Can simple clinical measurements detect patient noncompliance?
Haynes R B,Taylor D W,Sackett D L,Gibson E S,Bernholz C D,Mukherjee J
Hypertension (Dallas, Tex. : 1979)
Measurement of patient compliance is essential if management of low compliance is to be performed efficiently. We assessed the value of several easily obtained clinical assessments compared to quantitative pill counts among 134 newly treated hypertensive male steelworkers during the first 6 months of their treatment with antihypertensive medication. Patient's self-reports obtained on structured interview correlated best with pill count compliance (r = 0.74, p less than 0.0001). Patients overestimated their compliance by an average of 17% but 90% of those who admitted to being noncompliant were found so. Qualitative urinary chlorthalidone and hydrochlorothiazide levels and changes in serum potassium, uric acid, and blood pressure also correlated with pill count compliance but were less accurate than interviews. Assessment of the patient's "health beliefs" and a variety of sociodemographic and health traits and perceptions did not provide useful information on compliance. Interviewing the patient is a simple and useful approach in assessing compliance with antihypertensive therapy.
Impact of non-adherence on the safety and efficacy of uric acid-lowering therapies in the treatment of gout.
Hill-McManus Daniel,Soto Elena,Marshall Scott,Lane Steven,Hughes Dyfrig
British journal of clinical pharmacology
AIMS:Dual-urate-lowering therapy (ULT) with xanthine oxidase inhibitor and uricosuric medications is a treatment option for severe gout. Uricosuric agents can cause hyperuricosuria, a risk factor for nephrolithiasis and acute uric acid nephropathy. The aims of the present study were to simulate the relationship between suboptimal drug adherence and efficacy, and to quantify the risk of hyperuricosuria in gout patients receiving mono- and dual-ULTs. METHODS:The impact of poor medication adherence was studied using two-compartment pharmacokinetic (PK) models based on published evidence, and a semi-mechanistic four-compartment pharmacodynamic (PD) model. The PKPD model was used to simulate mono and dual-ULT in gout patients with either under-excretion (lowered clearance) or overproduction of uric acid, with suboptimal adherence modelled as either a single drug holiday of increasing duration or doses taken at random. RESULTS:Simulation results showed a surge in urinary uric acid occurring when dosing is restarted following missed doses. For under-excreters taking a 20-day drug holiday, the addition of 200 mg (or 400 mg) lesinurad to 80 mg febuxostat increased the percentage of patients experiencing hyperuricosuria from 0% to 1.4% (or 3.1%). In overproducers, restarting ULTs following drug holidays of more than 5 days leads to over 60% of patients experiencing hyperuricosuria. CONCLUSIONS:Suboptimal medication adherence may compromise the safety and efficacy of mono- and dual-ULTs, especially in patients with gout resulting from an overproduction of uric acid. Clinicians and pharmacists should consider counselling patients with respect to the risks associated with partial adherence, and offer interventions to improve adherence or tailor treatments, where appropriate.
Beliefs about medicines among Hong Kong hospital outpatients.
Wan Bosco K F,Cheung Walter H K,Ball Patrick A,Jackson David M,Maynard Gregg J
The International journal of pharmacy practice
OBJECTIVES:(1) To identify demographic characteristics associated with different patients' belief attitudes among older Hong Kong hospital outpatients. (2) To identify important implementation criteria for developing a more effective adherence-improving intervention. METHODS:Six hundred and ninety-eight patients completed a questionnaire consisting of demographic information and Belief about Medicines Questionnaire. Findings were statistically analysed. KEY FINDINGS:Among respondents, 56.9% were either in the hesitant (Mixed-feelings and Indifferent) or negative (Distrustful) medication belief constructs. The majority of these patients were younger females, with better education, taking fewer regular medications and for shorter duration. Rheumatoid and gout accounted for 46.1% of cases in the Distrustful construct, while cardiovascular and diabetic conditions accounted for 63.8% of cases in the positive (In-favour) construct. Patients' concerns about medications were reaffirmed to be a predominant factor affecting medication beliefs. The mean Necessity-Concern Differential scores in the two hesitant constructs illustrated that patients within these two constructs were more pliant towards medicines and, therefore, were predicted to be more subject to modification. CONCLUSIONS:Our results identified the demographic characteristics of patients with negative or hesitant belief attitudes about medicines. In order to effectively achieve improvement in long-term beliefs about medications, the design of interventions should target positively modifying belief attitudes in these two patient groups. Furthermore, addressing patients' concern about their medicines was reaffirmed to be an important criterion for researchers to focus on when designing effective interventions in the future.
Predictors of reaching a serum uric acid goal in patients with gout and treated with febuxostat.
Sheer Richard,Null Kyle D,Szymanski Keith A,Sudharshan Lavanya,Banovic Jennifer,Pasquale Margaret K
ClinicoEconomics and outcomes research : CEOR
PURPOSE:Clinical guidelines recommend febuxostat as first-line pharmacologic urate-lowering therapy for patients with gout to achieve a goal serum uric acid (sUA) <6 mg/dL; however, little is known about other contributing factors. This study identified clinical characteristics of patients treated with febuxostat to develop and validate a predictive model for achieving a goal sUA. PATIENTS AND METHODS:Patients with Humana Medicare or commercial insurance, diagnosed with gout and newly initiated on febuxostat (index date February 1, 2009 - December 31, 2013), were identified for a retrospective cohort study. Patients were followed for 365 days and the first valid sUA test result ≥120 days after index was retained. A stepwise logistic regression with backward elimination was estimated to model sUA goal attainment, and a linear model was estimated to model the impact of predictor variables on sUA level. RESULTS:The study sample (n=678) was divided into a development (training) dataset (n=453) and a validation (holdout) dataset (n=225). In the training sample, patients in the sUA <6 mg/dL group were on febuxostat for a longer time, were more adherent, and had a lower average base-line sUA level (all <0.0001) vs patients in the sUA ≥6 mg/dL group. In the logistic model, febuxostat adherence (odds ratio [OR]=1.03, <0.0001) and baseline sUA level (OR=0.84, <0.0001) increased the odds of attaining sUA <6 mg/dL. In the linear regression model, increase in febuxostat adherence (<0.0001), baseline sUA level (<0.0001), advanced age (=0.0021), and not having congestive heart failure (<0.05) were associated with a reduction of sUA level. Pre-index allopurinol use was a marginally significant predictor of sUA level reduction (=0.06). CONCLUSIONS:Among febuxostat users diagnosed with gout in a real-world setting, adherence to febuxostat and lower baseline sUA level were the strongest predictors of attaining sUA goal. These findings may help clinicians to identify appropriate patients most likely to benefit from febuxostat treatment, and underscore the importance of medication adherence in this challenging patient population.
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.
Gout: state of the art after a decade of developments.
Pascart Tristan,Lioté Frédéric
Rheumatology (Oxford, England)
This review article summarizes the relevant English literature on gout from 2010 through April 2017. It emphasizes that the current epidemiology of gout indicates a rising prevalence worldwide, not only in Western countries but also in Southeast Asia, in close relationship with the obesity and metabolic syndrome epidemics. New pathogenic mechanisms of chronic hyperuricaemia focus on the gut (microbiota, ABCG2 expression) after the kidney. Cardiovascular and renal comorbidities are the key points to consider in terms of management. New imaging tools are available, including US with key features and dual-energy CT rendering it able to reveal deposits of urate crystals. These deposits are now included in new diagnostic and classification criteria. Overall, half of the patients with gout are readily treated with allopurinol, the recommended xanthine oxidase inhibitor (XOI), with prophylaxis for flares with low-dose daily colchicine. The main management issues are related to patient adherence, because gout patients have the lowest rate of medication possession ratio at 1 year, but they also include clinical inertia by physicians, meaning XOI dosage is not titrated according to regular serum uric acid level measurements for targeting serum uric acid levels for uncomplicated (6.0 mg/dl) and complicated gout, or the British Society for Rheumatology recommended target (5.0 mg/dl). Difficult-to-treat gout encompasses polyarticular flares, and mostly patients with comorbidities, renal or heart failure, leading to contraindications or side effects of standard-of-care drugs (colchicine, NSAIDs, oral steroids) for flares; and tophaceous and/or destructive arthropathies, leading to switching between XOIs (febuxostat) or to combining XOI and uricosurics.
Investigational drugs for hyperuricemia, an update on recent developments.
Pascart Tristan,Richette Pascal
Expert opinion on investigational drugs
INTRODUCTION:The significant proportion of gout patients not reaching serum urate levels below 6.0 mg/dL and the debated pathogenicity of hyperuricemia (HU) itself motivate investigators to develop new drugs to decrease uricemia. AREAS COVERED:This review discusses the drugs considered to be in active development from pre-clinical to phase III studies. This review covers 11 drugs in development, including a xanthine oxidase inhibitor (topiroxostat), uricosurics (verinurad, arhalofenate, UR-1102, tranilast), dual inhibitors (RLBN1001, KUX-1151), a uricase (pergsiticase), an inhibitor of hypoxanthine production (ulodesine), and drugs with yet-to-explain mechanisms of action (levotofisopam, tuna extracts). EXPERT OPINION:Drugs well advanced in their development - particularly arhalofenate, verinurad and topiroxostat - open the prospect of patient-comorbidity-tailored HU management. Development of novel therapies provides new insight into our understanding of gout and HU, particularly potential pathogenicity. Apart from potency to decrease serum urate levels and good tolerance profiles, novel therapies will need to focus on administration modalities facilitating treatment adherence.
The target uric acid level in multimorbid patients with gout is difficult to achieve: data from a longitudinal Swiss single-centre cohort.
Ankli Barbara,Berger Christoph T,Haeni Nicolas,Kyburz Diego,Hügle Thomas,So Alexander K-L,Daikeler Thomas
Swiss medical weekly
OBJECTIVE:To characterise adherence and treat-to-target (T2T) strategy in gout patients within a Swiss tertiary hospital. METHODS:Consecutive presenting patients with proven gout were prospectively included in this cohort. Symptoms, comorbidities, medication and laboratory values were assessed (during hospitalisation and at planned 3- and 12-month follow-up assessments). RESULTS:116 patients (98 men) with a mean age of 67 (range 23–94 years) were included, 74% of whom had active arthritis. Comorbidities were frequent: hypertension, renal impairment, and obesity were present in 72, 55 and 35% of patients, respectively. Thirty-five percent of patients received urate-lowering treatment at inclusion. Only 62 and 50% attended the 3- and 12-month follow-up. The target serum uric acid level of <360 μmol/l was achieved in 22 and 57% of patients by the 3- and 12-month follow-up visits, respectively. Patients followed up by rheumatologists reached the target serum uric acid at follow-up more often than those that were not (p = 0.033). Median daily allopurinol dose at 12-month follow-up was 300 mg in those achieving T2T and 100 mg in the others (p = 0.033). Flares occurred during the first 3 months in 52% and during the subsequent 9 months in 47% of patients. CONCLUSION:Only half of patients attended the planned follow-up visits, indicating low awareness for gout. Of those attending follow-up, only approximately 50% had achieved the serum urate target at 12 months. Although new treatments are available, care for gout patients remains insufficient, notably in difficult-to-treat multimorbid patient subsets as described in this cohort.
Treatment approaches and adherence to urate-lowering therapy for patients with gout.
Aung Thanda,Myung Gihyun,FitzGerald John D
Patient preference and adherence
Gout is the most common inflammatory arthritis characterized by painful disabling acute attacks. It is caused by hyperuricemia and deposition of urate crystals in and around the joints. Long-standing untreated hyperuricemia can lead to chronic arthritis with joint damage, tophi formation and urate nephropathy. Gout is associated with significant morbidity and health care associated cost. The goal of long-term therapy is to lower the serum urate level to promote dissolution of urate crystals, reduce recurrent acute gout flares, resolve tophi and prevent joint damage. Despite the presence of established gout treatment guidelines and effective medications to manage gout, patient outcomes are often poor. Etiology for these shortcomings is multifactorial including both physician and patient characteristics. Poor adherence to urate-lowering therapy (ULT) is prevalent and is a significant contributor to poor patient outcomes. This article reviews the treatment strategies for the management of hyperuricemia in chronic gout, gaps in quality of care in gout management, factors contributing to poor adherence to ULT and discusses potential interventions to achieve improved gout-related outcomes. These interventions include initiation of prophylactic anti-inflammatory medication when starting ULT, frequent follow-ups, regular serum urate monitoring and improved patient education, which can be achieved through pharmacist- or nurse-assisted programs. Interventions such as these could improve adherence to ULT and, ultimately, result in optimal gout-related outcomes.
Improving adherence to gout therapy: an expert review.
Perez-Ruiz Fernando,Desideri Giovambattista
Therapeutics and clinical risk management
Gout is the most common form of inflammatory arthritis and is a considerable burden to patients and health care systems worldwide. Despite its clinical, economic, and social impact, patient persistence and adherence to prescribed urate-lowering therapies (ULT), ranging from 20% to 70%, is considered to be among the poorest of all chronic conditions. The majority of gout patients consequently receive suboptimal benefits of their prescribed pharmacotherapies. As gout is associated with several comorbidities along with an increased risk of premature mortality, achieving improved outcomes through adherence to ULT is crucial. Adherence to medication is complex and multidimensional and includes a combination of treatment-, patient-, and physician-related factors. This review explores the factors related to ULT adherence with the overall aim of helping health care providers better understand the barriers to adherence. Several interventions targeting pharmacists, nurses, and patients are being investigated to improve adherence. Furthermore, enhanced awareness and understanding of the need to treat-to-target in order to improve patient outcomes is needed among health care professionals. Greater understanding of the multidimensional nature of non-adherence can help physicians to treat gout more effectively and empower patients to improve self-management of this long-term disease.
Cross-Cultural Adaptation, Reliability, and Validity of the Turkish Version of the Compliance Questionnaire on Rheumatology in Patients With Behçet's Disease.
Cinar Fatma Ilknur,Cinar Muhammet,Yilmaz Sedat,Acikel Cengizhan,Erdem Hakan,Pay Salih,Simsek Ismail
Journal of transcultural nursing : official journal of the Transcultural Nursing Society
PURPOSE:The aim of this study was to examine the psychometric properties of the Turkish versionof the Compliance Questionnaire on Rheumatology (CQR-T) for patients with Behçet's disease (BD). METHOD:A sample of 105 Turkish patients with BD participated in this study. The scale was cross-culturally adapted through a process including translation, comparison with versions in other languages, back translation, and pretesting. Construct validity was evaluated by factor analysis, and criterion validity was evaluated using the Morisky Medication Adherence Scale. RESULTS:The CQR-T demonstrated acceptable internal consistency (Cronbach's α = .832), adequate test-retest reliability (intraclass correlation coefficient = .630), and correlations with Morisky Medication Adherence Scale scores (r = -.389, p< .001), indicating convergent validity. CONCLUSION:The CQR-T was found to be a valid and reliable instrument for evaluating the compliance of Turkish BD patients with prescribed medications. IMPLICATIONS FOR PRACTICE:The CQR-T might be a helpful tool in two ways: for determining the level of compliance of patients with BD and for adjusting their management and follow-up based on the results.
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.
Adherence and persistence to urate-lowering therapies in the Irish setting.
McGowan Bernie,Bennett Kath,Silke Carmel,Whelan Bryan
To identify adherence and persistence levels with urate-lowering therapies using the national administrative pharmacy claim database. This was a retrospective, pharmacy claims-based analysis of dispensed anti-gout medications on the Irish national HSE-PCRS scheme database between January 2008 and December 2012. Adherence is defined by the medication possession ratio (MPR), and patients were considered to be adherent if the MPR ≥80 % (good adherers) in any given time period. Persistence was defined as continued use of therapy with no periods exceeding a refill gap of >63 days (9 weeks). Logistic regression analysis was used to predict odd ratios (OR) and 95 % confidence interval (CI) for persistence and adherence in relation to age, gender and level of comorbidity. There was a 53 % increase in the number of patients prescribed anti-gout medications between 2008 and 2012 with an increase of 27 % in the associated ingredient cost of these medications. Allopurinol accounted for 87 % of the prescribing and febuxostat accounted for a further 9 %. In patients who started on 100 mg allopurinol, only 14.6 % were titrated to the 300 mg dose. For all those initiating urate-lowering therapies, 45.8 % of patients were persistent with treatment at 6 months decreasing to 22.6 % at 12 months. In multivariate analysis, females had poorer adherence (OR = 0.83 (0.77-0.90)), and increasing age was associated with increased adherence (OR = 4.19 (2.53-6.15)) Increasing comorbidity score was associated with increased adherence and persistence at 6 months (OR = 0.68 (0.59-0.79)). Adherence with anti-gout medications in this study cohort was relatively low. Sustained treatment for gouty arthritis is essential in the prevention of serious adverse outcomes.Significance and Innovations-Poor adherence to medications prescribed to patients for the management of chronic diseases such as gout is an ongoing problem which urgently needs to be addressed.-Some of the reasons identified for poor adherence to anti-gout medications include the risk of flare of acute gout with the initiation of urate-lowering therapy (ULT), poor response to ULT and persistence of attacks of acute gout, suboptimal dosing of allopurinol therapy and intolerance of allopurinol.-The results of this study identified adherence and persistence rates of approximately 50 % at 6 months which is in line if not lower than many of the other published studies to date which have measured adherence and persistence using pharmacy claims databases.-The results of poor adherence and persistence affect both the health of the patients with financial implications for the healthcare service.
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.
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.
Implication Of Character Traits In Adherence To Treatment In People With Gout: A Reason For Considering Nonadherence As A Syndrome.
Reach Gérard,Chenuc Gaëlle,Maigret Pascal,Elias-Billon Isabelle,Martinez Luc,Flipo René-Marc
Patient preference and adherence
Objective:Various aspects of nonadherence to therapy (including medication and lifestyle nonadherence) often appear together. Here we report the association between treatment adherence in gout and the two character traits of patience and obedience, which may explain this observation. Methods:Data were collected from a cross-sectional study conducted in a French cohort of 1441 adult patients. Patience was assessed using the choice between receiving €1500 in 1 year or €500 immediately. Obedience was evaluated with a single question assessing the use of the seatbelt in the rear seat of a car. Adherence to recommendations for medication, beverage, food and physical activity and smoking status was assessed using self-report questionnaires. Results:Patience and obedience were strong determinants of adherence to medication in multivariate analysis (OR 2.056, 95% CI [1.414-2.989], < 0.001; OR 1.844, 95% CI [1.273-2.671], =0.001). In univariate analysis, adherence to medication was also associated with compliance with dietary directives (<0.001), lower alcohol consumption on an ordinary day (< 0.001), never consuming soda (<0.001) or beer (<0.001), practice of physical activity (=0.002), being a nonsmoker (<0.001) and monitoring serum levels of uric acid regularly (=0.011). Multiple-correspondence analysis illustrated the associations of these different aspects of adherence (medication, diet and exercise, smoking status and monitoring of disease control) with patience and obedience. Finally, we observed a link between patience and obedience (< 0.001). Conclusion:Character traits, which shape preferences, may cause the clustering of different aspects of nonadherence in the form of a syndrome, elucidating the still enigmatic link between nonadherence to placebo and mortality in randomised clinical trials. This concept may also explain, at least in part, the difficulty of improving adherence to long-term therapies and may lead to ethical issues.
Adherence and Outcomes with Urate-Lowering Therapy: A Site-Randomized Trial.
Mikuls Ted R,Cheetham T Craig,Levy Gerald D,Rashid Nazia,Kerimian Artak,Low Kimberly J,Coburn Brian W,Redden David T,Saag Kenneth G,Foster P Jeffrey,Chen Lang,Curtis Jeffrey R
The American journal of medicine
PURPOSE:The purpose of this study was to test a pharmacist-led intervention to improve gout treatment adherence and outcomes. METHODS:We conducted a site-randomized trial (n=1463 patients) comparing a 1-year, pharmacist-led intervention to usual care in patients with gout initiating allopurinol. The intervention was delivered primarily through automated telephone technology. Co-primary outcomes were the proportion of patients adherent (proportion of days covered ≥0.8) and achieving a serum urate <6.0 mg/dl at 1 year. Outcomes were reassessed at year 2. RESULTS:Patients who underwent intervention were more likely than patients of usual care to be adherent (50% vs 37%; odds ratio [OR] 1.68; 95% confidence interval [CI] 1.30, 2.17) and reach serum urate goal (30% vs 15%; OR 2.37; 95% CI 1.83, 3.05). In the second year (1 year after the intervention ended), differences were attenuated, remaining significant for urate goal but not for adherence. The intervention was associated with a 6%-16% lower gout flare rate during year 2, but the differences did not reach statistical significance. CONCLUSIONS:A pharmacist-led intervention incorporating automated telephone technology improved adherence and serum urate goal in patients with gout initiating allopurinol. Although this light-touch, low-tech intervention was efficacious, additional efforts are needed to enhance patient engagement in gout management and ultimately to improve outcomes.
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.
Education Preferences of People With Gout: Exploring Differences Between Indigenous and Nonindigenous Peoples from Rural and Urban Locations.
Treharne Gareth J,Richardson Aimee C,Neha Tia,Fanning Niamh,Janes Ronald,Hudson Ben,Judd Andrea,Pitama Suzanne,Stamp Lisa K
Arthritis care & research
OBJECTIVE:Gout typically responds well to medications, but adherence might be improved by education that meets individuals' needs in a way that is inclusive of their ethnicity and rurality. The aim of this study was to compare education preferences of Māori and New Zealand European (NZEuropean) individuals with gout, and of those living in rural or urban areas. METHODS:People with gout managed in primary care were recruited from 2 rural regions and 1 city within Aotearoa/New Zealand. Focus groups were held with 26 Māori and 42 NZEuropean participants (44 rural, 24 urban). Participants discussed education preferences for diet, medication, and ways of communicating. The nominal group technique was employed, whereby the group compiled a list of ideas and then participants individually ranked the 3 most important ideas for each topic. RESULTS:The most frequently prioritized ideas for the 3 topics were knowing one's own food triggers, knowing side effects of medications, and communicating via a general practitioner (GP) or specialist. More Māori participants prioritized natural remedies, easy to understand information, and communicating via television. More NZEuropean participants prioritized knowing the kinds of alcohol that trigger gout, communicating via GP/specialist, and receiving written information. More urban participants prioritized knowing to stay hydrated and medication doses as important information. CONCLUSION:Māori and NZEuropean individuals with gout report different understandings and education preferences around personal triggers of gout, treatment options, and ways of receiving information about gout. Further research is required to develop ethnicity-specific gout education resources internationally.
Education and non-pharmacological approaches for gout.
Abhishek Abhishek,Doherty Michael
Rheumatology (Oxford, England)
The objectives of this review are as follows: to highlight the gaps in patient and physician knowledge of gout and how this might impede optimal disease management; to provide recommended core knowledge points that should be conveyed to people with gout; and to review non-pharmacological interventions that can be used in gout management. MeSH terms were used to identify eligible studies examining patients' and health-care professionals' knowledge about gout and its management. A narrative review of non-pharmacological management of gout is provided. Many health-care professionals have significant gaps in their knowledge about gout that have the potential to impede optimal management. Likewise, people with gout and the general population lack knowledge about causes, consequences and treatment of this condition. Full explanation about gout, including the potential benefits of urate-lowering treatment (ULT), motivates people with gout to want to start such treatment, and there is evidence, albeit limited, that educational interventions can improve uptake and adherence to ULT. Additionally, several non-pharmacological approaches, such as rest and topical ice application for acute attacks, avoidance of risk factors that can trigger acute attacks, and dietary interventions that may reduce gout attack frequency (e.g. cherry or cherry juice extract, skimmed milk powder or omega-3 fatty acid intake) or lower serum uric acid (e.g. vitamin C), can be used as adjuncts to ULT. There is a pressing need to educate health-care professionals, people with gout and society at large to remove the negative stereotypes associated with gout, which serve as barriers to optimal gout management, and to perceive gout as a significant medical condition. Moreover, there is a paucity of high-quality trial evidence on whether certain simple individual dietary and lifestyle factors can reduce the risk of recurrent gout attacks, and further studies are required in this field.
Achieving serum urate targets in gout: an audit in a gout-oriented rheumatology practice.
Corbett Elizabeth J M,Pentony Peta,McGill Neil W
International journal of rheumatic diseases
AIM:To assess the proportion of patients with gout who achieve target serum urate levels, the drug regime required and the reasons for failing to do so. METHODS:We reviewed the files of all patients with gout who presented to a gout-oriented rheumatology practice between January 2010 and September 2014. RESULTS:Two hundred and thirty patients agreed to commence urate lowering therapy (ULT); 73% achieved their urate target, including 74% with non-tophaceous gout (target ≤ 0.36 mmol/L) and 71% with tophi (target ≤ 0.30 mmol/L). Of the 62 who failed to reach target, in 61 it was due to non-adherence and in one due to inefficacy. CONCLUSION:Adherence remains the major challenge to successful long-term gout management.
Patient perspectives in gout: a review.
Singh Jasvinder A
Current opinion in rheumatology
PURPOSE OF REVIEW:Recent studies have produced evidence regarding the patient perspectives in gout including from disease experience to disease outcomes. Therefore, an overview on the topic can help improve our understanding of the patient experience. RECENT FINDINGS:This article explores several aspects of the patient perspective including the impact of gout on a patient's life, patient knowledge and beliefs regarding gout and its treatments, patient-perceived barriers to optimal medication adherence in gout and patient's perception of their gout. This article also summarizes any evidence of the association of patient perceptions to patient outcomes in gout. SUMMARY:A recognition of patient perspectives in gout has the potential to positively impact clinical care for gout. Discussion of disease impact, misperceptions about benefits/harms of urate-lowering therapy (ULT), and patient values/preferences regarding pharmacological and nonpharmacological treatments can lead to a better shared decision-making and improved outcomes in gout. These findings emphasize the importance of inclusion of patient perspective not only in clinical care and quality improvement and research initiatives but also in the design and implementation of the research agenda in gout. Inclusion of patient-reported outcomes in clinical research is likely to improve its relevance to patients with gout.
Are Target Urate and Remission Possible in Severe Gout? A Five-year Cohort Study.
Alvarado-de la Barrera Claudia,López-López Carlos Omar,Álvarez-Hernández Everardo,Peláez-Ballestas Ingris,Gómez-Ruiz Citlallyc,Burgos-Vargas Rubén,Vázquez-Mellado Janitzia
The Journal of rheumatology
OBJECTIVE:Determine the proportion of patients achieving target serum urate (SU), defined as < 6 mg/dl for patients with non-severe gout and < 5 mg/dl for patients with severe gout, as well as the proportion of patients achieving remission after 5 years of followup. METHODS:Patients from the Gout Study Group (GRESGO) cohort were evaluated at 6-month intervals. Demographic and clinical data were obtained at baseline. Visits included assessments of serum urate, flares, tophus burden, health-related quality of life using the EQ-5D, activity limitations using the Health Assessment Questionnaire adapted for gout, and pain level and patient's global assessment using visual analog scales. Treatment for gout and associated diseases was prescribed according to guidelines and available drugs. RESULTS:Of 500 patients studied, 221 had severe gout (44%) and 279 had non-severe gout (56%) at baseline. No significant differences were observed across the study in percentages of severe gout versus non-severe gout patients achieving SU 6 mg/dl or 5 mg/dl. The highest proportion of patients achieving target SU (50-70%) and remission (39%) were found after 3-4 years of followup. In the fifth year, these proportions decreased and 28% of the patients were in remission, but only 40 patients remained in the study. None of the patients with severe gout achieved remission. CONCLUSION:In patients with severe gout, target SU was hard to achieve and remission was not possible. The main obstacles for target SU and gout remission include poor medication adherence, persistent tophi, and loss to followup.
Methods to improve medication adherence in patients with chronic inflammatory rheumatic diseases: a systematic literature review.
Lavielle Matthieu,Puyraimond-Zemmour Déborah,Romand Xavier,Gossec Laure,Senbel Eric,Pouplin Sophie,Beauvais Catherine,Gutermann Loriane,Mezieres Maryse,Dougados Maxime,Molto Anna
Objective:Lack of adherence to treatment is frequent in chronic inflammatory rheumatic diseases and is associated with poorer outcomes. The objective of this study was to describe and evaluate interventions that have been proposed to enhance medication adherence in these conditions. Methods:A systematic literature review was performed in Pubmed, Cochrane, Embase and clinicaltrials.gov databases completed by the rheumatology meeting (ACR, EULAR and SFR) abstracts from last 2 years. All studies in English or French evaluating an intervention to improve medication adherence in chronic inflammatory rheumatic diseases (rheumatoid arthritis (RA), spondyloarthritis (SpA), crystal related diseases, connective tissue diseases, vasculitis and Still's disease) were included. Interventions on adherence were collected and classified in five modalities (educational, behavioural, cognitive behavioural, multicomponent interventions or others). Results:1325 abstracts were identified and 22 studies were finally included (18 studies in RA (72%), 4 studies in systemic lupus erythematosus (16%), 2 studies in SpA (8%) and 1 study in gout (4%)). On 13 randomised controlled trials (RCT) (1535 patients), only 5 were positive (774 patients). Educational interventions were the most represented and had the highest level of evidence: 8/13 RCT (62%, 1017 patients) and 4/8 were positive (50%). In these studies, each patient was individually informed or educated by different actors (physicians, pharmacists, nurses and so on). Supports and contents of these educational interventions were heterogenous. Conclusion:Despite the importance of medication adherence in chronic inflammatory rheumatic disorders, evidence on interventions to improve medication adherence is scarce.
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.
Improving gout education from patients' perspectives: a focus group study of Māori and Pākehā people with gout.
Rolston Cassandra J,Conner Tamlin S,Stamp Lisa K,Neha Tia,Pitama Suzanne,Fanning Niamh,Janes Ron,Judd Andrea,Hudson Ben,Hegarty Roisin M,Treharne Gareth J
Journal of primary health care
INTRODUCTION Gout is a common form of arthritis that is typically managed in primary care. Gout management guidelines emphasise patient education for successful treatment outcomes, but there is limited literature about the educational experiences of people living with gout in New Zealand, particularly for Māori, who have higher gout prevalence and worse gout outcomes than Pākehā. AIM To explore gout patient education in primary care from the perspectives of Māori and Pākehā people with gout. METHODS In total, 69 people with gout were recruited through primary care providers in three locations across New Zealand. Nine semi-structured focus groups were run with Māori and Pākehā participants in separate groups. RESULTS Thematic analysis yielded two themes in relation to gout education: (i) 'Multiple sources of gout education'; and (ii) 'Gaps in gout knowledge'. Participants received education from general practitioners, educational resources, family and friends, and their own experiences. Māori participants preferred information to be kanohi-ki-te-kanohi (face-to-face) and with significant others present where necessary. Participants disclosed gaps in gout's epidemiology and management. Pākehā and Māori participants reported limited understanding of the genetic basis of gout or the biological underpinnings of the condition and its treatments, but learned treatment adherence through experience. DISCUSSION Despite improved gout patient education, knowledge gaps remain and may contribute to poor medication adherence. Gout patient education interventions need to be tailored to culture and incorporate suitable methods of disseminating information about gout management.
How Can We Improve Disease Education in People with Gout?
Fields Theodore R,Batterman Adena
Current rheumatology reports
PURPOSE OF REVIEW:Gout management is currently suboptimal despite excellent available therapy. Gout patient education has been shown to enhance medication adherence and self-management, but needs improvement. We explored the literature on gout patient education including gaps in gout patient knowledge; use of written materials; in-person individual and group sessions; education via nurses, pharmacists, or multi-disciplinary groups; and use of phone, web-based, mobile health app, and text messaging educational efforts. RECENT FINDINGS:Nurse-led interventions have shown significant improvement in reaching urate goals. Pharmacist-led programs have likewise succeeded, but to a lesser degree. A multi-disciplinary approach has shown feasibility. Needs-assessments, patient questionnaires, and psychosocial evaluations can enhance targeted education. An interactive and patient-centered approach can enhance gout educational interventions. Optimal programs will assess for and address educational needs related to knowledge gaps, health literacy, race, gender, socio-economic status, and level of social support.
Gout prevalence and predictors of urate-lowering therapy use: results from a population-based study.
Pisaniello Huai Leng,Lester Susan,Gonzalez-Chica David,Stocks Nigel,Longo Marie,Sharplin Greg R,Dal Grande Eleonora,Gill Tiffany K,Whittle Samuel L,Hill Catherine L
Arthritis research & therapy
BACKGROUND:Gout has an increasing global prevalence. Underutilization of urate-lowering therapy (ULT) is thought to be common, via both suboptimal dosing and poor medication adherence. The aims of this study were to determine the prevalence of self-reported gout and the key predictors of ULT use in those with gout in a representative population survey in South Australia. METHODS:Data were obtained from the Spring 2015 South Australian Health Omnibus Survey, a multilevel, systematic, survey in a representative population sample involving face-to-face interviews (n = 3005). This study analyzed responses from respondents aged ≥ 25 years (n = 2531) about self-reported gout, ULT use, sociodemographic factors, lifestyle factors, and comorbidities, using survey weighting. Univariate and subsequent adjusted logistic regression analyses on self-reported gout were performed. ULT use was divided into three categories (never use, prior use, and current use) and these data were analyzed using a multinomial logistic regression model. RESULTS:Self-reported gout prevalence was 6.8% (95% CI 5.8, 7.9). The mean age of respondents with gout was 64 years (standard deviation 16) and 82% were male. As expected, older age, male gender, lower socioeconomic status (SES), and higher body mass index (BMI) were associated with gout, as were high alcohol consumption, current smoking, other forms of arthritis, and hypertension or hypercholesterolemia medication, after adjustment for sociodemographic variables. Two thirds of respondents with gout reported ULT use (36% current; 29% previous) with only 55% continuing treatment. Predictors of ULT use included male gender, low SES, and concomitant cholesterol-lowering therapy. Respondents with gout with a higher BMI were more likely to remain on ULT. CONCLUSIONS:Despite gout being a common, potentially disabling joint disease, only 55% of respondents with gout in this study adhered to ULT. Identification of key predictors of ULT use will provide guidance on prescribing strategy in clinical practice and on the quality of gout care in the community.
Overcoming adherence issues and other barriers to optimal care in gout.
Nasser-Ghodsi Navine,Harrold Leslie R
Current opinion in rheumatology
PURPOSE OF REVIEW:This review presents research published over the last year examining use of urate-lowering therapy (ULT) as well as trends over time in adherence to this class of agents. Additionally, it explores factors associated with nonadherence to ULTs for chronic gout and interventions to improve chronic gout management. RECENT FINDINGS:New literature suggests prescriptions of ULTs for prevalent and incident gout patients remains lower than expected based on the burden of the disease in the population. Overall ULT adherence remains suboptimal, in part related to inadequate patient education and copayment costs; although one study demonstrated improvement in adherence over a 15-year study period. Finally, interventions that include patient education and medication titration based on laboratory results successfully lowered serum urate levels to less than 6 mg/dl in the majority of patients. SUMMARY:Gout remains a prevalent disease that is poorly managed despite effective treatments. Recent research suggests that ULTs are underutilized and even when prescribed are not well adhered to. Patient-centered interventions that focus on education about pharmacologic therapy and lifestyle modifications with medication titration have resulted in a greater proportion of patients achieving recommended serum urate levels.
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.
Long-term adherence and persistence with febuxostat among male patients with gout in a routine clinical setting.
Lee Sunggun,So Min Wook,Ahn Eunyoung
To assess long-term adherence and persistence to febuxostat (FBX) and factors that might contribute to non-adherence and non-persistence to FBX in male patients with gout during a 3-year period. Adherence to FBX was assessed by the clinic nurses through pill counts at the scheduled visits and non-adherence was defined as less than 80% of the prescribed dose taken. Non-persistence was defined as discontinuation of FBX longer than 60 days. A total of 220 patients were recruited. The percentage of adherence and persistence was 71.8% and 80.9% at 1 year, 65.5% and 68.2% at 2 years and 58.2% and 56.4% at 3 years, respectively. The logistic regression analysis identified high income status, current smoking, absence of hypertension and previous history of non-persistence with urate-lowering therapy (ULT) as the independent factors associated with non-adherence, and the unmarried, absence of hypertension and previous history of non-persistence with ULT as the independent factors associated with non-persistence. Variable risk factors that are correlated with poor adherence or persistence and easily assessed can be used to identify patients at a particular risk of poor adherence or persistence.
Exploring current and potential roles of Australian community pharmacists in gout management: a qualitative study.
Counsell Allyce B,Nguyen Amy D,Baysari Melissa T,Kannangara Diluk R W,McLachlan Andrew J,Day Richard O
BMC family practice
BACKGROUND:Gout is an increasingly prevalent form of inflammatory arthritis. Although effective treatments for gout exist, current management is suboptimal due to low medication adherence rates and treatments that are non-concordant with guidelines. Medications are the mainstay and most effective form of gout management. Thus, there is potential for community pharmacists to play an important primary health care role in gout management, however their current role and their potential to improve management of gout treatment is currently unclear. The purpose of the study is to explore the views of Australian pharmacists on their roles in gout management and to identify factors influencing their involvement in gout management. METHODS:A convenience sample of community pharmacists were invited to participate using a snowballing recruitment strategy. Semi-structured, face-to-face interviews were conducted with 15 pharmacists of varying age, gender and pharmacy experience. Interviews focused on pharmacists' experiences of managing gout, interactions with people living with gout and their perceived roles and responsibilities in gout management. Interviews were transcribed verbatim and independently analysed by two reviewers to identify themes. RESULTS:The main role of pharmacists reported in gout management was providing patient education. The greatest facilitator to pharmacists involvement in gout management was identified to be pharmacists' good understanding of gout and its management. Barriers to pharmacists involvement were identified to be difficulties in monitoring adherence to gout medications, low priority given to gout in the pharmacy compared to other chronic health conditions, and lack of specific training and/or continuing education in gout prevention and management. CONCLUSIONS:Pharmacists can expand their primary health care role in gout management, particularly in the area of ongoing provision of education to people living with gout and in monitoring medication adherence in patients. However, a number of barriers need to be overcome including difficulties in monitoring patient adherence to medications, ensuring a higher priority is given to chronic gout management and providing continuing training to community pharmacists about gout. Implications for pharmacist practice include initiating conversations about medication adherence and education when dispensing medications and undertaking continuing education in gout.
Rate of adherence to urate-lowering therapy among patients with gout: a systematic review and meta-analysis.
Yin Rulan,Li Lin,Zhang Guo,Cui Yafei,Zhang Lijuan,Zhang Qiuxiang,Fu Ting,Cao Haixia,Li Liren,Gu Zhifeng
INTRODUCTION:Reported adherence to urate-lowering therapy (ULT) in gout varies widely (17%-83.5%). Variability may partly be due to different adherence measurement methods. This review aimed to quantify ULT adherence in adult patients with gout. METHODS:This analysis examined studies in PubMed, Web of Science, CNKI Scholar and WanFang databases from inception to January 2017. Papers were selected by inclusion and exclusion criteria in the context. Random-effect meta-analysis estimated adherence. RESULTS:22 studies were found by the inclusion criteria, which involved 1 37 699 patients with gout. Four ways to define adherence were reported. Meta-analysis revealed that the overall adherence rate was 47% (95% CI 42% to 52%, I=99.7%). Adherence rate to ULT was 42% (95% CI 37% to 47%, I=99.8%) for prescription claims, 71% (95% CI 63% to 79%) for pill count, 66% (95% CI 50% to 81%, I=86.3%) for self-report and 63% (95% CI 42% to 83%, I=82.9%) for interview, respectively. The influential factor on adherence rate was country of origin. CONCLUSIONS:Among adult patients with gout, overall adherence rate to ULT was as low as 47%, which suggested that clinicians should pay more attention to medication adherence in patients with gout to effectively improve adherence to ULT.
Adherence with urate-lowering therapies among male patients with gout in a routine clinical setting.
Lee Sunggun,So Min Wook
OBJECTIVES:To assess adherence (compliance and persistence) and factors that might contribute to nonadherence to urate-lowering therapies (ULT) in patients with gout in a routine clinical setting. METHODS:This prospective observational cohort study was conducted in the rheumatology center of a local tertiary hospital. A total of 132 male adults aged 75 years or younger who were incidentally diagnosed with gout were included. Adherence to ULT was assessed by the clinic nurses through pill counts. RESULTS:Of the 132 patients, 94 (71.2%) was compliant and 81 (61.4%) was persistent with ULT. The logistic regression analysis revealed that the absence of chronic kidney disease (CKD) and the previous history of non-persistence with ULT are the independent factors associated with noncompliance and the absence of CKD is an independent factor associated with non-persistence. The average serum urate levels of the noncompliant (p = 0.001) and non-persistent (p = 0.002) patients were significantly higher than those of the compliant and persistent patients. CONCLUSIONS:The absence of CKD and the previous history of non-persistence of ULT that are correlated with poor adherence and easily assessed can be used to identify patients at a particular risk of poor adherence.
The Duality of Economic Issues With Medication Non-adherence in Patients With Inflammatory Arthritis.
Campbell Natasha K J,Saadeldin Khalid,De Vera Mary A
Current rheumatology reports
PURPOSE OF REVIEW:In this review, we synthesize current data on non-adherence across inflammatory arthritides and explore (1) the effects of economic factors on non-adherence and (2) the impacts of non-adherence on economic outcomes. RECENT FINDINGS:Recent evidence demonstrates medication non-adherence rates as high as 74% in ankylosing spondylitis (AS), 90% in gout, 50% in psoriatic arthritis (PsA), 75% in systemic lupus erythematosus (SLE), and 82% in rheumatoid arthritis (RA). The effects of socioeconomic factors have been studied most in RA and SLE but with inconsistent findings. Nonetheless, the evidence points to having prescription coverage and costs of treatment as important factors in RA and education as an important factor in SLE. Limited data in AS and gout, and no studies of the effects of socioeconomic factors in PsA, show knowledge gaps for future research. Finally, there is a dearth of data with respect to the impacts of non-adherence on economic outcomes.
Rebranding Gout: Could a Name Change for Gout Improve Adherence to Urate-Lowering Therapy?
Coleshill Matthew J,Aung Eindra,Carland Jane E,Faasse Kate,Stocker Sophie,Day Richard O
Therapeutic innovation & regulatory science
Gout is the most common form of inflammatory arthritis in men, yet both patients and the public often do not recognise gout as a form of arthritis. Instead, due to historical misconceptions, gout is typically seen as a lifestyle disease caused by poor diet. In reality, there are a number of risk factors that contribute to gout, including genetic factors. Views of gout as precipitated by lifestyle alone can lead to stigma, and maladaptive beliefs that it should be treated primarily through dietary changes. This is thought to contribute to poor uptake of, and adherence to, effective pharmaceutical treatments. Gout has some of the poorest medication adherence rates of any chronic disease, contributing to suboptimal health outcomes for patients. Recent research suggests that when gout is referred to as 'urate crystal arthritis' (a rarely used name for gout), the perception of the disease by members of the public was more accurate. It was viewed as being less under personal control (i.e. less appropriately managed by behaviours such as dietary intake), and more appropriately managed by long-term medical treatment. This finding raises the possibility that patients themselves might also benefit from gout being explicitly labelled as arthritis. Indeed, parallels can be drawn between this case and other diseases that have recently had their names changed to improve outcomes, namely primary biliary cirrhosis and schizophrenia. A movement away from the term gout may benefit those living with the disease by changing illness perceptions and increasing uptake of, and adherence to, guideline-recommended treatment(s).
[Effects of gout web based self-management program on knowledge related to disease, medication adherence, and self-management].
Oh Hyun Soo,Park Won,Kwon Seong Ryul,Lim Mie Jin,Suh Yeon Ok,Seo Wha Sook,Park Jong Suk
Journal of Korean Academy of Nursing
PURPOSE:This study was conducted to examine the changing patterns of knowledge related to disease, medication adherence, and self-management and to determine if outcomes were more favorable in the experimental group than in the comparison group through 6 months after providing a web-based self-management intervention. METHODS:A non-equivalent control group quasi-experimental design was used and 65 patients with gout, 34 in experimental group and 31 in comparison group, were selected from the rheumatic clinics of two university hospitals. Data were collected four times, at baseline, at 1 month, 3 months, and 6 months after the intervention. RESULTS:According to the study results, the changing patterns of knowledge and self-management were more positive in the experimental group than in the control group, whereas difference in the changing pattern of medication adherence between two groups was not significant. CONCLUSION:The results indicate that the web-based self-management program has significant effect on improving knowledge and self-management for middle aged male patients with gout. However, in order to enhance medication adherence, the web-based intervention might not be sufficient and other strategies need to be added.
Utility of the Morisky Medication Adherence Scale in gout: a prospective study.
Tan Csl,Teng G G,Chong K J,Cheung P P,Lim Ayn,Wee H L,Santosa A
Patient preference and adherence
BACKGROUND:The outcomes of any chronic illness often depend on patients' adherence with their treatment. A tool is lacking to assess adherence in gout that is standardized, allows real-time feedback, and is easy to understand. OBJECTIVE:We set out to evaluate the utility of the 8-item Morisky Medication Adherence Scale (MMAS-8) in monitoring medication adherence in a multiethnic Asian gout cohort on urate-lowering therapy (ULT). METHODS:This cohort study recruited patients with gout where baseline and 6-monthly clinical data, self-report of adherence, and health status by Gout Impact Scale (GIS) and EuroQoL-5 dimension 3 levels were collected. Those who received at least 9 months of ULT were analyzed. Convergent and construct validities of MMAS-8 were evaluated against medication possession ratio (MPR) and known groups, clinical outcomes, and patient-reported outcomes. Internal consistency and test-retest reliability were assessed using Cronbach's alpha and intraclass correlation coefficient (ICC), respectively. RESULTS:Of 91 patients, 92.3% were male, 72.5% Chinese with mean age 53.5 years. MMAS-8 (mean 6.17) and MPR (mean 96.3%) were poorly correlated (=0.069, =0.521). MMAS-8 did not differ between those who did or did not achieve target serum urate (SU) <360 µmol/L (=0.852); or among those whose SU improved, stagnated, or worsened during follow-up (=0.777). Adherence was associated with age (β=0.256, =0.015) and education level (=0.011) but not comorbidities, polypharmacy, or flare frequency. Concerns for medication side effects and anxiety or depression were associated with lower MMAS-8 (<0.005). Internal consistency was acceptable (α=0.725) and test-retest reliability was satisfactory (ICC =0.70, 95% confidence interval [CI] 0.36-0.88). CONCLUSION:MMAS-8 had limited construct validity in assessing medication adherence to ULT in our gout patients. Nevertheless, it identified patients bothered or worried about ULT side effects, and those with underlying anxiety or depression, for whom targeted education and coping support may be useful.
Impact of Non-Adherence and Flare Resolution on the Cost-Effectiveness of Treatments for Gout: Application of a Linked Pharmacometric/Pharmacoeconomic Model.
Hill-McManus Daniel,Marshall Scott,Soto Elena,Lane Steven,Hughes Dyfrig
Value in health : the journal of the International Society for Pharmacoeconomics and Outcomes Research
BACKGROUND:Dual urate-lowering therapy (ULT) with lesinurad in combination with either allopurinol or febuxostat is an option for patients with gout unsuccessfully treated on either monotherapy. Treatment failure is often a result of poor medication adherence. Imperfect adherence in clinical trials may lead to biased estimates of treatment effect and confound the results of cost-effectiveness analyses. OBJECTIVES:To estimate the impact of varying medication adherence on the cost effectiveness of lesinurad dual therapy and estimate the value-based price of lesinurad at which the incremental cost-effectiveness ratio is equal to £20,000 per quality-adjusted life-year (QALY). METHODS:Treatment effect was simulated using published pharmacokinetic-pharmacodynamic models and scenarios representing adherence in clinical trials, routine practice, and perfect use. The subsequent cost and health impacts, over the lifetime of a patient cohort, were estimated using a bespoke pharmacoeconomic model. RESULTS:The base-case incremental cost-effectiveness ratios comparing lesinurad dual ULT with monotherapy ranged from £39,184 to £78,350/QALY gained using allopurinol and £31,901 to £124,212/QALY gained using febuxostat, depending on the assumed medication adherence. Results assuming perfect medication adherence imply a per-quarter value-based price of lesinurad of £45.14 when used in dual ULT compared with allopurinol alone and £57.75 compared with febuxostat alone, falling to £25.41 and £3.49, respectively, in simulations of worsening medication adherence. CONCLUSIONS:The estimated value-based prices of lesinurad only exceeded that which has been proposed in the United Kingdom when assuming both perfect drug adherence and the eradication of gout flares in sustained treatment responders.
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.
Medication adherence in gout: a systematic review.
De Vera Mary A,Marcotte Greg,Rai Sharan,Galo Jessica S,Bhole Vidula
Arthritis care & research
OBJECTIVE:Recent data suggesting the growing problem of medication nonadherence in gout have called for the need to synthesize the burden, determinants, and impacts of the problem. Our objective was to conduct a systematic review of the literature examining medication adherence among patients with gout in real-world settings. METHODS:We conducted a search of Medline, Embase, International Pharmaceutical Abstracts, PsycINFO, and CINAHL databases and selected studies of gout patients and medication adherence in real-world settings. We extracted information on study design, sample size, length of followup, data source (e.g., prescription records versus electronic monitoring versus self-report), type of nonadherence problem evaluated, adherence measures and reported estimates, and determinants of adherence reported in multivariable analyses. RESULTS:We included 16 studies that we categorized according to methods used to measure adherence, including electronic prescription records (n = 10), clinical records (n = 1), electronic monitoring devices (n = 1), and self-report (n = 4). The burden of nonadherence was reported in all studies, and among studies based on electronic prescription records, adherence rates were all below 0.80 and the proportion of adherent patients ranged from 10-46%. Six studies reported on determinants, with older age and having comorbid hypertension consistently shown to be positively associated with better adherence. One study showed the impact of adherence on achieving a serum uric acid target. CONCLUSION:With less than half of gout patients in real-world settings adherent to their treatment, this systematic review highlights the importance of health care professionals discussing adherence to medications during encounters with patients.
The rate of adherence to urate-lowering therapy and associated factors in Chinese gout patients: a cross-sectional study.
Yin Rulan,Cao Haixia,Fu Ting,Zhang Qiuxiang,Zhang Lijuan,Li Liren,Gu Zhifeng
The aim of this study was to assess adherence rate and predictors of non-adherence with urate-lowering therapy (ULT) in Chinese gout patients. A cross-sectional study was administered to 125 gout patients using the Compliance Questionnaire on Rheumatology (CQR) for adherence to ULT. Patients were asked to complete the Treatment Satisfaction Questionnaire for Medication version II, Health Assessment Questionnaire, Confidence in Gout Treatment Questionnaire, Gout Knowledge Questionnaire, Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, and 36-Item Short Form Health Survey. Data were analyzed by independent sample t test, rank sum test, Chi-square analysis as well as binary stepwise logistic regression modeling. The data showed that the rate of adherence (CQR ≥80%) to ULT was 9.6% in our investigated gout patients. Adherence was associated with functional capacity, gout-related knowledge, satisfaction with medication, confidence in gout treatment and mental components summary. Multivariable analysis of binary stepwise logistic regression identified gout-related knowledge and satisfaction of effectiveness with medication was the independent risk factors of medication non-adherence. Patients unaware of gout-related knowledge, or with low satisfaction of effectiveness with medication, were more likely not to adhere to ULT. Non-adherence to ULT among gout patients is exceedingly common, particularly in patients unaware of gout-related knowledge, or with low satisfaction of effectiveness with medication. These findings could help medical personnel develop useful interventions to improve gout patients' medication adherence.
Outcome Measures in Rheumatology - Interventions for medication Adherence (OMERACT-Adherence) Core Domain Set for Trials of Interventions for Medication Adherence in Rheumatology: 5 Phase Study Protocol.
Kelly Ayano,Tong Allison,Tymms Kathleen,March Lyn,Craig Jonathan C,De Vera Mary,Evans Vicki,Hassett Geraldine,Toupin-April Karine,van den Bemt Bart,Teixeira-Pinto Armando,Alten Rieke,Bartlett Susan J,Campbell Willemina,Dawson Therese,Gill Michael,Hebing Renske,Meara Alexa,Nieuwlaat Robby,Shaw Yomei,Singh Jasvinder A,Suarez-Almazor Maria,Sumpton Daniel,Wong Peter,Christensen Robin,Beaton Dorcas,de Wit Maarten,Tugwell Peter,
BACKGROUND:Over the last 20 years, there have been marked improvements in the availability of effective medications for rheumatic conditions such as gout, osteoporosis and rheumatoid arthritis (RA), which have led to a reduction in disease flares and the risk of re-fracture in osteoporosis, and the slowing of disease progression in RA. However, medication adherence remains suboptimal, as treatment regimens can be complex and difficult to continue long term. Many trials have been conducted to improve adherence to medication. Core domains, which are the outcomes of most relevance to patients and clinicians, are a pivotal component of any trial. These core domains should be measured consistently, so that all relevant trials can be combined in systematic reviews and meta-analyses to reach conclusions that are more valid. Failure to do this severely limits the potential for trial-based evidence to inform decisions on how to support medication adherence. The Outcome Measures in Rheumatology (OMERACT) - Interventions for Medication Adherence study by the OMERACT-Adherence Group aims to develop a core domain set for interventions that aim to support medication adherence in rheumatology. METHODS/DESIGN:This OMERACT-Adherence study has five phases: (1) a systematic review to identify outcome domains that have been reported in interventions focused on supporting medication adherence in rheumatology; (2) semi-structured stakeholder interviews with patients and caregivers to determine their views on the core domains; (3) focus groups using the nominal group technique with patients and caregivers to identify and rank domains that are relevant to them, including the reasons for their choices; (4) an international three-round modified Delphi survey involving patients with diverse rheumatic conditions, caregivers, health professionals, researchers and other stakeholders to develop a preliminary core domain set; and (5) a stakeholder workshop with OMERACT members to review, vote on and reach a consensus on the core domain set for interventions to support medication adherence in rheumatology. DISCUSSION:Establishing a core domain set to be reported in all intervention studies undertaken to support patients with medication adherence will enhance the relevance and the impact of these results and improve the lives of people with rheumatic conditions.
Allopurinol Medication Adherence as a Mediator of Optimal Outcomes in Gout Management.
Coburn Brian W,Bendlin Kayli A,Sayles Harlan,Meza Jane,Russell Cynthia L,Mikuls Ted R
Journal of clinical rheumatology : practical reports on rheumatic & musculoskeletal diseases
BACKGROUND:Patient and provider factors, including allopurinol medication adherence, affect gout treatment outcomes. OBJECTIVES:The aim of this study was to examine associations of patient and provider factors with optimal gout management. METHODS:Linking longitudinal health and pharmacy dispensing records to questionnaire data, we assessed patient and provider factors among 612 patients with gout receiving allopurinol during a recent 1-year period. Associations of patient (medication adherence and patient activation) and provider factors (dose escalation, low-dose initiation, and anti-inflammatory prophylaxis) with serum urate (SU) goal achievement of less than 6.0 mg/dL were examined using multivariable logistic regression. Medication adherence was assessed as a mediator of these factors with goal achievement. RESULTS:A majority of patients (63%) were adherent, whereas a minority received dose escalation (31%). Medication adherence was associated with initiation of daily allopurinol doses of 100 mg/d or less (odds ratio [OR], 1.82; 95% confidence interval [CI], 1.20-2.76). In adjusted models, adherence (OR, 2.35; 95% CI, 1.50-3.68) and dose escalation (OR, 2.48; 95% CI, 2.48-4.25) were strongly associated with SU goal attainment. Low starting allopurinol dose was positively associated with SU goal attainment (OR, 1.11; 95% CI, 1.02-1.20) indirectly through early adherence, but also had a negative direct association with SU goal attainment (OR, 0.21; 95% CI, 0.12-0.37). CONCLUSIONS:Medication adherence and low starting dose combined with dose escalation represent promising targets for future gout quality improvement efforts. Low starting dose is associated with better SU goal attainment through increased medication adherence, but may be beneficial only in settings where appropriate dose escalation is implemented.
Patient and Caregiver Priorities for Medication Adherence in Gout, Osteoporosis, and Rheumatoid Arthritis: Nominal Group Technique.
Kelly Ayano,Tymms Kathleen,de Wit Maarten,Bartlett Susan J,Cross Marita,Dawson Therese,De Vera Mary,Evans Vicki,Gill Michael,Hassett Geraldine,Lim Irwin,Manera Karine,Major Gabor,March Lyn,O'Neill Sean,Scholte-Voshaar Marieke,Sinnathurai Premarani,Sumpton Daniel,Teixeira-Pinto Armando,Tugwell Peter,van den Bemt Bart,Tong Allison
Arthritis care & research
OBJECTIVE:This study aimed to identify and prioritize factors important to patients and caregivers with regard to medication adherence in gout, osteoporosis (OP), and rheumatoid arthritis (RA) and to describe the reasons for their decisions. METHODS:Patients with gout, OP, and RA and their caregivers, purposively sampled from 5 rheumatology clinics in Australia, identified and ranked factors that they considered important for medication adherence using nominal group technique and discussed their decisions. An importance score (IS; scale 0-1) was calculated, and qualitative data were analyzed thematically. RESULTS:From 14 focus groups, 82 participants (67 patients and 15 caregivers) identified 49 factors. The top 5 factors based on the ranking of all participants were trust in doctor (IS 0.46), medication effectiveness (IS 0.31), doctor's knowledge (IS 0.25), side effects (IS 0.23), and medication-taking routine (IS 0.13). The order of the ranking varied by participant groupings, with patients ranking "trust in doctor" the highest, while caregivers ranked "side effects" the highest. The 5 themes reflecting the reasons for factors influencing adherence were as follows: motivation and certainty in supportive individualized care; living well and restoring function; fear of toxicity and cumulative harm; seeking control and involvement; and unnecessarily difficult and inaccessible. CONCLUSION:Factors related to the doctor, medication properties, and patients' medication knowledge and routine were important for adherence. Strengthening doctor-patient trust and partnership, managing side effects, and empowering patients with knowledge and skills for taking medication could enhance medication adherence in patients with rheumatic conditions.
Medication adherence among gout patients initiated allopurinol: a retrospective cohort study in the Clinical Practice Research Datalink (CPRD).
Scheepers Lieke E J M,Burden Andrea M,Arts Ilja C W,Spaetgens Bart,Souverein Patrick,de Vries Frank,Boonen Annelies
Rheumatology (Oxford, England)
Objectives:When urate lowering therapy is indicated in patients with gout, medication adherence is essential. This study assesses non-persistence and non-adherence in patients with newly diagnosed gout, and identifies factors associated with poor medication adherence. Methods:A retrospective data analysis was performed within the UK Clinical Practice Research Datalink (1987-2014) among incident gout patients, aged ⩾40 years and starting allopurinol (n = 48 280). The proportion of patients non-persistent (a first medication gap of ⩾90 days) after 1 and 5 years, and median time until a first 90-day gap was estimated using Kaplan-Meier statistics in those starting allopurinol and restarting after a first interruption. Non-adherence (proportion of days covered <80%) over the full observation period was calculated. Multivariable Cox- or logistic regressions assessed factors associated with non-persistence or non-adherence, respectively. Results:Non-persistence increased from 38.5% (95% CI: 38.1, 38.9) to 56.9% (95% CI: 56.4, 57.4) after 1 and 5 years of initiation. Median time until a first 90-day gap was 1029 days (95% CI: 988, 1078) and 61% were non-adherent. After a first gap, 43.3% (95% CI: 42.7, 43.9) restarted therapy within 1 year, yet only 52.3% (95% CI: 51.4, 53.1) persisted for 1 year. Being female and a current smoker increased the risk for non-persistence and non-adherence, while older age, overweight, receiving anti-hypertensive medication or colchicine and suffering from dementia, diabetes or dyslipidaemia decreased the risk. Conclusion:Medication adherence among gout patients starting allopurinol is poor, particularly among females and younger patients and patients with fewer comorbidities. Medication adherence remains low in those reinitiating after a first gap.
Factors influencing medication adherence in patients with gout: A descriptive correlational study.
Chua Xin Hui Jasmine,Lim Siriwan,Lim Fui Ping,Lim Yee Nah Anita,He Hong-Gu,Teng Gim Gee
Journal of clinical nursing
AIMS AND OBJECTIVES:To examine the factors influencing adherence to urate-lowering therapy in patients with gout in Singapore. BACKGROUND:Gout is the most common type of chronic inflammatory arthritis. Urate-lowering therapy is used to treat gout by reducing serum uric acid levels. However, adherence to urate-lowering therapy among patients remains poor. To date, there have been no available studies based on a conceptual framework that examined factors influencing medication adherence in patients with gout. DESIGN:Cross-sectional, descriptive correlational study. METHODS:A convenience sample of outpatients (n = 108) was recruited between October 2014-January 2015 from a tertiary hospital in Singapore. Outcomes were measured by relevant valid and reliable instruments. Descriptive statistics and parametric tests including multiple linear regression were used to analyse the data. RESULTS:Although 44.4% of the participants were high adherers to urate-lowering therapy, the mean adherence level was moderate. Significant differences in medication adherence scores were found among the subgroups of gender, ethnicity, marital status, employment status and presence of comorbidity. Medication adherence was positively significantly correlated with age, number of comorbidities and beliefs about medicines. Linear regression showed that higher level of beliefs about medicines, presence of comorbidity and being married were factors positively influencing medication adherence. CONCLUSIONS:This study revealed moderate adherence to urate-lowering therapy in patients with gout in Singapore, indicating the need for strategies to improve adherence by considering its main influencing factors. Future research should be conducted to develop interventions targeted at modifying patients' beliefs about medicines in order to improve medication adherence. RELEVANCE TO CLINICAL PRACTICE:Findings from this study allow healthcare providers to quickly and easily identify patients who may have low adherence. Nurses should take the lead in educating patients on the mechanism of urate-lowering therapy and highlight the importance of adhering to it.
Medication adherence among patients with gout: A systematic review and meta-analysis.
Scheepers Lieke E J M,van Onna Marloes,Stehouwer Coen D A,Singh Jasvinder A,Arts Ilja C W,Boonen Annelies
Seminars in arthritis and rheumatism
OBJECTIVE:In the management of chronic gout, a large proportion of patients need long-term management with urate lowering therapy (ULT). This study reviews medication adherence to ULT and summarizes factors associated with adherence. METHODS:We performed a systematic literature search for studies on adherence to ULT among gout patients in PubMed, Embase, CINAHL, and PsycINFO. We conducted meta-analysis, with a random effect model, for the studies reporting the proportion of patients considered adherent to at least 80% of prescribed medication or time taken. We explored potential sources of heterogeneity, including geographic area and measure of adherence. Narrative summaries were made for data on adherence assessed/defined by Medication Event Monitoring System (MEMS)/pill-count or patient-reported, occurrence of a gap in therapy ≥30 days (non-persistence), and factors associated with adherence. RESULTS:Of the 24 studies, 16 assessed adherence using prescription/claims data, two by the MEMS or pill count, and six by patient-reported data. The pooled proportion of adherent patients (n = 13) was 46% (95% CI: 41-51); 45% across studies conducted in the USA (n = 8) and 48% in other countries (n = 5). Adherence assessed by MEMS/pill count and patient-reported was much higher than by studies using prescription/claims data. Non-persistence (n = 6) ranged from 54% to 87%. Factors associated with adherence were investigated in 18 studies. Strong evidence for a positive association with older age, more comorbidities, and the presence of diabetes or hypertension was found. CONCLUSION:Medication adherence to ULT among gout patients was poor. Better insight into reasons and consequences or poor adherence is needed.
What are the effects of medication adherence interventions in rheumatic diseases: a systematic review.
Galo Jessica S,Mehat Pavandeep,Rai Sharan K,Avina-Zubieta Antonio,De Vera Mary A
Annals of the rheumatic diseases
OBJECTIVES:Consistent reports of suboptimal treatment adherence among patients with inflammatory arthritis underscore the importance of understanding how adherence can be promoted and supported. Our objectives were to identify and classify adherence interventions; and assess the evidence on the effects of adherence interventions on outcomes of patients with rheumatic diseases. METHODS:We conducted a mapped search of Medline, Embase and International Pharmaceutical Abstract databases to identify studies meeting inclusion criteria of: (1) patient population with inflammatory arthritis; (2) evaluation of an intervention or programme targeting medication adherence directly or indirectly; (3) reporting of one or more measures of medication adherence and disease outcome; (4) publication in English, French or Spanish. For our first objective, we applied a structured framework to classify interventions according target (patient vs provider), focus (educational vs behavioural vs affective), implementation (generalised vs tailored), complexity (single vs multifaceted) and provider. For the second objective, we appraised the evidence of effects of interventions on adherence and disease outcomes. RESULTS:We identified 23 studies reporting adherence interventions that directly or indirectly addressed treatment adherence in rheumatic diseases and further appraised included RCTs. Interventions that were shown to impact adherence outcomes were generally interventions directed at adherence, tailored to patients and delivered by a healthcare provider. For interventions that were not shown to have impacts, reasons may be those related to the intervention itself, patient characteristics or study methodology. CONCLUSIONS:Our systematic review shows limited research on adherence interventions in rheumatic diseases with inconsistent impacts on adherence or disease outcome.
Adherence to gout guidelines: where do we stand?
Ho Gary H,Pillinger Michael H,Toprover Michael
Current opinion in rheumatology
PURPOSE OF REVIEW:Although gout is a common, well-recognized, and extensively researched rheumatologic disease, it continues to be underappreciated and undertreated. Although the prevalence of gout has been rising over the past several decades, adherence to urate lowering therapy continues to be suboptimal. Recent studies have underscored the potential success of guideline-directed therapy. RECENT FINDINGS:Adherence to gout treatment continues to be suboptimal according to multinational metaanalyses. Moreover, studies measuring adherence are prone to overestimation and each methodologic approach has intrinsic limitations. Adherence may be analyzed from the perspective of patient adherence to taking a medication, or provider adherence to treatment guidelines. In addition to considering traditional risk factors, adherence should be viewed through the lens of healthcare disparities. The RAmP-Up trial and Nottingham Gout Treatment trial demonstrate the success of protocolized gout treatment using existing guidelines for reference. SUMMARY:Standardized gout treatment protocols should be established for all primary care and specialty practices. Two successful methods of improving adherence include using nonphysician providers to coordinate urate lowering therapy titration and monitoring serum urate. Having more frequent outpatient visits to focus on direct patient care and education has also been successful.