Monthly gout clinic appointments are the key to achieving urate targets

An Adelaide hospital gout clinic has shown that providing monthly visit appointments to titrate urate-lowering therapy (ULT) can bring the condition under control within a year for the majority of patients with long-standing disease.

Almost 60% of patients who took part in the Queen Elizabeth Hospital Gout Clinic protocol achieved the target serum urate level of < 0.36 mmol/L within 12 months, according to rheumatologists at the clinic.

Writing in the Internal Medicine Journal, they said their protocol for more frequent appointments resulted in a rapid and progressive rate of serum urate reduction based on increasing the dose of allopurinol by 100mg a month until target urate levels were achieved.

Other key components of the protocol included education of both patients and GPs in the importance of continuing ULT during gout flares and having an individualised gout management plan to address other factors such as co-morbidities.

Led by rheumatologists Nieves Leonardo and Maureen Rischmueller, the study authors said the QEH gout clinic protocol had been developed to address the common problems of gout patients languishing on suboptimal doses of ULT (typically 100mg) and/or discontinuing treatment after a flare due to the misconception that the medication had failed or contributed to the worsening of their gout.

The gout clinic, run by a rheumatologist, rheumatology registrar and basic physician trainee, offered patients monthly appointments initially with consultations focused on education and on titrating the dose of allopurinol up by 100mg per visit (50mg for patients with chronic renal disease) until serum urate targets were met.

When patients achieve a target of 0.36 mmol/L, or 0.30 mmol/L for those with complex disease and/or tophi, they were reviewed at three-monthly and six monthly appointments to confirm the appropriateness of the final ULT dose. Management plans were shared with the patient’s GP.

In a review of outcomes for 43 newly referred patients with gout they found that the median serum urate level at baseline was 0.55 mmol/L despite most patients (27/43) already taking allopurinol, presumably because the dose was low (median 100 mg).

When followed up at 12 months, 58% of patients in the gout clinic protocol had achieved serum urate target levels, while 22% had dropped out and 5% died. For patients who achieved urate targets, the median allopurinol dose was 200 mg for those without tophi and 400 mg for those with tophi. There was no difference in allopurinol dose at urate target in patients with or without renal disease.

The rheumatologists also noted that most of the gout patients had been unable to make monthly appointments, and were seen approximately every two months. As expected, patients with more frequent appointments achieved a faster rate of reduction in serum urate than patients seen less frequently and there was also  a higher probability of reaching urate target with higher doses of ULT (300 and 400mg).

They said their audit had shown that frequent scheduled visits at a rheumatology gout clinic resulted in successful reduction in serum urate levels in more than half of patients within a year, and that patients seen monthly reached target significantly faster.

The clinic had also proved to be an important educational and support resource for patients and GPs, as well as trainees. Its relatively high drop out rate might be improved “by measures such as sending appointment reminders to patients and follow-up phone calls from the dedicated rheumatology nurse,” they suggested.

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