Timely Dose Adjustments of Urate-Lowering Therapy Improve Gout Outcomes

Timely dose adjustments to urate-lowering therapies (ULTs) can improve outcomes in people living with gout, according to an editorial published in the International Journal of Rheumatic Diseases.

Because gout is known to have one of the poorest adherence rates (47%) among chronic diseases as opposed to the standard 80%, the researchers aimed to examine the various factors that affect adherence and adherence practices.

Healthcare practitioners frequently prescribe similar ULT doses to all patients, leading to lower urate concentrations, which can lead to gout flares. Also, ULTs can, soon after initiation, produce acute gout attacks that may lead to discontinuation of treatment if proper education is not provided.

To improve adherence, researchers explored a method involving patient education and counseling, a self-managed treatment plan consisting of prophylaxis for acute attacks and long‐term ULT, appropriate dose titration according to serum urate concentrations, and referrals to dietitians, along with follow‐up visits with nurses and rheumatologists. This led to 56% of participants achieving target serum urate concentrations. Further research on this program by investigators showed that it was 85% more likely to be cost-effective than usual care.

Another researcher proposed a nurse-led intervention model where nurses were trained to perform patient education, shared decision‐making, administered acute gout attack prophylaxis, and used appropriate titration of ULT. In this model, 97% of those with gout had higher uptake of ULT after 12 months compared with 47% in the usual care group. In addition, 95% reached the target serum urate concentration compared with 26% of the usual care group.

Yet another study examined a pharmacist-led intervention in which a pharmacist engaged with people with gout and managed titration of ULT based on serum urate concentrations along with acute gout attack prophylaxis. This study had no specific duration, with participants staying in the program until they either withdrew or achieved sustained serum target urate concentrations for 3 months. This approach led to 82% achieving target urate concentrations within an average of 12 months and 80% sustaining urate concentrations below 0.36 mmol/L at follow‐up.

Researchers recommended that self-management along with practitioner-led approaches can improve adherence. Use of a mobile application can help educate people about gout and its management, and can be used to self‐monitor serum urate concentrations, gout attacks, and triggers. However, these do not address the issue of suboptimal dosing of ULTs. Therefore, a combination of timely dose adjustment of ULTs and acute attack management along with patient education and self-management support can help improve outcomes in gout.

For this to be achieved, clinicians need to have continuing education on the management of acute and chronic gout with an emphasis on ULT titration to reach serum urate targets. Also, the effectiveness of e-health interventions needs to be studied for effective utilization.

Reference

Coleshill MJ, Aung E, Nguyen AD, et al. Improving adherence to urate‐lowering therapy in people living with gout. Int J Rheum Dis. 2019;22(4):542-544.