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Multiple retrospective studies have previously assessed pharmacologic and nonpharmacologic interventions among patients hospitalized with gout; however, authors of a systematic review published in Rheumatology found no prospective studies evaluating strategies to prevent readmission among this patient population.1 In light of the growing number of patients hospitalized with gout, the authors of the review concluded that there was an urgent need for prospective, high-quality data.
Research has shown that gout is a highly treatable disease. The European Alliance of Associations for Rheumatology (EULAR) recommends a treat-to-target approach to lower serum urate levels to 5 to 6 mg/dL to prevent deposition of monosodium urate crystals.2 Despite these guidelines, patient adherence to urate-lowering therapy (ULT) has been poor.3 Between 1993 and 2011, hospitalizations for gout flares doubled from 4.4 to 8.8 admissions per 100,000 adults, respectively.4 However, hospitalizations provide an opportunity to educate patients and engage them in shared decision-making to implement or improve their ULT uptake.
Russell et al conducted a systematic review to evaluate evidence-based interventions for the management of patients hospitalized with gout flares.1 The authors searched the MEDLINE, Embase, and Cochrane Library databases and identified studies that evaluated evidence-based interventions for adult patients who were hospitalized or admitted to the emergency department (ED) with a primary or secondary diagnosis of gout.
In total, 4197 studies were identified and 19 were included in the review. Of these, 5 were randomized control trials (RCTs), 1 was a prospective cohort study, and 13 were retrospective analyses.
Eleven studies evaluated pharmacologic interventions; all of them reported improved patient outcomes. The treatments used in these analyses (allopurinol, prednisolone, nonsteroidal anti-inflammatory drugs, and anakinra) are known to be effective in treating and preventing gout flares. Two retrospective studies reported lower hospitalizations and ED usage among patients receiving ULT.5,6
Eight studies evaluated nonpharmacologic interventions of which 7 assessed inpatient rheumatology consultations and reported improved patient outcomes. In 1 study, a protocol for nonrheumatologists treating gout flare hospitalization was implemented.7 The protocol included recommendations for continuing ULT, administering anti-inflammatory medications, performing joint aspirations, and consulting with rheumatologists as needed. The intervention resulted in an improvement in the continuation of allopurinol, reduction in treatment delays, and an increase in rheumatology consults.
Authors of the systematic review found no prospective studies evaluating strategies to improve ULT and prevent readmissions in patients hospitalized with gout flares.1 The majority of the studies identified were limited by their small size and potential for bias. Other limitations included wide variations in inclusion criteria and outcome measures.
To better understand the need and means to improve outcomes of patients hospitalized with gout, we spoke with rheumatologist Brian LaMoreaux, MD, MS, medical director of Medical Affairs at Horizon Therapeutics.
What strategies can providers use to engage patients who are hospitalized with gout for better disease management?
Educating patients and helping them to understand the severity of the disease and its impact beyond the flare is critical. While in the hospital, patients tend to know and understand that something is wrong, which can make them receptive to teachings from a gout specialist while they are admitted. Additionally, it is crucial for rheumatologists to utilize this time with a patient to emphasize the importance of proactively treating gout and educating on therapies that not only address gout flares, but also tackle the underlying issue of elevated uric acid levels, which could help to avoid future hospitalizations for gout.
To further drive home the message, providers can provide online resources, like GoutRevealed.com, for patients to review after they leave the hospital.
Why is it important for the rheumatologist to be consulted in the hospital setting to discuss appropriate education and therapies with patients?
It is important that rheumatologists are involved when a patient with gout is admitted to the hospital because they can ensure appropriate treatments are given in addition to providing the necessary education on long-term therapies to better manage the disease after discharge. Clinicians often prescribe primarily anti-inflammatory medicines that treat gout flares, allowing the patient to temporarily return to their normal life; but, if the underlying cause of gout – elevated uric acid levels – is not addressed, symptoms will return. Treating the inflammation from gout alone is a short-term solution to a long-term disease. Rheumatologists tend to appreciate the significant impact that urate crystal deposition in gout can have on the body, so they are much more likely to provide targeted education and recommend or initiate ULTs. If the underlying issue of elevated uric acid levels is not addressed, it is likely that these patients will end up in the hospital with gout flares.
Current gout management guidelines include interventions associated with improved outcomes for hospitalized patients. What are the barriers to implementing these interventions?
The lack of research surrounding gout is the most significant barrier. Until recently, many clinicians were taught that gout is simply a disease of intermittent flares and inflammation. As a result, many patients would be prescribed anti-inflammatory medications that addresses their pain but not the root cause of gout. Now we understand that gout is a systemic disease of urate crystal deposition that can have a significant impact on many parts of the body, including permanent joint damage, bone erosions, or even other health conditions like diabetes and cardiovascular disease. To overcome these barriers, clinicians need to evolve their understanding of gout, which hopefully will lead to better education for their patients in finding the right tools to manage their gout.
References
- Russell MD, Clarke BD, Roddy E, Galloway JB. Improving outcomes for patients hospitalized with gout: a systematic review. Rheumatology (Oxford). Published online July 10, 2021. doi:10.1093/rheumatology/keab539
- Richette P, Doherty M, Pascual E, et al. 2016 updated EULAR evidence-based recommendations for the management of gout. Ann Rheum Dis. Published online July 25, 2016. doi:10.1136/annrheumdis-2016-209707
- Aung T, Myung G, FitzGerald JD. Treatment approaches and adherence to urate-lowering therapy for patients with gout. Patient Prefer Adherence. Published online April 19, 2017. doi:10.2147/PPA.S97927
- Lim SY, Lu N, Oza A, et al. Trends in Gout and Rheumatoid Arthritis Hospitalizations in the United States, 1993-2011. JAMA. Published online June 7, 2016. doi:10.1001/jama.2016.3517
- Pattanaik D, Ali Z, Freire A. AB0880 Acute gouty arthritis related emergency department visits among us veterans: Characteristics, predictors and areas of improvement. Ann Rheum Dis. 2017;51(4):301-306. doi:10.1136/annrheumdis-2019-eular.1507
- Hutton I, Gamble G, Gow P, Dalbeth N. Factors associated with recurrent hospital admissions for gout: a case-control study. J Clin Rheumatol. 2009;15(6):271-274. doi:10.1097/RHU.0b013e3181b562f8
- Kamalaraj N, Gnanenthiran SR, Kathirgamanathan T, Hassett GM, Gibson KA, McNeil HP. Improved management of acute gout during hospitalization following introduction of a protocol. Int J Rheum Dis. 2012;15(6):512-20. doi:10.1111/j.1756-185X.2011.01642.x
