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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