An update on gout diagnosis and management for the primary care provider.

Gout is the most common inflammatory arthritis in the US, affecting 3.9% of the population. Although many effective gout therapies are available for acute flares and chronic management, it is suboptimally treated worldwide, and recurrent gout flares can cause significant pain and irreversible joint damage.

A nurse-led, rheumatologist-assisted telemedicine intervention for dose escalation of urate-lowering therapy in gout.

AIMS: Urate-lowering therapy (ULT) is effective in gout, but suboptimal management with wide variability in dose escalation remains widespread. We protocolized dose escalation of ULT to improve gout management. The aim was to reduce time to achieve target serum urate (SU) <360 µmol/L. METHODS: Process improvement tools were used to identify underlying causes of prolonged time to target SU. We designed a nurse-led telemedicine intervention for dose escalation of ULT. Patients with gout with SU ≥360 µmol/L meeting indications for ULT at a single institution were recruited. Exclusion criteria were estimated glomerular filtration rate <30 mL/min, pregnancy, cognitive impairment and poor mobility. A nurse-led telemedicine clinic was set up to perform patient education, monitoring of adverse events and drug escalation. We partnered with primary healthcare centers for routine blood tests. RESULTS: From July 2016 to December 2017, 127 patients were recruited. Median time to target SU was 19.0 weeks (interquartile range [IQR] 11.0-31.0). Median dose of allopurinol was 300 mg/d (IQR 200-400) in normal renal function and lower in renal impairment. Median telemedicine calls required to achieve target SU was 2 (IQR 1-3). No patient was hospitalized for gout flares. Two patients had adverse drug reactions, one required cessation of allopurinol for rash with eosinophilia, the other had self-resolving ulcers and allopurinol was continued. Lower baseline SU and number of gout flares were associated with attainment of target SU. CONCLUSION: A nurse-led telemedicine for gout care is effective and safe. Our results affirm the utility of telemedicine in increasing access to care and lower healthcare utilization.

Nurse-led care is preferred over GP-led care of gout and improves gout outcomes: results of Nottingham Gout Treatment Trial follow-up study.

OBJECTIVES: To explore patient satisfaction, gout knowledge, medication adherence and flares among participants receiving nurse-led or general practitioner (GP)-led care of gout in the Nottingham Gout Treatment Trial phase-II (NGTT-II). METHODS: A total of 438 participants of NGTT-II were sent a questionnaire enquiring about gout knowledge, satisfaction with health-care practitioner, urate-lowering treatment being undertaken, and gout flares ⩾1 year after their final visit. Nurse-led care participants were asked about their preference for receiving gout treatment from either a GP or a nurse. RESULTS: Completed questionnaires were returned by 82% of participants. Participants previously receiving nurse-led care reported greater satisfaction with health-care practitioner (P < 0.001), had better gout knowledge (P = 0.02), were more likely to be taking urate-lowering treatment [adjusted relative risk (95% CI) 1.19 (1.09, 1.30)], and self-reported fewer flares in the previous 12 months [median (inter-quartile range) 0 (0-0) vs 1 (0-3), P < 0.001] than those receiving GP-led care. Of participants receiving nurse-led care, 41-63% indicated preference for receiving gout treatment from a nurse, while only 5-20% indicated preference for receiving treatment from GPs. CONCLUSION: The results of this study favour nurse-led care, involving individualized patient education and engagement and a treat-to-target strategy, in terms of patient acceptability, long-term adherence, and flares. Further research is required to evaluate the feasibility of implementing such a model of care in clinical practice.

Guía de práctica clínica para el manejo de pacientes con gota / Clinical practice guide for the management of patients with gout

Las recomendaciones de la CPC para el Manejo de los pacientes con Gota se centran en novedosos aspectos terapéuticos como el empleo de combinaciones de medicamentos. También en el empleo de las técnicas de imagen como control de la respuesta al tratamiento o el manejo en situaciones clínicas especiales y complejas, concretamente en un entorno de riesgo o evento cardiovascular, en situaciones de enfermedad renal, trasplante de órgano sólido y diálisis. Además, se ha tenido en cuenta la carga que supone la enfermedad de gota en España y que el empoderamiento de los pacientes, para que participen en las decisiones y en la responsabilidad del manejo de su enfermedad, es muy importante, especialmente en aquellas medidas que mejoren la adherencia al tratamiento. De ahí la inclusión del papel de los profesionales de enfermería y la opinión de los propios pacientes.

Implication of nurse intervention on engagement with urate-lowering drugs: A qualitative study of participants in a RCT of nurse led care.

OBJECTIVES: To explore patient perception of the role of a nurse-led complex package of care in facilitating engagement with urate-lowering therapies (ULTs) in the management of gout. METHODS: Thirty people who had participated in a randomised controlled trial investigating the effect of a nurse-led complex package of care for gout, were purposively sampled and interviewed between 18-26 months after the end of the trial. Interviews were recorded, transcribed and analysed using a modified grounded-theory approach. Data were managed using Nvivo. STATA v15 was used to describe summary statistics. RESULTS: Participants described their views and experiences of engaging with a nurse-led intervention designed to provide holistic assessment, individualised patient education, and involvement in shared decision-making for the long-term management of gout. The analysis revealed key themes in how nurse-led intervention facilitated engagement with ULT, namely by proving improved knowledge and understanding of gout and its treatment, involvement of patients in decision-making about treatment, and increased confidence about benefits from treatment. However, some treatment uncertainty and concern remained and one participant free of gout flares discontinued ULT, while another halved the dose after the end of the trial. CONCLUSIONS: This study reports data on patient experience of engaging with ULT to manage gout after receiving nurse-led care. It demonstrates that shared decision-making and the joint efforts of fully informed practitioners and patients persuades patients to engage with ULTs, and that experiencing the benefits of curative treatment motivates them to maintain adherence.

Efficacy and cost-effectiveness of nurse-led care involving education and engagement of patients and a treat-to-target urate-lowering strategy versus usual care for gout: a randomised controlled trial.

BACKGROUND: In the UK, gout management is suboptimum, with only 40% of patients receiving urate-lowering therapy, usually without titration to achieve a target serum urate concentration. Nurses successfully manage many diseases in primary care. We compared nurse-led gout care to usual care led by general practitioners (GPs) for people in the community. METHODS: Research nurses were trained in best practice management of gout, including providing individualised information and engaging patients in shared decision making. Adults who had experienced a gout flare in the previous 12 months were randomly assigned 1:1 to receive nurse-led care or continue with GP-led usual care. We assessed patients at baseline and after 1 and 2 years. The primary outcome was the percentage of participants who achieved serum urate concentrations less than 360 µmol/L (6 mg/dL) at 2 years. Secondary outcomes were flare frequency in year 2, presence of tophi, quality of life, and cost per quality-adjusted life-year (QALY) gained. Risk ratios (RRs) and 95% CIs were calculated based on intention to treat with multiple imputation. This study is registered with www.ClinicalTrials.gov, number NCT01477346. FINDINGS: 517 patients were enrolled, of whom 255 were assigned nurse-led care and 262 usual care. Nurse-led care was associated with high uptake of and adherence to urate-lowering therapy. More patients receiving nurse-led care had serum urate concentrations less than 360 µmol/L at 2 years than those receiving usual care (95% vs 30%, RR 3·18, 95% CI 2·42-4·18, p<0·0001). At 2 years all secondary outcomes favoured the nurse-led group. The cost per QALY gained for the nurse-led intervention was £5066 at 2 years. INTERPRETATION: Nurse-led gout care is efficacious and cost-effective compared with usual care. Our findings illustrate the benefits of educating and engaging patients in gout management and reaffirm the importance of a treat-to-target urate-lowering treatment strategy to improve patient-centred outcomes. FUNDING: Arthritis Research UK.

Patient education is vital in gout management.

Essential facts Gout is the most common cause of inflammatory arthritis worldwide. Incidence and severity is increasing in the UK, with about 2.5% of the population affected.

Long-term persistence and adherence on urate-lowering treatment can be maintained in primary care-5-year follow-up of a proof-of-concept study.

Objectives: To evaluate the persistence and adherence on urate-lowering treatment (ULT) in primary care 5 years after an initial nurse-led treatment of gout. Methods: One hundred gout patients initiated on up-titrated ULT between March and July 2010 were sent a questionnaire that elicited information on current ULT, reasons for discontinuation of ULT if applicable, medication adherence and generic and disease-specific quality-of-life measures in 2015. They were invited for one visit at which height and weight were measured and blood was collected for serum uric acid measurement. Results: Seventy-five patients, mean age 68.13 years ( s . d . 10.07) and disease duration 19.44 years ( s . d . 13), returned completed questionnaires. The 5-year persistence on ULT was 90.7% (95% CI 81.4, 91.6) and 85.3% of responders self-reported taking ULT ⩾6 days/week. Of the 65 patients who attended the study visit, the mean serum uric acid was 292.8 µmol/l ( s . d . 97.2). Conclusion: An initial treatment that includes individualized patient education and involvement in treatment decisions results in excellent adherence and persistence on ULT >4 years after the responsibility of treatment is taken over by the patient's general practitioner, suggesting that this model of gout management should be widely adopted.

Pilot study of a multidisciplinary gout patient education and monitoring program.

OBJECTIVE: Gout patient self-management knowledge and adherence to treatment regimens are poor. Our objective was to assess the feasibility and acceptability of a multidisciplinary team-based pilot program for the education and monitoring of gout patients. METHODS: Subjects completed a gout self-management knowledge exam, along with gout flare history and compliance questionnaires, at enrollment and at 6 and 12 months. Each exam was followed by a nursing educational intervention via a structured gout curriculum. Structured monthly follow-up calls from pharmacists emphasized adherence to management programs. Primary outcomes were subject and provider program evaluation questionnaires at 6 and 12 months, program retention rate and success in reaching patients via monthly calls. RESULTS: Overall, 40/45 subjects remained in the study at 12 months. At 12 months, on a scale of 1 (most) to 5 (least), ratings of 3 or better were given by 84.6% of subjects evaluating the usefulness of the overall program in understanding and managing their gout, 81.0% of subjects evaluating the helpfulness of the nursing education program, and 50.0% of subjects evaluating the helpfulness of the calls from the pharmacists. Knowledge exam questions that were most frequently answered incorrectly on repeat testing concerned bridge therapy, the possibility of being flare-free, and the genetic component of gout. CONCLUSIONS: Our multidisciplinary program of gout patient education and monitoring demonstrates feasibility and acceptability. We identified variability in patient preference for components of the program and persistent patient knowledge gaps.

Treatment and prevention of gout.

Gout is a disorder of purine metabolism that primarily occurs in adult males. Elevated plasma uric acid concentrations (hyperuricemia) cause deposits of urate crystals in joint spaces causing severe, repeated attacks of arthritis.

Nurse-led cardiovascular disease risk management intervention for patients with gout.

BACKGROUND: Patients with gout are at high risk for cardiovascular disease (CVD), and this risk is frequently under-managed. AIMS: To evaluate a nurse-led multidisciplinary approach to improve CVD risk management in patients with gout. METHODS: Patients referred to rheumatology clinics for gout management received a structured nurse-led CVD risk assessment. For the patients with an initial 5 year risk >10%, interventions for CVD prevention were identified and goals developed. These patients were then reassessed approximately 6 months later to determine changes in CVD risk management and profile. RESULTS: Of 210 patients with gout, 73% had either a 5-year CVD risk >10% or had known CVD. Of these higher risk patients, 84% were available for follow-up. Compared with the initial visit there were improvements at follow-up in: the prescription of aspirin, statins, nicotine replacement therapy, uptake of self-reported activity levels, mean systolic and diastolic blood pressure, with a trend towards reduced cigarette smoking. CONCLUSION: A nurse-led intervention to assess and manage cardiovascular risk in patients with gout is effective in improving uptake of preventative interventions.

La gota / Gout

La gota es una enfermedad curable que se caracteriza por episodiosde artritis aguda y recurrente como consecuencia de la formacióny depósito de cristales de urato monosódico. Afecta más a varones,en una proporción 3:1. El manejo terapéutico de la gota,cuyo objetivo fundamental es eliminar los cristales de urato monosódicoprecisa de tratamiento farmacológico y no farmacológico,además de tener en consideración factores de comorbilidad asociados.Los cuidados enfermeros, en esta patología, pueden ser muyimportantes para facilitar el autocuidado y el afrontamiento eficazde la enfermedad y deberían estar centrados en programas estructuradosde Educación para la Salud dirigidos específicamente a estosenfermos.En este artículo, octavo de una serie dirigida a los cuidados enfermerosen reumatología, se presenta la gota, recorriendo generalidadesde esta patología, sus manifestaciones clínicas y manejo del régimenterapéutico en estos pacientes (AU)

Gout is a curable disease characterized by episodes of acute andrecurrent arthritis due to the formation and deposit of monosodiumurate crystals. It is more common in males than females, in a ratioof 3:1. Therapeutic management of gout, which aims mainly toeliminate the monosodium urate crystals, encompasses pharmacologicaland non-pharmacological treatment, while taking associatedcomorbidity factors into account. Nursing care in this pathologycan be very important to facilitate self-care and effective copingwith the disease and should be focused on structured health educationprograms aimed specifically at these patients.This article, eighth in a series focused on rheumatology nursing care,presents gout, covering the general characteristics of this pathology,its clinical manifestations and the management of the therapeuticregimen of these patients (AU)