Pharmacist-Managed Titration May Effectively Lower Serum Urate Levels in Gout

Compared with patients who receive standard gout management, patients with gout treated with pharmacist-managed titration may achieve lower serum uric acid levels, according to study results published in Rheumatology International.

Investigators evaluated data from patients with gout treated at a rheumatology clinic in Seattle, Washington. Patients indicated to receive urate-lowering therapy (ULT) according to the 2012 American College of Rheumatology guidelines were eligible for referral to the pharmacist-managed titration program. Referred patients comprised the intervention group, and nonreferred patients were included in the control group. The pharmacist-managed program was derived from existing gout management guidelines; referred patients underwent repeat serum uric acid tests and metabolic panels every 2 to 5 weeks, and ULT dosages were increased as necessary. Pharmacists also provided patients with lifestyle and dietary counseling. Patients who were not referred to the program continued standard gout management with their providers. Clinical and demographic data were collected from a chart review at baseline and 12 months after initiation of the referral process.

The intervention group included 19 patients of median age 61±18 years, among whom 13 (68%) were men. The control group included 28 patients of median age 54±14 years, among whom 23 (82%) were men. Over the study period, the intervention group comprised 50 clinic visits, including rheumatology provider and clinical pharmacist encounters. The control group included 57 cumulative visits with rheumatology providers. At the end of follow-up, the average doses of allopurinol were 388.5 mg and 279.2 mg for the intervention and control groups, respectively (P =.07). For febuxostat, mean doses were 76 mg and 40 mg in the intervention and control groups, respectively (P =.04).

Median baseline serum uric acid at the time of referral was 8.8±2 mg/dL in the intervention group and 7.6±2.8 mg/dL in the control group (P =.2). At the end of the study period, median serum uric acid level was 6.1±1.4 mg/dL in the intervention group and 6.8±3.2 mg/dL in the control group (P =.08). At the end of follow-up, 13% of the intervention group and 25% of the control group met the goal, although there were no statistically significant differences between the groups (P =.3).

Results also indicated that compared with 96% of the control group, only 63% of the intervention group listed their preferred language as English. The resource-intensive nature of treating patients with language difficulties may have led to fewer patients in the intervention group achieving the serum uric acid goal. Further research is necessary to identify the most effective means of treating gout in patients with additional needs.

Overall, the pharmacist-managed titration program achieved lower median serum uric acid levels in referred patients compared with patients who received standard gout treatment. The nonrandomized trial design and small sample size restrict the strength of these conclusions; however, the current data support the integration of pharmacists into rheumatology clinics for assistance in ULT.

Reference

Huang IJ, Liew JW, Morcos MB, Zuo S, Crawford C, Bays AM. Pharmacist-managed titration of urate-lowering therapy to streamline gout management. Rheumatol Int. 2019;39(9):1637-1641.