Gout is a controllable disease, and simple, safe treatments are available. But chronic gout remains poorly managed. So Australian authors analyzed the reasons why (among the factors are inconsistencies in treatment guidelines and patient and physician barriers to optimal gout care) and offer practical suggestions for improving patient care.
Inconsistencies in the levels of evidential support in current guidelines for gout have led to a major discrepancy between generalist and subspecialty perspectives and contributed to uncertainty in treatment, they noted.
Common physician barriers to gout care:
- Treatment regimens often are insufficient to control attacks or prevent complications; fewer than 30% of patients undergo serum uric acid (SUA) monitoring and only one-third of them achieve the target SUA level.
- Patients often remain on the starting dose of allopurinol without titration to achieve the target SUA level.
- The allopurinol dosage can be increased to 600 mg/d or a uricosuric agent can be added to achieve target SUA, but the approach is futile if the patient is not adherent to the medication regimen.
- Many clinicians believe they have the knowledge and skills to educate patients who have gout, but clinician education is lacking.
Common patient barriers to care:
- More than half of patients with chronic gout are nonadherent to the medication regimen and close to three-fourths have interrupted therapy.
- Most nonadherence is “purposeful,” resulting from clinical/financial factors (eg, concerns about adverse effects and medication interactions).
- Patients may think that urate‑lowering therapy (ULT) drugs need not be taken continuously if there are no acute flares.
- Some patients report that potential complications of gout have not been explained and they have a poor understanding that gout is an arthritis.
- Patients typically think gout is a self-inflicted consequence of aging and are reluctant to seek medical advice.
- Some patients hesitate to seek help despite intense pain.
A general treatment approach for patients with episodic gout:
- Measure SUA out of context of an acute attack.
- Do not start allopurinol (or other ULT) in the context of an acute attack.
- When starting ULT, make sure the patient is taking prophylactic therapy — colchicine, NSAIDs, or corticosteroids.
- Inform the patient of the objectives of treatment.
- Consider offering dietary advice. Patients generally do not comply with low-urate diets, but diets compatible with optimal glycemic control and primary cardiovascular prevention are usually acceptable.
- Assess patients for the presence of manageable comorbidities (eg, hypertension, obesity, type 2 diabetes/metabolic syndrome, and cardiovascular disease).
Suggestions for the use of allopurinol for ULT:
- Explain to patients that allopurinol is a preventative strategy, not a treatment for an acute attack.
- Begin with allopurinol 100 mg/d (maximum) or, if eGFR ≤50 ml/min, 50 mg/d.
- Increase the dose of allopurinol by 50 to 100 mg every 3 or 4 weeks, monitoring for rash/itch.
- Increase allopurinol to a maintenance dose sufficient to reduce the SUA to <0.35 mmol/L in non-tophaceous disease or 0.25 to 0.30 mmol/L in tophaceous disease.
- Continue for up to 3 months after a stable dose of ULT sufficient to reach target SUA, or 3 months after an acute attack has occurred, whichever is longer.
- If a gout attack occurs, do not stop allopurinol; treat the acute attack as appropriate.
- Monitor SUA when other blood tests are taken.
- Do not cease allopurinol (or other ULT) even if the patient has been free of attacks.
“Patient education may be the most effective means of improving adherence to treatment,” the authors noted. “Ideally, provision of education by nurse specialists will achieve target SUA levels in more than 90% of patients.”
- The most common target SUA is <6 mg/dL (360 mmol/L = 0.36 mmol/L), but levels differ in value and unit measurement.
- The most common indicator for ULT is the presence of tophi.
- Guidelines vary on when to initiate ULT.
- All guidelines establish allopurinol as a first-line ULT, and some recommend febuxostat as a comparable first-line agent.
The article appears in a recent issue of The Australian Journal of General Practice.
Last updated on 9/14/19.