Optimising gout treatment: insights from a nurse-led cohort study.

OBJECTIVES: Currently, gout management, particularly urate-lowering therapy (ULT), is often suboptimal. Nurses successfully manage various diseases including gout. As gout prevalence is rising, and rheumatologists and general practitioners face shortages, a new approach is imperative. This real-life prospective cohort study evaluated the effectiveness of nurse-led care employing a treat-to-target strategy for gout management over a 2-year period. METHODS: All consecutively confirmed gout patients were included. The nurse-led clinic provided a structured treatment plan with consultations, patient leaflets, telephone contacts and laboratory monitoring. After a year of nurse-led care, patients transitioned to continued care in general practice. Follow-up data were complete through registries. The primary outcome was achieving target p-urate levels (<0.36 mmol/L) at 2 years after diagnosis. Secondary outcomes included treatment continuation and achievement of target p-urate levels in specific subgroups. The results were compared with patients diagnosed in the same clinic but followed up in 'usual care'. RESULTS: In the nurse-led group (n=114), 83% achieved target p-urate levels and ULT was continued by 98%. This trend persisted across various patient subgroups. Only 44% of patients in usual care achieved target p-urate and with insufficient doses of allopurinol . Nurse-led care involved an average of two visits and three telephone contacts over 336 days. The 2-year mortality rate was 15%. CONCLUSIONS: Nurse-led gout care, employing a targeted approach, was associated with a very high uptake of and adherence to ULT. The encouraging results were not achieved in usual care although a direct comparison might be influenced by selection bias.

Patients with severe gout treated in mixed settings.

INTRODUCTION We aimed to investigate whether patients with a definite gout diagnosis who were treated in mixed real-life settings (various hospital departments or general practice) followed treatment recommendations. METHODS We included all patients in the hospital's uptake area in 2015-2017 who had been diagnosed with gout after microscopy findings of urate crystals. Data regarding comorbidities and indications for urate-lowering therapy (ULT) were collected. The criteria for treatment success were a p-urate level less-than 6 mg/dl (less-than 0.36 mmol/l) or less-than 5 mg/dl (less-than 0.30 mmol/l) if tophi were present. All patients were followed up for 24 months. RESULTS The study included 100 patients with a median age of 70 years, and 82% of patients were males. An indication for ULT was present in 99 patients and initiated in 79 patients. Fourteen of these 99 patients died within one year. For the remaining 85 patients, p-urate was measured, and the target was reached by 22 (26%) patients, not reached by 33 (39%) patients and not measured in 30 (35%) patients. Treatment success was positively associated with a written treatment plan in the rheumatology record after microscopy, initiation of ULT in the clinic, provision of a gout leaflet, a higher number of outpatient visits and non-smoking status. CONCLUSIONS Many patients with crystal-proven gout did not receive ULT as recommended. Even if ULT was initiated, the p-urate level was monitored infrequently and the dose of ULT was not escalated when necessary. The best outcomes were associated with continued care in a rheumatology clinic. FUNDING none. TRIAL REGISTRATION The study was assessed by the Ethics Committee, which decided it was a quality assurance project and the study was subsequently approved by the Regions data protection office service with ID 2018-62.