Gout Treatments Effective If Patients Maintain Lifelong Adherence to Therapies

Although gout is one of the most effectively treated of all rheumatic diseases, it is among the worst-managed diseases long term, as shown by many studies. “Treatments are excellent, yet are dramatically under-utilized,” says Theodore Fields, MD, FACP, rheumatologist, Hospital for Special Surgery (HSS), New York. “This is because some gout patients feel better between attacks and stop taking their medication, or they ignore or never fully assimilate the need for lifelong therapy.”

Further, they focus on alternative therapies, such as diet, as a way to relieve symptoms. “Diet alone is rarely sufficient [for patients] to reach remission,” Dr. Fields says. “Patients may feel guilty about not adhering to dietary guidelines and, therefore, avoid discussing self-induced flares with their physicians.”

“Concerns about the side effects of gout medications may also play a role in patients not sticking to medication regimens,” Dr. Fields continues. “When a patient starts taking a urate-lowering therapy (ULT), they may get mobilization flares, conclude the medication is not working and stop taking it—which is the wrong thing to do. Or because gout has been shown to have multiple co-morbidities, such as hypertension, kidney disease and diabetes mellitus, patients may decide they are taking too many pills and stop the gout-related medications.”

Working Together to Reduce Gout Flares

Suffering, loss of quality of life and loss of work time have been well documented as substantial for gout patients. There are more than 8.3 million gout patients; the great majority are presently followed by primary care physicians.^1,2 Although rheumatologists don’t see all gout patients, Dr. Fields says they can play a major role in managing the most difficult gout patients and in educating primary care physicians about optimal gout management.

“Rheumatologists can help gout patients by developing effective and ongoing strategies for patient education and monitoring so they truly understand why they are being asked to take on the burdens of urate monitoring, diet and lifestyle modification, and lifelong therapy,” Dr. Fields says. “Patients need ongoing reminders about why they need to stay on their ULT and follow up on their urate level to allow for appropriate dose titration.

“Every gout patient should know their uric acid level goal just as a diabetic knows their HbA1c goal or a hypertensive patient has a blood pressure goal,” he says. Rheumatologists should educate their primary care colleagues about the importance of closely monitoring gout patients, and referring them to a rheumatologist when a patient is having difficulty reaching a urate goal or managing refractory flares.

A Need for Education

Because successful gout management requires a complex regimen of medications and self-management involving medication adherence and dietary guidelines, it is essential that patients have a good understanding of how and why medications are used, and how diet affects attacks.

Research findings suggest that there are significant knowledge gaps in gout patients regarding these issues.^3,4 In the context of a brief medical office visit, it can be difficult to convey all of the information patients need to effectively manage gout.

“Written patient education materials to supplement physician-provided information are helpful references, but they do not replace in-person education that gives patients the opportunity to ask questions and clarify complex medical information,” says Adena Batterman, MSW, LCSW, senior manager, Inflammatory Arthritis Support and Education Programs, HSS.

To address these educational needs, HSS held a multi-disciplinary gout symposium, which was planned with the input of rheumatologists, nurses, a nutritionist and a social worker.

Planning Steps

The first step was to identify gout-specific knowledge gaps and gout patients’ informational preferences to inform content of the symposium. “We developed a 26-item needs assessment to ascertain patient self-efficacy around essential gout-related knowledge and patient-identified needs to enhance self-management,” Ms. Batterman says. The assessment was administered to 100 gout patients.

The symposium content was developed around evidence-based clinical guidelines regarding gout treatment, as well as lifestyle and diet management, and was further informed by the results of the needs assessment. Literacy issues were carefully considered in developing content to ensure information was accessible to a broad audience with varying levels of education and understanding of medical terminology. “The purpose was to provide essential disease and treatment-related information to enhance self-management strategies, which incorporated patient perspective and patient-identified concerns and preferences,” Ms. Batterman says.

‘Diet alone is rarely sufficient [for patients] to reach remission,’ Dr. Fields says. ‘Patients may feel guilty about not adhering to dietary guidelines &, therefore, avoid discussing self-induced flares with their physicians.’

Different Medications for Different Stages

Dr. Fields, a rheumatologist with a specific clinical interest in gout treatment and gout patient education, presented on disease background, etiology, diagnosis and treatment. He emphasized the importance of developing a patient/provider partnership to work together to reduce flares, with the ultimate goal of eliminating flares.

Dr. Fields spent a significant amount of time providing details about the types of medications used to treat gout—why they are used and for how long—and treatment goals for each type, including detailed information about the concept of “bridge therapy” and the need for ULT. Additionally, emphasis was placed on how to control gout flares early in treatment initiation, how to minimize flares and the rationale for long-term, continued treatment, even when attacks seem well controlled. “If the patient understands these points, it can contribute to treatment adherence,” Ms. Batterman says.

Dr. Fields finds it helpful to explain to patients that there are three different groups of treatments for gout, and that medications that help for one aspect, such as an acute flare, won’t help for lowering urate, and vice versa.

Treatments available for acute flares, or “rescue” therapies, include non-steroidal anti-inflammatory drugs, oral and injected corticosteroids, and colchicine. For most refractory cases, Dr. Fields prescribes an interleukin 1 (IL-1) inhibitor, such as anakinra.

Secondly, ULT is critical for long-term disease remission. These therapies include the xanthine oxidase inhibitors, allopurinol and febuxostat; the uricosurics, probenecid and lesinurad; and the intravenous uricase, pegloticase. Most HSS gout patients take a xanthine oxidase inhibitor as their first mediation.

A third group of medications is used as bridge therapy, generally for the first six months of urate-lowering therapy, to prevent mobilization flares that often accompany the early phases of lowering urate. This group includes colchicine, the most studied and most commonly used bridging agent, low-dose non-steroidal anti-inflammatory drugs, or occasionally a low-dose oral corticosteroid. In special circumstances, an IL-1 inhibitor is used.

In particular, Dr. Fields has found that a lot of gout patients meet criteria for urate lowering, but either don’t take this medication despite guideline recommendations, such as those by the ACR, or are on suboptimum doses. “Getting patients to their urate goal, most commonly less than 6.0 mg/dL, has been well shown to be effective in getting gout patients to remission, and careful titration of our present urate-lowering medications is generally quite successful in attaining this goal,” Dr. Fields says. “But unfortunately, patients commonly stop their ULT, or remain on a low dose without follow-up of their urate levels, and so never attain or maintain their urate goal.”

Other Components

Additional topics that the symposium covered included:

• The causes of gout, including the genetic component;
• An emphasis on appropriate optimal treatment outcomes and goals (i.e., most patients should expect to have no gout attacks as the long-term outcome);
• Effective treatment requires patience and diligence;
• Importance of understanding uric acid goals, how, specifically, medication works to address this, and how and why uric acid levels are monitored. Understanding this goal as the underpinning of treatment contributes to a concrete, measurable goal for the patient and physician to achieve together;
• Putting side effects and risks of treatment into perspective, and providing context of short- and long-term benefits;
• An overview of co-morbidities and conditions—putting treatment and management into context of these conditions (i.e., kidney dysfunction, coronary heart disease, obesity, high cholesterol and triglycerides and diabetes);
• Effective treatment requires patience and diligence; and
• Dietary guidelines for gout management, presented by a nutritionist.

After the symposium, all participants were asked to complete an evaluation, which included questions regarding key discussion points. Participants were also asked if they intended to change self-management behavior, and the likelihood of them discussing their gout treatment and management with their provider as a result of attending the program.

“Results from written evaluations on these measures were overwhelmingly positive and indicated that participants understood key discussion points,” Ms. Batterman says. “Perhaps, as important, participants indicated they were likely to bring this information to providers to further the patient/doctor dialogue and partnership in managing their gout symptoms.”

Karen Appold is a medical writer in Pennsylvania.

References

1. Zhu Y, Pandya BJ, Choi HK. Prevalence of gout and hyperuricemia in the US general population: The National Health and Nutrition Examination Survey 2007-2008. Arthritis Rheum. 2011 Oct;63(10):3136–3141.
2. Krishnan E, Lienesch D, Kwoh CK. Gout in ambulatory care settings in the United States. J Rheumatol. 2008 Mar;35(3):498–501.
3. Spencer K, Carr A, Doherty M. Patient and provider barriers to effective management of gout in general practice: A qualitative study. Annals Rheum Dis. 2012 Sep;71(9):1490–1495.
4. Harrold LR, Mazor KM, Peterson D, et al. Patients’ knowledge and beliefs concerning gout and its treatment: A population based study. BMC Musculoskelet Disord. 2012 Sep 21;13:180.