Is it time to let nurses lead gout care?

Tuesday, 30 Oct 2018

Prof Nicola Dalbeth

A nurse-led model of treat-to-target gout care is the way to achieve the best outcomes for patients, a leading rheumatologist says.

Professor Nicola Dalbeth, from the Bone and Joint Research Group in the University of Auckland’s Department of Medicine says new results from a UK trial provide strong support for a community-based model of gout care based on education and feedback that results in high levels of adherence to urate-lowering medication and also higher doses than currently used by clinicians.

The findings from the primary care trial involving more than 500 patients with gout also provide backing for rheumatologists in the debate over treat-to-target gout guidelines against professional groups such as the American College of Physicians who recommend a less aggressive “treat-to-avoid-symptoms” strategy to urate-lowering therapy.

Writing in a Lancet commentary, Professor Dalbeth says the UK researchers “show a path forward for improved gout outcomes, demonstrating a package of care that leads to sustained adherence and clinical benefits through individualised education focusing on the central concept of gout as a chronic disease of urate crystal deposition and through using a well tolerated proactive treat-to-target approach.”

In their trial, 255 patients with a recent gout flare were assigned nurse-led care and 262 usual care. The nurse-led treat-to-target approach was based on oral allopurinol as first line treatment, started at 100 mg once per day and titrated upwards in 100 mg increments every 3–4 weeks according to serum urate concentrations, to a maximum of 900 mg once per day. urateFebuxostat and benzbromarone were available as second line options.

Over the two year study period, adherence to urate lowering therapy was high, at 95%, compared to 56% in the usual care group.

The primary outcome of achieving serum urate concentrations less than 360umol/L was achieved in 95% of patients receiving nurse led care and 30% of patients in usual GP care.

Secondary outcomes also favoured the nurse-led care group. The proportion of patients having two or more gout flares at two years was 8% vs 24% for the nurse-led vs usual care groups. Presence of tophi rates were 2.9% vs 11.3% respectively.

The study investigators note that the doses of allopurinol used were greater than 300 mg/day in 80% patients in the nurse-led group at one year and in 79% at two years, compared with 11% and 10%, respectively, in the usual-care group.

They said their findings reaffirmed the importance of education and engagement of patients in gout management and the usefulness of a treat-to-target strategy

“These findings add to the evidence that refutes the American College of Physicians advice, which seems to ignore patients’ involvement in deciding whether urate-lowering therapy should be used, and, when it is used, to not treat to a target serum urate concentration,” they wrote.

In her commentary, Professor Dalbeth adds that a nurse-led model of care for gout deserves consideration in other settings and could be successful in the same way as anticoagulation clinics in hospitals.

Highly efficacious and cost-effective gout management can be readily achieved by educating and spending time with patients,” she writes with co-author DrTuhina Neogi of the Boston University School of Medicine.

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