Patient education and engagement in treat-to-target gout care
Authors: Tuhina Neogi, Nicola Dalbeth
Journal: The Lancet (2018)

Gout is the most common inflammatory arthritis worldwide, affecting 4·0% of adults in the USA and 2·5% of adults in the UK.1Kuo CF Grainge MJ Zhang W Doherty M Global epidemiology of gout: prevalence, incidence and risk factors.Nat Rev Rheumatol. 2015; 11: 649-662Crossref PubMed Scopus (730) Google Scholar The pathophysiology of this crystal arthritis is well understood, and inexpensive urate-lowering drugs that address the underlying cause of the disease are widely available. Yet gout remains poorly managed, with 70% of patients experiencing recurrent gout flares2Neogi T Hunter DJ Chaisson CE Allensworth-Davies D Zhang Y Frequency and predictors of inappropriate management of recurrent gout attacks in a longitudinal study.J Rheumatol. 2006; 33: 104-109PubMed Google Scholar and substantial burden from tophi and joint damage, which lead to functional limitations and diminished quality of life. Patients with gout often have concomitant cardiovascular disease, renal insufficiency, and diabetes, making treatment of gout challenging. Compounding this complexity is the time-limited nature of visits with general practitioners (GPs) who provide most gout care in many countries. Moreover, management controversies have arisen due to discordance between recommendations for the management of gout.3Dalbeth N Bardin T Doherty M et al.Discordant American College of Physicians and international rheumatology guidelines for gout management: consensus statement of the Gout, Hyperuricemia and Crystal-Associated Disease Network (G-CAN).Nat Rev Rheumatol. 2017; 13: 561-568Crossref PubMed Scopus (58) Google Scholar, 4Neogi T Mikuls TR To treat or not to treat (to target) in gout.Ann Intern Med. 2017; 166: 71-72Crossref PubMed Scopus (16) Google Scholar Guidelines from rheumatology organisations universally support a treat-to-target strategy that aims to lower urate concentrations to prevent crystallisation and the associated clinical manifestations.5Khanna D Fitzgerald JD Khanna PP et al.2012 American College of Rheumatology guidelines for management of gout. Part 1: systematic nonpharmacologic and pharmacologic therapeutic approaches to hyperuricemia.Arthritis Care Res (Hoboken). 2012; 64: 1431-1446Crossref PubMed Scopus (1218) Google Scholar, 6Richette P Doherty M Pascual E et al.2016 updated EULAR evidence-based recommendations for the management of gout.Ann Rheum Dis. 2017; 76: 29-42Crossref PubMed Scopus (873) Google Scholar By contrast, the American College of Physicians' guidelines state that there are insufficient data to support such a strategy, and suggest that a strategy of treating to avoid symptoms may be reasonable.7Qaseem A Harris RP Forciea MA Clinical Guidelines Committee of the American College of PhysiciansManagement of acute and recurrent gout: a clinical practice guideline from the American College of Physicians.Ann Intern Med. 2017; 166: 58-68Crossref PubMed Scopus (208) Google Scholar Furthermore, questions have been raised about the cardiovascular safety of the urate-lowering drug febuxostat8White WB Saag KG Becker MA et al.Cardiovascular safety of febuxostat or allopurinol in patients with gout.N Engl J Med. 2018; 378: 1200-1210Crossref PubMed Scopus (456) Google Scholar and, therefore, optimising the use of allopurinol is gaining attention.9Choi H Neogi T Stamp L Dalbeth N Terkeltaub R Implications of the cardiovascular safety of febuxostat and allopurinol in patients with gout and cardiovascular morbidities (CARES) trial and associated FDA public safety alert.Arthritis Rheumatol. 2018; (published online June 5.)DOI:10.1002/art.40583Crossref Scopus (65) Google Scholar In The Lancet, Michael Doherty and colleagues10Doherty M Jenkins W Richardson H et al.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.Lancet. 2018; 392: 1403-1412Summary Full Text Full Text PDF PubMed Scopus (161) Google Scholar report the findings of a UK community-based randomised controlled trial of nurse-led care that involved education and engagement of patients and use of a treat-to-target urate-lowering strategy in 255 patients compared with usual care, led by GPs, in 262 patients. The primary outcome was achievement of serum urate concentrations of less than 360 μmol/L at 2 years, the accepted outcome for gout trials by regulatory agencies, reflecting the level below which serum urate should not crystallise under physiological conditions. In the nurse-led group, 95% of patients compared with 30% in the usual-care group achieved the primary endpoint after 2 years (risk ratio [RR] 3·18, 95% CI 2·42–4·18; p<0·0001). A similar effect was noted in the 1-year assessment (95% vs 26%, RR 3·59, 95% CI 2·72–4·75). The clinically relevant patient-centred endpoints of gout flares and tophi were also significantly lower among patients in the nurse-led group than those in the usual-care group. The risk of having two or more flares per year in year 2 was 67% lower in the nurse-led group than in the usual-care group (RR 0·33, 95% CI 0·19–0·57). Resolution of tophi occurred only in the nurse-led group, and the risk of having any tophi at the end of follow-up was 79% lower than in the usual-care group (RR 0·21, 95% CI 0·08–0·52). The cost per quality-adjusted life-year gained for nurse-led care at 2 years was £5066 and was projected to be cost saving by 5 years. A limitation of this study was the lack of blinding, which potentially led to improvements in usual care by GPs. The true effects, therefore, might be even more pronounced than reported. Adverse effects were not uniformly assessed in the usual-care group, which makes comparison of this aspect of care not possible. Nonetheless, among 24 (9·6%) participants in the nurse-led group who discontinued first-line treatment, all were successfully taking another urate-lowering therapy by the end of year 1. Doherty and colleagues' findings add to the evidence of the efficacy of urate-lowering therapy on clinical endpoints in gout. Two randomised trials, one with febuxostat11Dalbeth N Saag KG Palmer WE et al.Effects of febuxostat in early gout: a randomized, double-blind, placebo-controlled study.Arthritis Rheumatol. 2017; 69: 2386-2395Crossref PubMed Scopus (57) Google Scholar and the other with pegloticase,12Sundy JS Baraf HS Yood RA et al.Efficacy and tolerability of pegloticase for the treatment of chronic gout in patients refractory to conventional treatment: two randomized controlled trials.JAMA. 2011; 306: 711-720Crossref PubMed Scopus (8) Google Scholar showed improvements in gout flares, and in the pegloticase trial tophi resolution was greater than with placebo. Taken together, there are now ample data from randomised trials supporting a treat-to-target approach for urate-lowering therapy to improve patient-centred outcomes. In contrast to previous studies that have reported low adherence to gout management strategies, adherence to urate-lowering therapy in the nurse-led programme in the study by Doherty and colleagues10Doherty M Jenkins W Richardson H et al.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.Lancet. 2018; 392: 1403-1412Summary Full Text Full Text PDF PubMed Scopus (161) Google Scholar was high at 2 years (96%) compared with 56% adherence in the usual-care group. Doses of allopurinol were higher in the nurse-led than in the usual-care group, with 79% and 10% of patients, respectively, taking doses greater than 300 mg/day at 2 years (mean dose 430 mg/day in the nurse-led group vs 230 mg/day in the usual-care group). Both these factors contributed to the marked beneficial effects in the nurse-led group. The findings suggest that patients adhere to treatment when they receive information about the pathophysiological causes of gout, have regular follow-up and feedback, and a treat-to-target approach is used. GPs might not have the time for provision of gout care in this manner, but models of care involving non-physician health-care professionals in other settings, such as anticoagulation clinics and direct observation therapy for tuberculosis, have been successful. Development and training of the health-care workforce to implement this approach in gout care is now a priority. Doherty and colleagues10Doherty M Jenkins W Richardson H et al.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.Lancet. 2018; 392: 1403-1412Summary Full Text Full Text PDF PubMed Scopus (161) Google Scholar show a path forward for improved gout outcomes, demonstrating a package of care that leads to sustained adherence and clinical benefits through individualised education focusing on the central concept of gout as a chronic disease of urate crystal deposition and through using a well tolerated proactive treat-to-target approach. Highly efficacious and cost-effective gout management can be readily achieved by educating and spending time with patients. ND has received grants from Amgen, grants and personal fees from AstraZeneca, and personal fees from AbbVie, Horizon, Takeda, Kowa, Janssen, and Pfizer. ND is supported by the Health Research Council of New Zealand (15/576). In the past 5 years, she has been principal investigator on a clinical trial of febuxostat in early gout (funded by Takeda) and a clinical trial of lesinurad and febuxostat (funded by AstraZeneca) and co-investigator on a clinical trial of allopurinol dose escalation (funded by the Health Research Council of New Zealand). She is a member of the Eurogout genetics collaboration with Michael Doherty and Abhishek Abhishek and has published with Michael Doherty on various multiauthor consensus publications. She was a co-editor with Michael Doherty on the Oxford Textbook of Osteoarthritis and Crystal Arthropathy. TN is supported by the US National Institutes of Health (K24 AR070892, P60 AR47785, R01 AR062506) and is on the steering committee for a clinical trial of febuxostat compared with allopurinol funded by a grant from the US Department of Veterans Affairs (VA CSP-594). 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 trialNurse-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. Full-Text PDF Open Access