HPE Grunenthal handbook - Page 15

step-up prescription of the doses of urate-lowering medications, or absence of prophylactic treatment. Some patients may need high doses of medications that are not commonly prescribed in primary practice (such as allopurinol at doses exceeding 300mg/day), combination of medications (such as XOIs and uricosurics), hospital/ specialist prescriptions (such as canakinumab or benzbromarone), use of off-label doses (febuxostat 120 or 240mg/day) or off-label indications (anakinra). Also, presence of comorbidities such as advanced chronic kidney disease, chronic heart failure, or solid organ transplant, might be situations in which specialised consultation is required. patients with longstanding disease (Figure 1). Elderly patients with arthritis may show both chondrocalcinosis and hyperuricaemia, making it difficult to differentiate clinically gout from acute pyrophosphate arthritis, also known as ‘pseudogout’ (Figure 2). Other patients might present psoriatic skin lesions, hyperuricaemia, and symmetrical involvement of the joints of the lower limbs that can make it difficult to differentiate gout from psoriatic arthritis. In such cases, aspiration of the current or a previously involved joint may be useful to visualise urate crystals in synovial fluid, along with some imaging modalities, when indicated. Figure 2 The presence of X-ray chondrocalcinosis may hamper the diagnosis of acute arthritis in patients with hyperuricaemia; in this patient, both calcium pyrophosphate and urate were observed in synovial fluid (Oxford) 2018;57(suppl_1): i20–i26. 6 Kiltz U et al. Treat-to-target (T2T) recommendations for gout. Ann Rheum Dis 2016; 76(4):632–8. 7 National Institute for Health and Care Excellence. Appraisal consultation document. Lesinurad for treating chronic hyperuricaemia in people with gout. www.nice.org.uk/guidance/ ta506/documents/appraisal- consultation-document (accessed Septemebr 2018). 8 Khanna D, et al. 2012 American College of Rheumatology guidelines for management of gout. Part 1: Systematic nonpharmacologic and pharmacologic therapeutic approaches to hyperuricemia. Arthritis Care Res (Hoboken) 2012;64(10):1431–46. 9 Hui M et al. The British Evaluation and control of comorbidities Patients with gout commonly show a variety of comorbid conditions, including hypertension, adult-onset diabetes, and hyperlipidaemia. These conditions are major risk factors for the development of cardiovascular events, most of which are managed by the primary care team. The presence of comorbid conditions that might need periodic specialised evaluation, such as chronic kidney disease or chronic heart failure, will require coordination between health care providers in order to provide timely and cost-effective interventions. Conclusions In summary, most patients with gout are evaluated and treated in primary care. Here is where the bases for success are determined, with additional support for diagnosis, evaluation, and treatment, if needed. Collaboration between primary and secondary care is presumably more fruitful in selected clinical scenarios, mostly involving complex patients. Difficult treatment In some instances, ‘difficult to treat’ gout may be a cause for referral to a rheumatologist. In such cases, a certain diagnosis would be preferable to ensure that lack of response to treatment is not caused by misdiagnosis. Also, the lack of clinical response might be caused, as mentioned previously, by lack of References 1 Kuo CF et al. Global epidemiology of gout: prevalence, incidence and risk factors. Nat Rev Rheumatol 2015;11(11): 649–62. 2 Janssens HJ et al. A diagnostic rule for acute gouty arthritis in primary care without joint fluid analysis. Arch Intern Med 2010;170(13):1120–6. 3 Perez RF et al. Improvement in diagnosis and treat-to-target management of hyperuricemia in gout: Results from the GEMA-2 Transversal Study on Practice. Rheumatol Ther 2018;5(1): 243–53. 4 Richette P et al. 2016 updated EULAR evidence- based recommendations for the management of gout. Ann Rheum Dis 2017;76(1):29–42. 5 Perez-Ruiz F et al. Treat to target in gout. Rheumatology The cornerstone role of primary care in gout Education and adherence to treatment A majority of patients with gout are managed in primary care. Adherence to treatment is vital to succeed in the treatment of chronic diseases, and the benefits of proper adherence should be reinforced during follow-up. 19 Information and education on causes, outcomes, targets, interventions, and expectations constitute an important component of management of any chronic disease, and has been shown to be effective in order to achieve adherence and therapeutic targets. 19 Education has to be reinforced during follow-up, and such tasks may be effectively comprised by the primary care team, including physicians, nurses, and other healthcare professionals. 16 Society for Rheumatology Guideline for the management of gout. Rheumatology (Oxford) 2017;56(7):1056–9. 10 Jellinger PS et al. American Association of Clinical Endocrinologists and American College of Endocrinology Gudelines for management of dyslipemia and prevention of cardiovascular disease – executive summary. Endocr Pract 2017;23(4):479–97. 11 Qaseem A, Harris RP, Forciea MA. Management of acute and recurrent gout: A clinical practice guideline from the American College of Physicians. Ann Intern Med 2017;166(1):58–68. 12 Li S et al. Comparative efficacy and safety of urate- lowering therapy for the treatment of hyperuricemia: a systematic review and network meta-analysis. Sci Rep 2016;6:33082. 13 Bardin T et al. Lesinurad in combination with allopurinol: a randomised, double-blind, placebo-controlled study in patients with gout with inadequate response to standard of care (the multinational CLEAR 2 study). Ann Rheum Dis 2017;76(5):811–20. 14 Perez-Ruiz F, Herrero-Beites AM, Carmona L. A two-stage approach to the treatment of hyperuricemia in gout: The “Dirty Dish” hypothesis. Arthritis Rheum 2011;63(12):4002–6. 15 Wortmann RL et al. Effect of prophylaxis on gout flares after the initiation of urate-lowering therapy: analysis of data from three phaseIII trials. Clin Ther 2011;32(14):2386–97. 16 Rees F, Jenkins W, Doherty M. Patients with gout adhere to curative treatment if informed appropriately: proof-of-concept observational study. Ann Rheum Dis 2013;72(6):826–30. 17 Perez-Ruiz F, Gonzalez Mielgo FJ, Herrero-Beites A. Optimisation of the treatment of acute gout. Biodrugs 2000;13:45–53. 18 Neogi T et al. Frequency and predictors of inappropriate management of recurrent gout attacks in a longitudinal study. J Rheumatol 2006;33(1):104–9. 19 Abhishek A, Doherty M. Education and non- pharmacologucal approaches for gout. Rheumatology (Oxford) 2018;57(suppl1):i51–i58. hospitalpharmacyeurope.com | 2018 | 15