Gout management needs a new model of care


By Mardi Chapman

21 Aug 2019

A multi-disciplinary approach to gout management, incorporating nurse-led education and follow-up by pharmacists, might be required to improve the proportion of patients with gout reaching target serum urate levels.

A five-year study of 129 inpatients and outpatients treated for gout at the Royal Brisbane and Women’s Hospital (RBWH) has confirmed the findings of other local and overseas studies – that treatment is often sub-optimal.

The study, led by Associate Professor Philip Robinson, found about 85% of patients intentionally discharged from the clinic by a rheumatologist had reached target serum urate levels (<0.36 mmol/L without tophi; <0.30 mmol/L with tophi).

Target was achieved after an average of 3.6 appointments.

The remaining 15% of patients intentionally discharged were on track to receive further titration of their urate levels with a GP or at another rheumatology service.

However only 56% of the patients that were no longer being followed up at the RBWH service at the end of the study period, for reasons including failure to attend, had reached target.

The group included two patients who did not reach target despite more than eight appointments and combination therapy with probenecid.

Of the patients who still had follow up organised with the service at the end of the study, 40% had reached their target serum urate.

Patients with poorer renal function were less likely to reach target than other patients.

“Overall this study supports findings from previous studies in the hospital and general practice settings that, despite the best efforts of experienced clinicians and adherence to guidelines with a treat-to-target approach, patients are achieving suboptimal SU levels,” the study authors wrote in the paper published in the Internal Medicine Journal.

They said the causes were likely to be multifactorial, including difficulty coordinating blood test results and clinic appointments in order to make dose adjustments.

“Anecdotally, some patients appeared to have inadequate understanding about their dose changes, flare management and the rationale behind ULT, leading to failure to take the correct escalated dose, self-ceasing medication and cancelling follow up appointments after a brief period of relief from acute flares.”

The study authors suggested that a different model of care including a predominately nurse-led intervention might provide more scope for better patient education. And pharmacist-led models of care have also shown some potential.

“It appears that suboptimal success in treating gout is achieved in specialist rheumatology clinics, despite adherence to treatment guidelines,” they concluded.

“More research is needed to determine how improved patient education and monitoring can be achieved in this setting, and recent research indicates that a multidisciplinary approach may be the best method of achieving this.”

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