Facilitating equitable prevention and management of gout for Maori in Northland, New Zealand, through a collaborative primary care approach.

INTRODUCTION The Gout Stop Programme was developed for primary care in Northland, New Zealand, to address inequitable health outcomes for Maori and Pacific people with gout. AIM The aim of the programme was to make it easier for clinicians to prescribe urate-lowering treatment, facilitate patient adherence through education and support, and reduce barriers to gout prevention and long-term management. METHODS From 2015 to 2017, patients with acute gout who met inclusion criteria were prescribed treatment according to a 'Gout Stop Pack' option, based on renal function and diabetes status. Patients were monitored by community pharmacists. Gout educators and a Gout Kaiawhina (community support worker) provided education and support to patients and whanau (families). Patient completion of the programme and outcomes, according to target serum urate level, were recorded. Patient experience was documented using a questionnaire and rating scale. RESULTS In total, 160 clinicians prescribed therapy at 887 patient presentations; 71% were Maori and Pacific patients. The completion rate was 55% in this group and 84% for the non-Maori and non-Pacific group. In the Maori and Pacific group, 40% reached the target serum urate level (≤0.36 mmol L-1) in 91 days, and 26% required further titration. In the non-Maori/non-Pacific group, these rates were 51% and 19% respectively. Following programme completion, 68% of Maori and Pacific patients and 65% of non-Maori and non-Pacific patients continued to take allopurinol. The 21 patients interviewed rated the programme as excellent or very good. DISCUSSION Culturally appropriate education and support for patients and the primary care team was essential. Collaboration between prescribers, community pharmacists and support workers reduced barriers to initiating prevention and long-term urate-lowering treatment and urate testing in this high-needs gout population.

Footwear characteristics and factors influencing footwear choice in patients with gout.

OBJECTIVE: Gout is associated with foot pain, impairment, and disability. The aim of this study was to assess footwear characteristics and key factors influencing footwear choice in patients with gout. We also wanted to evaluate the relationship between footwear characteristics and foot disability. METHODS: Fifty patients with a history of acute gout were recruited from rheumatology clinics during the summer months. Clinical characteristics, global function, and foot impairment and disability measures were recorded. Footwear characteristics and the factors associated with choice of footwear were identified using validated assessment tools. Suitability of footwear was assessed using predetermined criteria for assessing adequacy of footwear, based on a previous study of foot pain. RESULTS: The patients had moderate to severe foot pain, impairment, and disability. Poor footwear characteristics included poor cushioning, lack of support, lack of stability, and motion control. More than 50% of shoes were ≥12 months old and demonstrated excessive wear patterns. Patients reported comfort (98%), fit (90%), support (90%), and cost (60%) as important factors in choosing their own footwear. No correlation was found between footwear characteristics (length and width) and foot characteristics (foot pain, impairment, and disability). Patients with poor footwear reported higher foot-related impairment and disability. CONCLUSION: Use of poor footwear is common in patients with chronic gout and is associated with foot disability and impairment.

Outcome of patients on azathioprine: a need for a better pre-treatment assessment and dosing guideline.

BACKGROUND: Azathioprine (AZA) is a commonly used drug for the management of various rheumatologic disorders. Due to individual variation of the metabolism of AZA, related to genetic polymorphism of the thiopurine methyl transferase (TPMT), serious toxic effects can result if inappropriate dose is administered. AZA dosing according to patients TPMT status can reduce drug-induced morbidity and can be cost effective. AIM: To determine the current local practice of AZA dosing, identify AZA-related toxicity and to compare the local practice with the British Society of Rheumatology (BSR) recommendations. METHODS: Retrospective review of patients on AZA for various rheumatologic conditions from inpatient (n=22) and outpatient (n=38) database at Middlemore Hospital, from January 2003 to January 2007. Data were collected on patient's demographics, treatment history including AZA dosing regimen, TPMT testing, drug-related toxicities and their management. RESULTS: The mean age was 53 years; 73% were females. 43% of European ethnicity; mean weight of patient was 75±25 kg. 42% had SLE, 22% had rheumatoid arthritis, and 13% had systemic vasculitis. Average initial dose of AZA prescribed was 100±37 mg. 45% developed AZA related toxicity. AZA was withdrawn in 35 % of patients due to drug-related side-effects and inefficacy.15% of the patients required dose reduction. TPMT status was tested in 6 (10%) patients; three had low TMPT level, needing dose reduction. BSR recommendation for AZA dosing was followed in 15% cases. CONCLUSION: A significant proportion of the studied cohort of rheumatologic patients on AZA had drug-related toxicity resulting in discontinuation of AZA. Our data suggests that better pre-treatment assessment including TPMT testing and the practice of guideline based dosing regimen would reduce the incidence of undue side-effects and discontinuation of such treatment.

Cardiovascular disease risk factor assessment and management in gout: an analysis using guideline-based electronic clinical decision support.

AIM: To assess the need for cardiovascular disease (CVD) risk management in patients with gout. METHODS: We studied 100 consecutive patients referred to the rheumatology service for management of gout. CVD risk factor and management data were collected. PREDICT CVD decision support software was used to calculate Framingham 5-year CVD risk, and to analyse therapeutic targets. RESULTS: Fifty-nine (59%) patients had a high (>15%) or very high (> or = 20%) 5-year CVD risk. For those at high risk of CVD, target systolic blood pressure was achieved in 34%; target LDL-cholesterol in 49%, target HDL-cholesterol in 56%; and 81% did not smoke. For patients with diabetes, target HbA1c was reached in 40%. For high-risk individuals only 50% of eligible patients were on aspirin, 64% on beta-blockers, 53% statins, and 65% ACE inhibitors. There were no significant differences in duration of gout, presence of tophaceous disease, use of urate-lowering therapy or C-reactive protein between patients at high risk of CVD, and those with lower risk. CONCLUSIONS: Patients with gout referred to secondary care are at high risk for CVD, and have a large burden of modifiable risk factors. Implementation of CVD screening and management programs in these patients should have high therapeutic yield.

Colchicine prescribing and safety monitoring in patients with gout.

AIM: To assess current colchicine prescribing and safety monitoring in patients with gout. METHODS: Colchicine dosing was analysed by chart review of 50 consecutive patients presenting to Middlemore Hospital (South Auckland, New Zealand) with acute gout. The dose of colchicine was compared with the New Zealand Rheumatology Association (NZRA) consensus statement on colchicine use for acute gout. Safety monitoring was analysed by chart review of a separate group of 50 patients attending rheumatology clinics on long-term prophylactic colchicine and with renal impairment (creatinine > or = 0.17 mmol/L or creatinine clearance < or =0.83 ml/sec). Monitoring of creatine kinase (CK) and full blood count (FBC) was compared with published quality of care indicators regarding safety monitoring of colchicine. Risk factors for colchicine toxicity were recorded; age >75 years, statin use, renal transplant, haemodialysis, and renal impairment. RESULTS: Forty-eight (96%) patients treated for acute gout received colchicine at doses < or =2.5 mg/24 hours, in accordance with the NZRA statement. In this group, 60% had at least one risk factor for colchicine toxicity. For the long-term prophylactic colchicine treatment group, 76% had CK and FBC monitoring in accordance with the quality of care indicator. Additional risk factors for colchicine toxicity were present in 58% of patients on long-term colchicine. Laboratory monitoring identified colchicine-related adverse drug reaction in one patient. CONCLUSIONS: Current prescribing of colchicine for acute gout is in accordance with the NZRA consensus statement. For long-term colchicine use, there is reasonable adherence to the quality of care indicator for safety monitoring. These patients are at high risk for toxicity, and safety monitoring has an acceptable yield.