MUSCULOSKELETAL MATTERS – BULLETIN 8
Gout Management
Gout is one of the most treatable rheumatological conditions. In addition to the treatment of acute attacks to reduce pain and inflammation, current international guidelines encourage urate-lowering therapy( ULT) for patients who have two or more acute attacks of gout, tophi, renal stones, radiological damage or impaired renal function. Long-term management of gout is often suboptimal, with many patients experiencing recurrent gout attacks that are preventable.
ULT( e. g. allopurinol) should be prescribed and titrated according to serum uric acid( SUA) levels to achieve and maintain a target SUA of ≤360 μmol / l. Monitoring of SUA and up-titration of ULT to achieve this target are not performed in most patients. Only around 30 % of patients with gout are prescribed ULT. Less than half of these patients adhere to treatment, and up to 70 % have gaps in taking ULT – the majority within the first year of treatment.
This is a summary of independent research funded by the National Institute for Health Research School for Primary Care Research( NIHR SPCR), Grant Reference Number 136. The NIHR SPCR is hosted at the University of Oxford and is a partnership between the Universities of Birmingham, Bristol, Keele, Manchester, Nottingham, Oxford, Southampton and University College London. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.
Key findings and recommendations to improve gout management
Patients often perceive gout as an intermittent disease and do not understand the need for ULT to prevent long-term joint damage. Many patients believe that diet can be as effective as medication, but most patients are not able to reduce SUA levels enough without medication. Recommendation: ULT should be discussed with all patients with a diagnosis of gout, emphasising that it is a chronic condition. A clear explanation of the purpose of ULT will improve adherence.
Patients may not return to the GP after their first attack, choosing to self-treat subsequent attacks. Recommendation: Patients should be advised that the treatment of acute attacks is not sufficient as a long-term strategy. They should be advised to return if they experience subsequent attacks.
Patients are often concerned about potential adverse effects of taking long-term medication. Recommendation: Being informed about plans for regular monitoring( e. g. SUA, kidney and liver function) can reassure patients and improve adherence. Monthly blood tests are needed after starting ULT to check SUA levels. If levels are above the target, the dose of allopurinol should be increased gradually. Once target SUA levels are reached, blood tests should be done every 1-2 years to check that target levels are being maintained.
Patients can stop taking ULT because of various reasons including: not noticing immediate impacts on attack frequency; frustration with the titration process; and experiencing a ULT induced attack. Recommendation: Patients should be informed about how the titration process works, and that it can take up to 2 years for crystals to be completely cleared from the body so they may continue to have attacks initially. Patients should be advised that initiating ULT can trigger a gout attack, but that they should not stop taking medication if this occurs.
Patients’ views about ULT treatment can become more positive over time and with increasing knowledge of the condition. Recommendation: Opportunities to revisit and discuss patients’ initial decisions not to take longterm treatment should be utilised whenever possible.
This bulletin was written by Jennifer Liddle on behalf of the Patient Experiences of Gout research team( Jane Richardson, Jennifer Liddle, Samantha Hider, Christian Mallen and Edward Roddy)
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