Colchicine: the good, the bad, the ugly and how to minimize the risks.

Colchicine has an important role in managing various conditions, including gout, familial Mediterranean fever, amyloidosis, Behçet's syndrome, recurrent pericarditis and calcium pyrophosphate deposition disease. The adverse effect profile of colchicine is well understood. However, due to its narrow therapeutic index, colchicine has been associated with overdose and fatalities. When ingested in toxic amounts, the mainstay of management is supportive care. Strategies to minimize the risk of colchicine poisoning can focus on three broad causes: unauthorized access, intentional overdose and inappropriate dosing. Culturally safe and appropriate education about storage and appropriate use of colchicine is essential to minimize the risk of overdose.

Gout and its management.

Gout is a common and treatable chronic disease of monosodium urate crystal deposition. It is experienced as extremely painful episodes of joint inflammation that impact all aspects of the person's life. This Clinical Perspectives article provides an update on gout diagnosis, medications and strategies to improve the quality of gout care.

"Prescribing for the whole person": A qualitative study exploring prescribing pharmacist views on type 2 diabetes management in New Zealand.

BACKGROUND: Pharmacist prescribers have comprehensive pharmacotherapy knowledge that can be useful for management of complex health conditions such as type 2 diabetes, yet the number of pharmacist prescribers working in New Zealand primary care is low. AIM: To explore the experiences of pharmacist prescribers in supporting type 2 diabetes management in New Zealand primary care. METHODS: Qualitative research design using semi-structured interviews with six pharmacist prescribers working in NZ primary care. Thematic analysis guided this study and themes were finalised with the wider research team. RESULTS: Three major themes were identified: team approach, health inequity and the role of a pharmacist prescriber. This study found that pharmacist prescribers may improve health equity by providing advanced pharmacotherapy knowledge within a wider primary care team to support complex patient needs and understanding the wider social determinants of health that impact effective diabetes management. Participants reportedly had more time to spend with patients (than GPs or nurses) and could also contribute to improving health outcomes by directly educating and empowering patients. CONCLUSION: The views of pharmacist prescribers have seldom been explored and this study suggests that their role may be under-utilised in primary care. In particular, pharmacist prescribers can provide specialist prescribing (and often mobile) care, and may contribute to improving health outcomes and reducing inequity when used as part of a multi-disciplinary team.

General practitioner and nurse experiences of type 2 diabetes management and prescribing in primary care: a qualitative review following the introduction of funded SGLT2i/GLP1RA medications in Aotearoa New Zealand.

AIM: To explore the views of general practitioners (GPs) and nurses on type 2 diabetes (T2D) management, including the use of recently funded T2D medications in New Zealand (NZ) and their perceived barriers to providing optimal care. BACKGROUND: T2D is a significant health concern in NZ, particularly among Maori and Pacific adults. Characterised by prolonged hyperglycaemia, T2D is generally a progressive condition requiring long-term care. METHODS: Semi-structured interviews were conducted between July and December 2022 with 21 primary care clinicians (10 GPs and 11 nurses/nurse prescribers) from nine different general practice clinics across the Auckland and Waikato regions of NZ. Framework analysis was conducted to identify common themes in clinicians' perceptions and experiences with T2D management. FINDINGS: Three themes were identified: health-system factors, new medications, and solution-based approaches. Lack of clinician time, healthcare funding, staff shortages, and burn-out were identified as barriers to T2D management under health-system factors. The two newly funded medications, empagliflozin and dulaglutide, were deemed to be a positive change for T2D care in that they improved patient satisfaction and clinical outcomes, but several clinicians were hesitant to prescribe these medications. Participants suggested that additional education and specialist diabetes support would be helpful to inform optimal medication prescribing and that better use of a multi-disciplinary team (clinical and support staff) could support T2D care by reducing workload, addressing cultural gaps in healthcare delivery, and reducing burnout. An improved primary care work environment, including appropriate professional development to support prescribing of new medications and the value of collaboration with a non-regulated workforce, may be required to facilitate optimal T2D management in primary care. Future research should focus on interventions to increase support for both clinical teams and patients while adopting a culturally appropriate approach to increase patient satisfaction and improve health outcomes.

Easing the way to achieving target serum urate in people with gout: protocol for a non-inferiority randomised strategy trial using an allopurinol dosing model in Aotearoa/New Zealand (the Easy-Allo Study).

INTRODUCTION: Gout is one of the most common forms of arthritis worldwide. Gout is particularly prevalent in Aotearoa/New Zealand and is estimated to affect 13.1% of Maori men, 22.9% of Pacific men and 7.4% of New Zealand European men. Effective long-term treatment requires lowering serum urate to <0.36 mmol/L. Allopurinol is the most commonly used urate-lowering medication worldwide. Despite its efficacy and safety, the allopurinol dose escalation treat-to-target serum urate strategy is difficult to implement and there are important inequities in allopurinol prescribing in Aotearoa. The escalation strategy is labour intensive, time consuming and costly for people with gout and the healthcare system. An easy and effective way to dose-escalate allopurinol is required, especially as gout disproportionately affects working-age Maori men and Pacific men, who frequently do not receive optimal care. METHODS AND ANALYSIS: A 12-month non-inferiority randomised controlled trial in people with gout who have a serum urate ≥ 0.36 mmol/l will be undertaken. 380 participants recruited from primary and secondary care will be randomised to one of the two allopurinol dosing strategies: intensive nurse-led treat-to-target serum urate dosing (intensive treat-to-target) or protocol-driven dose escalation based on dose predicted by an allopurinol dosing model (Easy-Allo). The primary endpoint will be the proportion of participants who achieve target serum urate (<0.36 mmol/L) at 12 months. ETHICS AND DISSEMINATION: The New Zealand Northern B Health and Disability Ethics Committee approved the study (2022 FULL 13478). Results will be disseminated in peer-reviewed journals and to participants. TRIAL REGISTRATION NUMBER: ACTRN12622001279718p.

National prevalence of gout derived from administrative health data in Aotearoa New Zealand.

OBJECTIVE: Previous small studies in Aotearoa New Zealand have indicated a high prevalence of gout. This study sought to determine the prevalence of gout in the entire Aotearoa New Zealand population using national-level health data sets. METHODS: We used hospitalization and drug dispensing claims for allopurinol and colchicine for the entire Aotearoa New Zealand population from the Aotearoa New Zealand Health Tracker (ANZHT) to estimate the prevalence of gout in 2009, stratified by age, gender, ethnicity and socio-economic status (n = 4 295 296). RESULTS: were compared with those obtained from an independent large primary care data set (HealthStat, n = 555 313). Results. The all-ages crude prevalence of diagnosed gout in the ANZHT population was 2.69%. A similar prevalence of 2.89% was observed in the HealthStat population standardized to the ANZHT population for age, gender, ethnicity and deprivation. Analysis of the ANZHT population showed that gout was more common in Maori and Pacific people [relative risk (RR) 3.11 and 3.59, respectively], in males (RR 3.58), in those living in the most socio-economically deprived areas (RR 1.41) and in those aged >65 years (RR >40) (P-value for all <0.0001). The prevalence of gout in elderly Maori and Pacific men was particularly high at >25%. CONCLUSION: Applying algorithms to national administrative data sets provides a readily available method for estimating the prevalence of a chronic condition such as gout, where diagnosis and drug treatment are relatively specific for this disease. We have demonstrated high gout prevalence in the entire Aotearoa New Zealand population, particularly among Maori and Pacific people.

Potential unmet need for gout diagnosis and treatment: capture-recapture analysis of a national administrative dataset.

OBJECTIVE: To estimate the degree of undercount of people diagnosed with gout in administrative datasets using capture-recapture methods. METHODS: Hospitalization and drug dispensing claims (allopurinol or colchicine) data for all Aotearoa New Zealand were used to estimate the prevalence of gout in 2009 (n = 4 295 296). As a comparison, we calculated gout prevalence using a large primary care dataset using general practitioner diagnosis and prescribing records (n = 555 313). For each of these datasets, we estimated the undercount through capture-recapture analysis using a Poisson regression model. A two-list model was used, which included covariates such as age, gender, ethnic groups and New Zealand deprivation quintiles. RESULTS: The crude prevalence of diagnosed gout in the Aotearoa New Zealand population aged ≥ 20 years was 3.75%. The covariate-adjusted capture-recapture estimate of those not recorded but likely to have gout was 0.92%, giving an overall estimated prevalence of 4.67% (95% CI 4.49, 4.90%) for the population aged ≥ 20 years. This amounts to 80% of people with gout being identified by the algorithm for the Aotearoa New Zealand data-that is being recorded in either lists of dispensing of allopurinol or colchicine or hospital discharge. After capture-recapture, gout prevalence for all males aged ≥ 20 years was 7.3% and in older (≥ 65 years) Maori and Pacific men was >30%. CONCLUSION: Capture-recapture analysis of administrative datasets provides a readily available method for estimating an aspect of unmet need in the population-in this instance potentially 20% of those with gout not being identified and treated specifically for this condition.

Living with gout in New Zealand: an exploratory study into people's knowledge about the disease and its treatment.

BACKGROUND: In New Zealand, gout disproportionately affects Maori and Pacific people who also experience symptoms at an earlier age. Gout occurs predominantly in men and is associated with cardiovascular disease, diabetes, and renal disease. The impact on daily social activities, family, and work is enormous, and many people remain inadequately treated. OBJECTIVES: The objectives of this study were to explore the knowledge and perceptions of people with gout toward the disease and to determine the impact gout has on lifestyle including possible barriers to treatment. METHODS: Sixty people with gout from the Auckland and Waikato regions of New Zealand were invited to participate in 30-minute semistructured interviews. The data were analyzed using a general inductive thematic approach. RESULTS: Although 85% of participants were aware of dietary triggers of gout, these were not always avoided. Less than 50% knew something about how their medicines worked, and only 33% knew which medicines to use both acutely and chronically. The negative impact of gout episodes was noted through the number participants unable to work or participate in family activities. Healthcare professionals were not always the main source of information, which is an area that could be developed to improve knowledge about gout. CONCLUSIONS: There were substantial gaps in the knowledge about gout and its causes and management. All healthcare providers could help identify patients with suboptimal knowledge and improve the management of gout.

Inequities in people with gout: a focus on Maori (Indigenous People) of Aotearoa New Zealand.

Health equity can be defined as the absence of systematic disparities in health between more and less advantaged social groups. Gout is one of the most common forms of arthritis and disproportionally affects Indigenous peoples, including Maori in Aotearoa New Zealand. Inequities in gout management are well documented and clearly evidenced in Indigenous populations. For example, while gout occurs at a younger age and is more severe in Maori, there is less regular dispensing of urate-lowering therapies. Indigenous peoples are also under-represented in clinical trials. Herein, we will review inequities in gout using Aoteoaroa New Zealand as an example. We will explore reasons for health inequities and challenges that need to be faced to achieve health equity.

Compounding inequity: a qualitative study of gout management in an urban marae clinic in Auckland.

INTRODUCTION Gout remains a health equity issue; Maori and Pacific peoples are disproportionately afflicted, with increased burden and loss of quality of life, yet are less likely to receive appropriate management, which mainly occurs in primary care. AIM This study aims to understand the perspectives of the mainly Maori and Pacific clinicians and staff at an urban marae practice about barriers and challenges to delivering effective care to a Maori and Pacific community with high burden of gout. METHODS Semi-structured interviews were conducted with 10 staff members delivering health care to a mostly Indigenous community. Interviews sought to ascertain staff views of enablers and barriers to optimal gout management and analyse them thematically. RESULTS Three themes were identified: community disadvantage; demands unique to Indigenous providers; and challenges and opportunities for optimising gout management. High prevalence and heavy impact of gout on wellbeing in the community was intertwined with socioeconomic disadvantage, precariousness of employment and entrenched inaccurate (yet pliable) patient views on gout, to the detriment of focused, effective care. Structural and funding demands on providers inhibited staff focus on the clear community need. Providers saw the culturally safe and competent approach necessary for improvement as requiring community empowerment with appropriate clinical tools and adequate resourcing. DISCUSSION Despite provider intent to deliver culturally appropriate and safe care and equitable health outcomes for patients suffering from gout, general practice initiatives without aligned resourcing or incentives are inhibited when inequity is pervasive. Simply asking Maori providers to do more for the same amount of resource may not be effective.

Using a randomised controlled trial to test the effectiveness of social norms feedback to reduce antibiotic prescribing without increasing inequities.

AIMS: Antibiotic overprescription is a key driver of antimicrobial resistance, and rates of community dispensing of antibiotics in New Zealand are high compared to other developed countries. We aimed to test whether a social-norm-based intervention successful elsewhere would have an effect on GPs with high prescribing rates of antibiotics. We also aimed to assess the effects on prescribing for Maori and Pacific patients. METHODS: A randomised controlled trial (n=1,214) tested the effects of a letter mailed to high-prescribing GPs that presented their prescribing data in comparison to their peers. RESULTS: In September-December 2019, after the letters were mailed, the antibiotic prescribing rate in the control arm was 178.8 patients prescribed antibiotics per 1,000 patients prescribed any medicine, and in the intervention arm it was 162.3, a relative difference of 9.2% (p<0.001). GPs in the intervention arm were responsible for an average of 173.5 prescriptions, versus an average of 186.8 prescriptions for GPs in the control arm, a relative difference of 13.3 or 7.1% (p<0.01). Exploratory analyses showed the intervention reduced prescribing to Maori and Pacific patients among historically high prescribing GPs but had no statistically significant impact on low prescribers. CONCLUSIONS: A targeted intervention using social norms reduced prescribing of antibiotics by high-prescribing GPs. Such an approach may be promising to address inequities in access to and use of antibiotics by Maori and Pacific peoples, historically underserved by prescribers, but further investigation is needed.

Gender and Ethnic Inequities in Gout Burden and Management.

Although effective and low-cost urate-lowering therapy has been available for decades, inequities in gout management exist. Despite high impact of disease, rates of urate-lowering therapy prescription are low in women, in African-Americans in the United States, in Maori (Indigenous New Zealanders), and in Pacific peoples living in Aotearoa/New Zealand. Social determinants of health, barriers to accessing the health care system, health literacy demands, stigmatization, and bias contribute to inequities in gout burden and management. Approaches that focus on building health literacy and delivering culturally safe care lead to improved outcomes in gout, and offer important solutions to achieve health equity.

The impact of the illness label 'gout' on illness and treatment perceptions in Maori (Indigenous New Zealanders).

BACKGROUND: Despite contemporary advances in understanding pathogenesis and effective management of gout, beliefs about the disease continue to be focused on gout as a self-inflicted illness. The illness label itself may contribute to inaccurate perceptions of the disease and its management. In Aotearoa/New Zealand, Maori (Indigenous New Zealanders) have high prevalence of severe gout. The aim of this study was to examine the impact of the illness label 'gout' on perceptions of the disease and its management for Maori. METHODS: Maori supermarket shoppers (n = 172) in rural and urban locations were recruited into a study examining the perceptions about arthritis. Participants were randomised 1:1 to complete a questionnaire examining the perceptions of the same illness description labelled as either 'gout' or 'urate crystal arthritis'. Differences between the two illness labels were tested using independent sample t-tests. RESULTS: 'Gout' was most likely to be viewed as caused by diet, whereas 'urate crystal arthritis' was most likely to be viewed as caused by aging. 'Urate crystal arthritis' was seen as having a wider range of factors responsible for the illness, including stress or worry, hereditary factors and chance. 'Gout' was less likely to be viewed as having a chronic timeline, and was perceived as being better understood. Dietary management strategies were seen as more helpful for management of the gout-labelled illness. CONCLUSIONS: This study has demonstrated that for Maori, Indigenous New Zealanders who are disproportionately affected by gout, the illness label influences perceptions about gout and beliefs about management.

Pounamu: Achieving health equity in Aotearoa New Zealand: the contribution of medicines optimisation.

This paper aims to consider the various parts of what is required to achieve the best possible health outcomes from medicines in partnership with the person for whom they are prescribed. Specifically, it looks to highlight the process from an Indigenous view with respect to Maori in Aotearoa New Zealand, and claims a multi-dimensional approach is imperative. Attaining optimal use of medicines is necessary to help achieve health equity. There is an urgent need to understand and investigate models of care that achieve this optimal state.

Impact of prescription charges on people living in poverty: A qualitative study.

BACKGROUND: Prescription charges or copayments have been shown to reduce consumption of medicines. For people living in poverty, prescription charges can prevent them from getting the medicines they need, and this can result in poorer health status. Prescription charges are low in New Zealand compared to many other countries, but those living in poverty are not exempt from fees. OBJECTIVES: The aim of this study was to explore the lived experience of people who struggle to pay prescription charges and to propose a model for how being unable to afford prescription charges might affect health. METHODS: Participants were recruited through organizations that provide services entirely or predominantly to low income persons. Semi-structured interviews were carried out with 29 people who had been identified as having problems paying for prescriptions. Approximately half of the sample population was Maori (indigenous New Zealanders). Ethical approval was obtained from the University of Otago. RESULTS: Participants reported having to make difficult decisions when picking up their prescription medicines. These included choosing some medicines and leaving others, such as choosing medicines for mental health rather than physical health; cutting food consumption or eating less healthy food so as to pay for medicines; or picking up medicines for children while leaving those for adults. Participants also reported strategies like reducing doses to make prescriptions last longer; and delaying picking up medicines. These led to sub-optimal dosing or interrupted treatment. CONCLUSIONS: Even low financial barriers can have a significant impact on low income people's access to medicines and reduce the effectiveness of treatment. Not being able to afford prescription medicines may impact negatively on people's health directly by preventing access to medicines, through reducing expenditure on other items need for health, and by potentiating stigma.