medication possession ratio ≥80%. The interview protocol was constructed to explore key concepts related to gout self-management, including initial diagnosis of gout, beginning medical care for gout, the course of the gout, ULT medication adherence, dietary strategies, comorbidity and side effects, and social support. RESULTS:Thirty-five African American male veterans with gout who had ≥80% ULT adherence (most commonly, allopurinol) were interviewed at Birmingham (n = 18) or Philadelphia (n = 17) VA medical centers. Mean age was 65 years, mean body mass index was 31.9 kg/m , 97% had hypertension, 23% had coronary artery disease, and 31% had renal failure. The main themes motivating African American veterans to better gout self-management were fear of pain, adherence to medications, self-discipline, lifestyle changes, information gathering, and developing a positive outlook. Birmingham participants more frequently revealed skipping gout medications. More Philadelphia participants discussed lifestyle/diet changes to prevent gout flares, indicated limiting social activities that involved drinking, and sought more information about gout self-management from health care providers and internet sources. CONCLUSION:Identified themes, including cultural differences by site, led to the development of a patient-centered intervention to improve gout self-management in African American men with gout.
Poorly controlled gout: who is doing poorly?
Chia Faith Li-Ann
Singapore medical journal
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.
Pharmacist-managed titration of urate-lowering therapy to streamline gout management.
Huang Irvin J,Liew Jean W,Morcos Meredith B,Zuo Silu,Crawford Carol,Bays Alison M
The treat-to-target approach for serum uric acid is the recommended model in gout management according to the 2012 American College of Rheumatology (ACR) guidelines. Adherence to urate-lowering therapy (ULT) can be difficult for patients due to barriers, which include medication burden, financial hardship, and lack of medical literacy. Our aim was to create a pharmacist-managed referral for the titration of ULT to target serum uric acid (sUA) levels in a complex patient population. We utilized a clinical database to query patients seen at a rheumatology clinic over a 12-month period with an ICD-10 diagnosis for gout. The referral criteria were indications for ULT per the 2012 ACR guidelines. Rheumatology providers, consisting of attendings, fellows, and a physician assistant, were asked to refer the identified patients to the pharmacist-managed titration program. The intervention group consisted of 19 referred patients and the control group consisted of 28 non-referred patients. The baseline sUA (median (IQR)) at the time of referral was 8.8 (2) mg/dL for the intervention group and 7.6 (2.8) mg/dL for the control group (p = 0.2). At the end of the study period, the sUA was 6.1 (1.4) mg/dL for the intervention group and 6.8 (3.2) mg/dL for the control group (p = 0.08). At the end of the study period, 6 of 19 (32%) intervention group and 7 of 28 (25%) control group were at goal (p = 0.3). A newly instituted pharmacist-managed titration program was able to achieve lower average sUA levels in referred patients compared to demographically similar individuals who received standard gout management.
General practitioners' perspectives on the management of gout: a qualitative study.
Jeyaruban Andrew,Soden Muriel,Larkins Sarah
Postgraduate medical journal
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.
A cross-sectional internet-based patient survey of the management strategies for gout.
Singh Jasvinder A,Shah Nipam,Edwards N Lawrence
BMC complementary and alternative medicine
BACKGROUND:Almost half of the patients with gout are not prescribed urate-lowering therapy (ULT) by their health care provider and >50 % use complementary and alternative therapies. Diet modification is popular among gout patients due to known associations of certain foods with gout flares. The interplay of the use of dietary supplements, diet modification, and ULT adherence in gout patients is not known. Despite the recent interest in diet and supplements, there are limited data on their use. Our objective was to assess ULT use and adherence and patient preference for non-pharmacological interventions by patients with gout, using a cross-sectional survey. METHODS:People who self-reported physician-diagnosed gout during their visit to a gout website ( http://gouteducation.org ) were invited to participate in a brief anonymous cross-sectional Internet survey between 08/11/2014 to 04/14/2015 about the management of their gout. The survey queried ULT prescription, ULT adherence, the use of non-pharmacological interventions (cherry extract, diet modification) and the likelihood of making a lifelong diet modification for gout management. RESULTS:A total of 499 respondents with a mean age 56.3 years were included; 74% were males and 74% were White. Of these, 57% (285/499) participants were prescribed a ULT for gout, of whom 88% (251/285) were currently taking ULT. Of those using ULT, 78% (97/251) reported ULT adherence >80%. Gender, race, and age were not significantly associated with the likelihood of receiving a ULT prescription or ULT adherence >80%. Fifty-six percent of patients with gout preferred ULT as a lifelong treatment for gout, 24% preferred cherry extract and 16% preferred diet modification (4% preferred none). Men had significantly lower odds of preferring ULT as the lifelong treatment choice for gout vs. other choices (p = 0.03). We found that 38.3% participants were highly motivated to make a lifelong dietary modification to improve their gout (score of 9-10 on a 0-10 likelihood scale). Older age was significantly associated with high level of willingness to modify diet (p = 0.02). CONCLUSION:We found that only 57% of gout patients reported being prescribed ULT. 40% of gout patients preferred non- pharmacological interventions such as cherry extract and diet modification for gout management. The latter finding requires further investigation.
The Challenges of Approaching and Managing Gout.
Fields Theodore R
Rheumatic diseases clinics of North America
Despite many effective treatments for gout, its management remains a challenge internationally. Options for optimizing gout management may differ in different practice sizes and settings. Gout incidence is rising and it continues to be associated with increased mortality. Education of patients and medical providers is essential, and newer gout medications need to be used in the most appropriate ways for cost-effective therapy. Special consideration needs to be given to such populations as the elderly and those with renal and cardiovascular disease in gout management. New agents are in development, which may add to the armamentarium for gout management.
Are Doctors the Best People to Manage Gout? Is There a Role for Nurses and Pharmacists?
Latif Zahira,Abhishek Abhishek
Current rheumatology reports
PURPOSE OF REVIEW:To discuss alternate models of long-term gout management RECENT FINDINGS: Nurse-led care of gout appears to improve the uptake of and adherence to urate-lowering treatment in a research setting. Less impressive improvements were achieved with pharmacist-led remote management of gout; however, both strategies were more effective than usual primary care provider management of gout. Individualised education about gout, patient involvement in decision-making, and access to trained support in managing side-effects and gout flares can improve the uptake of fine and adherence to urate-lowering treatment. This may be best achieved with nurse-led care of gout. However, further research is required to evaluate if the model of nurse-led care of gout can be implemented in routine clinical practice and in different healthcare systems.
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.
Abhishek Abhishek,Jenkins Wendy,La-Crette Jonathan,Fernandes Gwen,Doherty Michael
Rheumatology (Oxford, England)
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.
Adherence to gout management recommendations of Chinese patients.
Sheng Feng,Fang Weigang,Zhang Bingqing,Sha Yue,Zeng Xuejun
Though efficacious and affordable treatments for gout are widely available, gout is still not well controlled in many countries of the world including China.To investigate patient adherence to gout management recommendations and potential barriers in Chinese male gout patients, a survey was carried out by telephone interview in male patients registered in the gout clinic at Peking Union Medical College Hospital. Adherence to dietary and medication recommendations was measured by a food frequency questionnaire and proportion of cumulative time adherent to chemical urate-lowering therapy (ULT), respectively. Dietary adherence was defined as consumption of alcohol, seafood and animal organs less than once per month, and reduced red meat after dietary counseling. Medication adherence was defined as ULT ≥80% of time in the past 12 months for patients with indications. Logistic regression models were used to identify patient characteristics associated with management adherence. Reasons for nonadherence were also sought by open-end questions.Dietary and medication adherence were 44.2% and 21.9%, respectively. Older age (odds ratio [OR] 7.90, 95% confidence interval [CI] 2.49-25.04 for age ≥60), higher serum uric acid (sUA) levels (OR 3.53, 95% CI 1.42-8.75 for the highest quartile), and tophi (OR 2.31, 95% CI 1.12-4.77) were associated with dietary adherence independently, while tophi (OR 14.05, 95% CI 2.67-74.08) and chronic kidney disease (OR 16.66, 95% CI 2.63-105.37) were associated with medication adherence independently. Reasons that patients reported for nonadherence to medication included remission after treatment (35.3%), concerns for potential side effects (22.7%), insufficient patient education (8.7%), and adverse events (8.2%).Patient adherence to gout management recommendations is poor in China. Older age, increased disease burden, and specific comorbidities were associated with management adherence.
Barriers to Care in Gout: From Prescriber to Patient.
Vaccher Stefanie,Kannangara Diluk R W,Baysari Melissa T,Reath Jennifer,Zwar Nicholas,Williams Kenneth M,Day Richard O
The Journal of rheumatology
OBJECTIVE:To explore the understanding of gout and its management by patients and general practitioners (GP), and to identify barriers to optimal gout care. METHODS:Semistructured interviews were conducted with 15 GP and 22 patients in Sydney, Australia. Discussions were focused on medication adherence, experiences with gout, and education and perceptions around interventions for gout. Interviews were audio recorded, transcribed verbatim, and analyzed for themes using an analytical framework. RESULTS:Adherence to urate-lowering medications was identified as problematic by GP, but less so by patients with gout. However, patients had little appreciation of the risk of acute attacks related to variable adherence. Patients felt stigmatized that their gout diagnosis was predominantly related to perceptions that alcohol and dietary excess were causal. Patients felt they did not have enough education about gout and how to manage it. A manifestation of this was that uric acid concentrations were infrequently measured. GP were concerned that they did not know enough about managing gout and most were not familiar with current guidelines for management. For example and importantly, the strategies for reducing the risk of acute attacks when commencing urate-lowering therapy (ULT) were not well appreciated by GP or patients. CONCLUSION:Patients and GP wished to know more about gout and its management. Greater success in establishing and maintaining ULT will require further and better education to substantially benefit patients. Also, given the prevalence, and personal and societal significance of gout, innovative approaches to transforming the management of this eminently treatable disease are needed.
Annals of internal medicine
This issue provides a clinical overview of gout, focusing on prevention and screening, diagnosis, and treatment. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of additional science writers and physician writers.
Dalbeth Nicola,Merriman Tony R,Stamp Lisa K
Lancet (London, England)
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.
Diagnosis of Gout: A Systematic Review in Support of an American College of Physicians Clinical Practice Guideline.
Newberry Sydne J,FitzGerald John D,Motala Aneesa,Booth Marika,Maglione Margaret A,Han Dan,Tariq Abdul,O'Hanlon Claire E,Shanman Roberta,Dudley Whitney,Shekelle Paul G
Annals of internal medicine
Background:Alternative strategies exist for diagnosing gout that do not rely solely on the documentation of monosodium urate (MSU) crystals. Purpose:To summarize evidence regarding the accuracy of clinical tests and classification algorithms compared with that of a reference standard of MSU crystals in joint aspirate for diagnosing gout. Data Sources:Several electronic databases from inception to 29 February 2016. Study Selection:21 prospective cohort, cross-sectional, and case-control studies including participants with joint inflammation and no previous definitive gout diagnosis who had MSU analysis of joint aspirate. Data Extraction:Data extraction and risk-of-bias assessment by 2 reviewers independently; overall strength of evidence (SOE) judgment by group. Data Synthesis:Recently developed algorithms including clinical, laboratory, and imaging criteria demonstrated good sensitivity (up to 88%) and fair to good specificity (up to 96%) for diagnosing gout (moderate SOE). Three studies of dual-energy computed tomography (DECT) showed sensitivities of 85% to 100% and specificities of 83% to 92% for diagnosing gout (low SOE). Six studies of ultrasonography showed sensitivities of 37% to 100% and specificities of 68% to 97%, depending on the ultrasonography signs assessed (pooled sensitivity and specificity for the double contour sign: 74% [95% CI, 52% to 88%] and 88% [CI, 68% to 96%], respectively [low SOE]). Limitation:Important study heterogeneity and selection bias; scant evidence in primary and urgent care settings and in patients with conditions that may be confused with or occur with gout. Conclusion:Multidimensional algorithms, which must be validated in primary and urgent care settings, may help clinicians make a provisional diagnosis of gout. Although DECT and ultrasonography also show promise for gout diagnosis, accessibility to these methods may be limited. Primary Funding Source:Agency for Healthcare Research and Quality. (Protocol registration: https://effectivehealthcare.ahrq.gov/ehc/products/564/1937/gout-protocol-140716.pdf).
Management of Gout: A Systematic Review in Support of an American College of Physicians Clinical Practice Guideline.
Shekelle Paul G,Newberry Sydne J,FitzGerald John D,Motala Aneesa,O'Hanlon Claire E,Tariq Abdul,Okunogbe Adeyemi,Han Dan,Shanman Roberta
Annals of internal medicine
Background:Gout is a common type of inflammatory arthritis in patients seen by primary care physicians. Purpose:To review evidence about treatment of acute gout attacks, management of hyperuricemia to prevent attacks, and discontinuation of medications for chronic gout in adults. Data Sources:Multiple electronic databases from January 2010 to March 2016, reference mining, and pharmaceutical manufacturers. Study Selection:Studies of drugs approved by the U.S. Food and Drug Administration and commonly prescribed by primary care physicians, randomized trials for effectiveness, and trials and observational studies for adverse events. Data Extraction:Data extraction was performed by one reviewer and checked by a second reviewer. Study quality was assessed by 2 independent reviewers. Strength-of-evidence assessment was done by group discussion. Data Synthesis:High-strength evidence from 28 trials (only 3 of which were placebo-controlled) shows that colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs), and corticosteroids reduce pain in patients with acute gout. Moderate-strength evidence suggests that low-dose colchicine is as effective as high-dose colchicine and causes fewer gastrointestinal adverse events. Moderate-strength evidence suggests that urate-lowering therapy (allopurinol or febuxostat) reduces long-term risk for acute gout attacks after 1 year or more. High-strength evidence shows that prophylaxis with daily colchicine or NSAIDs reduces the risk for acute gout attacks by at least half in patients starting urate-lowering therapy, and moderate-strength evidence indicates that duration of prophylaxis should be longer than 8 weeks. Although lower urate levels reduce risk for recurrent acute attacks, treatment to a specific target level has not been tested. Limitation:Few studies of acute gout treatments, no placebo-controlled trials of management of hyperuricemia lasting longer than 6 months, and few studies in primary care populations. Conclusion:Colchicine, NSAIDs, and corticosteroids relieve pain in adults with acute gout. Urate-lowering therapy decreases serum urate levels and reduces risk for acute gout attacks. Primary Funding Source:Agency for Healthcare Research and Quality. (Protocol registration: http://effectivehealth-care.ahrq.gov/ehc/products/564/1992/Gout-managment-protocol-141103.pdf).
Management of Acute and Recurrent Gout: A Clinical Practice Guideline From the American College of Physicians.
Qaseem Amir,Harris Russell P,Forciea Mary Ann, ,Denberg Thomas D,Barry Michael J,Boyd Cynthia,Chow R. Dobbin,Humphrey Linda L,Kansagara Devan,Vijan Sandeep,Wilt Timothy J
Annals of internal medicine
Description:The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on the management of gout. Methods:Using the ACP grading system, the committee based these recommendations on a systematic review of randomized, controlled trials; systematic reviews; and large observational studies published between January 2010 and March 2016. Clinical outcomes evaluated included pain, joint swelling and tenderness, activities of daily living, patient global assessment, recurrence, intermediate outcomes of serum urate levels, and harms. Target Audience and Patient Population:The target audience for this guideline includes all clinicians, and the target patient population includes adults with acute or recurrent gout. Recommendation 1:ACP recommends that clinicians choose corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), or colchicine to treat patients with acute gout. (Grade: strong recommendation, high-quality evidence). Recommendation 2:ACP recommends that clinicians use low-dose colchicine when using colchicine to treat acute gout. (Grade: strong recommendation, moderate-quality evidence). Recommendation 3:ACP recommends against initiating long-term urate-lowering therapy in most patients after a first gout attack or in patients with infrequent attacks. (Grade: strong recommendation, moderate-quality evidence). Recommendation 4:ACP recommends that clinicians discuss benefits, harms, costs, and individual preferences with patients before initiating urate-lowering therapy, including concomitant prophylaxis, in patients with recurrent gout attacks. (Grade: strong recommendation, moderate-quality evidence).
Performance of classification criteria for gout in early and established disease.
Taylor William J,Fransen Jaap,Dalbeth Nicola,Neogi Tuhina,Schumacher H Ralph,Brown Melanie,Louthrenoo Worawit,Vazquez-Mellado Janitzia,Eliseev Maxim,McCarthy Geraldine,Stamp Lisa K,Perez-Ruiz Fernando,Sivera Francisca,Ea Hang-Korng,Gerritsen Martijn,Scire Carlo,Cavagna Lorenzo,Lin Chingtsai,Chou Yin-Yi,Tausche Anne-Kathrin,da Rocha Castelar-Pinheiro Geraldo,Janssen Matthijs,Chen Jiunn-Horng,Slot Ole,Cimmino Marco,Uhlig Till,Jansen Tim L
Annals of the rheumatic diseases
OBJECTIVES:To compare the sensitivity and specificity of different classification criteria for gout in early and established disease. METHODS:This was a cross-sectional study of consecutive rheumatology clinic patients with joint swelling in which gout was defined by presence or absence of monosodium urate crystals as observed by a certified examiner at presentation. Early disease was defined as patient-reported onset of symptoms of 2 years or less. RESULTS:Data from 983 patients were collected and gout was present in 509 (52%). Early disease was present in 144 gout cases and 228 non-cases. Sensitivity across criteria was better in established disease (95.3% vs 84.1%, p<0.001) and specificity was better in early disease (79.9% vs 52.5%, p<0.001). The overall best performing clinical criteria were the Rome criteria with sensitivity/specificity in early and established disease of 60.3%/84.4% and 86.4%/63.6%. Criteria not requiring synovial fluid analysis had sensitivity and specificity of less than 80% in early and established disease. CONCLUSIONS:Existing classification criteria for gout have sensitivity of over 80% in early and established disease but currently available criteria that do not require synovial fluid analysis have inadequate specificity especially later in the disease. Classification criteria for gout with better specificity are required, although the findings should be cautiously applied to non-rheumatology clinic populations.
2016 updated EULAR evidence-based recommendations for the management of gout.
Richette P,Doherty M,Pascual E,Barskova V,Becce F,Castañeda-Sanabria J,Coyfish M,Guillo S,Jansen T L,Janssens H,Lioté F,Mallen C,Nuki G,Perez-Ruiz F,Pimentao J,Punzi L,Pywell T,So A,Tausche A K,Uhlig T,Zavada J,Zhang W,Tubach F,Bardin T
Annals of the rheumatic diseases
BACKGROUND:New drugs and new evidence concerning the use of established treatments have become available since the publication of the first European League Against Rheumatism (EULAR) recommendations for the management of gout, in 2006. This situation has prompted a systematic review and update of the 2006 recommendations. METHODS:The EULAR task force consisted of 15 rheumatologists, 1 radiologist, 2 general practitioners, 1 research fellow, 2 patients and 3 experts in epidemiology/methodology from 12 European countries. A systematic review of the literature concerning all aspects of gout treatments was performed. Subsequently, recommendations were formulated by use of a Delphi consensus approach. RESULTS:Three overarching principles and 11 key recommendations were generated. For the treatment of flare, colchicine, non-steroidal anti-inflammatory drugs (NSAIDs), oral or intra-articular steroids or a combination are recommended. In patients with frequent flare and contraindications to colchicine, NSAIDs and corticosteroids, an interleukin-1 blocker should be considered. In addition to education and a non-pharmacological management approach, urate-lowering therapy (ULT) should be considered from the first presentation of the disease, and serum uric acid (SUA) levels should be maintained at<6 mg/dL (360 µmol/L) and <5 mg/dL (300 µmol/L) in those with severe gout. Allopurinol is recommended as first-line ULT and its dosage should be adjusted according to renal function. If the SUA target cannot be achieved with allopurinol, then febuxostat, a uricosuric or combining a xanthine oxidase inhibitor with a uricosuric should be considered. For patients with refractory gout, pegloticase is recommended. CONCLUSIONS:These recommendations aim to inform physicians and patients about the non-pharmacological and pharmacological treatments for gout and to provide the best strategies to achieve the predefined urate target to cure the disease.
Treat-to-target (T2T) recommendations for gout.
Kiltz U,Smolen J,Bardin T,Cohen Solal A,Dalbeth N,Doherty M,Engel B,Flader C,Kay J,Matsuoka M,Perez-Ruiz F,da Rocha Castelar-Pinheiro G,Saag K,So A,Vazquez Mellado J,Weisman M,Westhoff T H,Yamanaka H,Braun J
Annals of the rheumatic diseases
OBJECTIVES:The treat-to-target (T2T) concept has been applied successfully in several inflammatory rheumatic diseases. Gout is a chronic disease with a high burden of pain and inflammation. Because the pathogenesis of gout is strongly related to serum urate levels, gout may be an ideal disease in which to apply a T2T approach. Our aim was to develop international T2T recommendations for patients with gout. METHODS:A committee of experts with experience in gout agreed upon potential targets and outcomes, which was the basis for the systematic literature search. Eleven rheumatologists, one cardiologist, one nephrologist, one general practitioner and one patient met in October 2015 to develop T2T recommendations based on the available scientific evidence. Levels of evidence, strength of recommendations and levels of agreement were derived. RESULTS:Although no randomised trial was identified in which a comparison with standard treatment or an evaluation of a T2T approach had been performed in patients with gout, indirect evidence was provided to focus on targets such as normalisation of serum urate levels. The expert group developed four overarching principles and nine T2T recommendations. They considered dissolution of crystals and prevention of flares to be fundamental; patient education, ensuring adherence to medications and monitoring of serum urate levels were also considered to be of major importance. CONCLUSIONS:This is the first application of the T2T approach developed for gout. Since no publication reports a trial comparing treatment strategies for gout, highly credible overarching principles and level D expert recommendations were created and agreed upon.
Efficacy and cost-effectiveness of nurse-led care involving education and engagement of patients and a treat-to-target urate-lowering strategy versus usual care for gout: a randomised controlled trial.
Doherty Michael,Jenkins Wendy,Richardson Helen,Sarmanova Aliya,Abhishek Abhishek,Ashton Deborah,Barclay Christine,Doherty Sally,Duley Lelia,Hatton Rachael,Rees Frances,Stevenson Matthew,Zhang Weiya
Lancet (London, England)
BACKGROUND:In the UK, gout management is suboptimum, with only 40% of patients receiving urate-lowering therapy, usually without titration to achieve a target serum urate concentration. Nurses successfully manage many diseases in primary care. We compared nurse-led gout care to usual care led by general practitioners (GPs) for people in the community. METHODS:Research nurses were trained in best practice management of gout, including providing individualised information and engaging patients in shared decision making. Adults who had experienced a gout flare in the previous 12 months were randomly assigned 1:1 to receive nurse-led care or continue with GP-led usual care. We assessed patients at baseline and after 1 and 2 years. The primary outcome was the percentage of participants who achieved serum urate concentrations less than 360 μmol/L (6 mg/dL) at 2 years. Secondary outcomes were flare frequency in year 2, presence of tophi, quality of life, and cost per quality-adjusted life-year (QALY) gained. Risk ratios (RRs) and 95% CIs were calculated based on intention to treat with multiple imputation. This study is registered with www.ClinicalTrials.gov, number NCT01477346. FINDINGS:517 patients were enrolled, of whom 255 were assigned nurse-led care and 262 usual care. Nurse-led care was associated with high uptake of and adherence to urate-lowering therapy. More patients receiving nurse-led care had serum urate concentrations less than 360 μmol/L at 2 years than those receiving usual care (95% vs 30%, RR 3·18, 95% CI 2·42-4·18, p<0·0001). At 2 years all secondary outcomes favoured the nurse-led group. The cost per QALY gained for the nurse-led intervention was £5066 at 2 years. INTERPRETATION:Nurse-led gout care is efficacious and cost-effective compared with usual care. Our findings illustrate the benefits of educating and engaging patients in gout management and reaffirm the importance of a treat-to-target urate-lowering treatment strategy to improve patient-centred outcomes. FUNDING:Arthritis Research UK.
How Would You Manage This Patient With Gout?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center.
Burns Risa B,Smith C Christopher,Shmerling Robert H,Tess Anjala
Annals of internal medicine
Gout is the most common form of inflammatory arthritis. In 2012, the American College of Rheumatology (ACR) issued a guideline, which was followed in 2017 by one from the American College of Physicians (ACP). The guidelines agree on treating acute gout with a corticosteroid, nonsteroidal anti-inflammatory drug, or colchicine and on not initiating long-term urate-lowering therapy (ULT) for most patients after a first gout attack and in those whose attacks are infrequent (<2 per year). However, they differ on treatment of both recurrent gout and problematic gout. The ACR advocates a "treat-to-target" approach, and the ACP did not find enough evidence to support this approach and offered an alternative strategy that bases intensity of ULT on the goal of avoiding recurrent gout attacks ("treat-to-avoid-symptoms") with no monitoring of urate levels. They also disagree on the role of a gout-specific diet. Here, a general internist and a rheumatologist discuss these guidelines; they debate how they would manage an acute attack of gout, if and when to initiate ULT, and the goals for ULT. Lastly, they offer specific advice for a patient who is uncertain about whether to begin this therapy.
2018 updated European League Against Rheumatism evidence-based recommendations for the diagnosis of gout.
Richette Pascal,Doherty Michael,Pascual Eliseo,Barskova Victoria,Becce Fabio,Castaneda Johann,Coyfish Malcolm,Guillo Sylvie,Jansen Tim,Janssens Hein,Lioté Frédéric,Mallen Christian D,Nuki George,Perez-Ruiz Fernando,Pimentao José,Punzi Leonardo,Pywell Anthony,So Alexander K,Tausche Anne-Kathrin,Uhlig Till,Zavada Jakub,Zhang Weiya,Tubach Florence,Bardin Thomas
Annals of the rheumatic diseases
Although gout is the most common inflammatory arthritis, it is still frequently misdiagnosed. New data on imaging and clinical diagnosis have become available since the first EULAR recommendations for the diagnosis of gout in 2006. This prompted a systematic review and update of the 2006 recommendations. A systematic review of the literature concerning all aspects of gout diagnosis was performed. Recommendations were formulated using a Delphi consensus approach. Eight key recommendations were generated. A search for crystals in synovial fluid or tophus aspirates is recommended in every person with suspected gout, because demonstration of monosodium urate (MSU) crystals allows a definite diagnosis of gout. There was consensus that a number of suggestive clinical features support a clinical diagnosis of gout. These are monoarticular involvement of a foot or ankle joint (especially the first metatarsophalangeal joint); previous episodes of similar acute arthritis; rapid onset of severe pain and swelling; erythema; male gender and associated cardiovascular diseases and hyperuricaemia. When crystal identification is not possible, it is recommended that any atypical presentation should be investigated by imaging, in particular with ultrasound to seek features suggestive of MSU crystal deposition (double contour sign and tophi). There was consensus that a diagnosis of gout should not be based on the presence of hyperuricaemia alone. There was also a strong recommendation that all people with gout should be systematically assessed for presence of associated comorbidities and risk factors for cardiovascular disease, as well as for risk factors for chronic hyperuricaemia. Eight updated, evidence-based, expert consensus recommendations for the diagnosis of gout are proposed.
Discordant American College of Physicians and international rheumatology guidelines for gout management: consensus statement of the Gout, Hyperuricemia and Crystal-Associated Disease Network (G-CAN).
Dalbeth Nicola,Bardin Thomas,Doherty Michael,Lioté Frédéric,Richette Pascal,Saag Kenneth G,So Alexander K,Stamp Lisa K,Choi Hyon K,Terkeltaub Robert
Nature reviews. Rheumatology
In November 2016, the American College of Physicians (ACP) published a clinical practice guideline on the management of acute and recurrent gout. This guideline differs substantially from the latest guidelines generated by the American College of Rheumatology (ACR), European League Against Rheumatism (EULAR) and 3e (Evidence, Expertise, Exchange) Initiative, despite reviewing largely the same body of evidence. The Gout, Hyperuricemia and Crystal-Associated Disease Network (G-CAN) convened an expert panel to review the methodology and conclusions of these four sets of guidelines and examine possible reasons for discordance between them. The G-CAN position, presented here, is that the fundamental pathophysiological knowledge underlying gout care, and evidence from clinical experience and clinical trials, supports a treat-to-target approach for gout aimed at lowering serum urate levels to below the saturation threshold at which monosodium urate crystals form. This practice, which is truly evidence-based and promotes the steady reduction in tissue urate crystal deposits, is promoted by the ACR, EULAR and 3e Initiative recommendations. By contrast, the ACP does not provide a clear recommendation for urate-lowering therapy (ULT) for patients with frequent, recurrent flares or those with tophi, nor does it recommend monitoring serum urate levels of patients prescribed ULT. Results from emerging clinical trials that have gout symptoms as the primary end point are expected to resolve this debate for all clinicians in the near term future.
Dalbeth Nicola,Choi Hyon K,Joosten Leo A B,Khanna Puja P,Matsuo Hirotaka,Perez-Ruiz Fernando,Stamp Lisa K
Nature reviews. Disease primers
Gout is a chronic disease caused by monosodium urate (MSU) crystal deposition. Gout typically presents as an acute, self-limiting inflammatory monoarthritis that affects the joints of the lower limb. Elevated serum urate level (hyperuricaemia) is the major risk factor for MSU crystal deposition and development of gout. Although traditionally considered a disorder of purine metabolism, altered urate transport, both in the gut and the kidneys, has a key role in the pathogenesis of hyperuricaemia. Anti-inflammatory agents, such corticosteroids, NSAIDs and colchicine, are widely used for the treatment of gout flare; recognition of the importance of NLRP3 inflammasome activation and bioactive IL-1β release in initiation of the gout flare has led to the development of anti-IL-1β biological therapy for gout flares. Sustained reduction in serum urate levels using urate-lowering therapy is vital in the long-term management of gout, which aims to dissolve MSU crystals, suppress gout flares and resolve tophi. Allopurinol is the first-line urate-lowering therapy and should be started at a low dose, with gradual dose escalation. Low-dose anti-inflammatory therapies can reduce gout flares during initiation of urate-lowering therapy. Models of care, such as nurse-led strategies that focus on patient engagement and education, substantially improve clinical outcomes and now represent best practice for gout management.
The Management of Gout in Renal Disease.
Estiverne Christopher,Mount David B
Seminars in nephrology
Gout, a debilitating inflammatory arthritis, currently affects more than 9 million Americans. Hyperuricemia, the laboratory abnormality associated with the development of gout, also occurs in a significant number of patients with chronic kidney disease (CKD), a condition that affects approximately 14% of the US population. Several recent studies have attempted to provide a definitive link between the presence of hyperuricemia and progression of CKD; however, the treatment of asymptomatic hyperuricemia in CKD is not supported by recent randomized controlled trials. The pharmacology of acute gout flares and urate lowering is complicated in patients who also have evidence of CKD, primarily because of an increased risk of medication toxicity. Recipients of kidney transplants are particularly at risk of debilitating gout and medication toxicity. We review the available data linking CKD, gout, and hyperuricemia, providing practice guidelines on managing gout in CKD patients and kidney transplant recipients. We advocate for much greater involvement of nephrologists in the management of gout in renal patients.
Gout epidemiology and comorbidities.
Singh Jasvinder A,Gaffo Angelo
Seminars in arthritis and rheumatism
OBJECTIVE:To review the epidemiology of gout and associated comorbidities. METHODS:We review the key published studies of the epidemiology of gout and associated comorbidities. RESULTS:The prevalence of gout ranged 1-4% worldwide and incidence ranged 0.1-0.3%. Gout is more common in men vs. women by 3:1 to 10:1. Gout incidence and prevalence increased by each decade of life, with prevalence increasing to 11-13% and incidence increasing to 0.4% in people older than 80 years. Racial minorities in the U.S., New Zealand Māori, Han Chinese and some ethnic groups in Asia have a higher prevalence of gout. Comorbidities are common in people with gout and complicate its management and disease outcomes. Hypertension is present in up to three-quarters of gout patients and could be in the causal pathway of its association with cardiovascular disease and stroke. Chronic kidney disease of stage 3 or greater severity is present in many patients with gout. Appropriate management can improve both gout and stabilize chronic kidney disease. Whether the association of gout with metabolic syndrome and diabetes is causal is still controversial. Given the biological anti-oxidant effect of serum urate, the association of gout with neurodegenerative disorders is being actively explored. CONCLUSIONS:Gout is the most common inflammatory arthritis in adults worldwide, with a disproportionate burden of disease in men, the elderly and racial/ethnic minorities. Comorbidities in gout are very common and add further to the disease morbidity and make its management challenging.
Gout: Rapid Evidence Review.
Clebak Karl T,Morrison Ashley,Croad Jason R
American family physician
Gout is caused by monosodium urate crystal deposition in joints and tissues. Risk factors include male sex; obesity; hypertension; alcohol intake; diuretic use; a diet rich in meat and seafood; chronic kidney disease; a diet heavy in fructose-rich food and beverages; being a member of certain ethnic groups, including Taiwanese, Pacific Islander, and New Zealand Maori; and living in high-income countries. Gout is characterized by swelling, pain, or tenderness in a peripheral joint or bursa, including the development of a tophus. Diagnosis of gout can be made using several validated clinical prediction rules. Arthrocentesis should be performed when suspicion for an underlying septic joint is present; synovial fluid or tophus analysis should be performed if the diagnosis is uncertain. Colchicine, nonsteroidal anti-inflammatory drugs, and corticosteroids relieve pain in adults with acute gout episodes. Indications for long-term urate-lowering therapy include chronic kidney disease, two or more flare-ups per year, urolithiasis, the presence of tophus, chronic gouty arthritis, and joint damage. Allopurinol and febuxostat are used to prevent flare-ups, although febuxostat is associated with an increase in all-cause and cardiovascular mortality and is therefore not routinely recommended.
Pathophysiology of Gout.
Narang Ravi K,Dalbeth Nicola
Seminars in nephrology
Multiple interacting checkpoints are involved in the pathophysiology of gout. Hyperuricemia is the key risk factor for gout and is considered a prerequisite for monosodium urate (MSU) crystal formation. Urate underexcretion through renal and gut mechanisms is the major mechanism for hyperuricemia in most people. Multiple genetic, environmental, and metabolic factors are associated with serum urate and alter urate transport or synthesis. Urate supersaturation is the most important factor for MSU crystal formation, and other factors such as temperature, pH, and connective tissue components also play a role. The nucleotide-binding oligomerization domain leucine-rich repeats and pyrin domain-containing protein 3 inflammasome plays a pivotal role in the inflammatory response to MSU crystals, and interleukin 1β is the key cytokine mediating the inflammatory cascade. Variations in the regulatory mechanisms of this inflammatory response may affect an individual's susceptibility to developing gout. Tophus formation is the cardinal feature of advanced gout, and both MSU crystals and the inflammatory tissue component of the tophus contribute to the development of structural joint damage owing to gout. In this article, we review the pathophysiologic mechanisms of hyperuricemia, MSU crystal formation and the associated inflammatory response, tophus formation, and structural joint damage in gout.
Gout, Hyperuricaemia and Crystal-Associated Disease Network (G-CAN) common language definition of gout.
Murdoch Rachel,Barry Michael J,Choi Hyon K,Hernandez Daniel,Johnsen Brianne,Labrador Manuel,Reid Susan,Singh Jasvinder A,Terkeltaub Robert,Vázquez Mellado Janitzia,Dalbeth Nicola
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.