Treatment approaches and adherence to urate-lowering therapy for patients with gout

Abstract

Gout is the most common inflammatory arthritis characterized by painful disabling acute attacks. It is caused by hyperuricemia and deposition of urate crystals in and around the joints. Long-standing untreated hyperuricemia can lead to chronic arthritis with joint damage, tophi formation and urate nephropathy. Gout is associated with significant morbidity and health care associated cost. The goal of long-term therapy is to lower the serum urate level to promote dissolution of urate crystals, reduce recurrent acute gout flares, resolve tophi and prevent joint damage. Despite the presence of established gout treatment guidelines and effective medications to manage gout, patient outcomes are often poor. Etiology for these shortcomings is multifactorial including both physician and patient characteristics. Poor adherence to urate-lowering therapy (ULT) is prevalent and is a significant contributor to poor patient outcomes. This article reviews the treatment strategies for the management of hyperuricemia in chronic gout, gaps in quality of care in gout management, factors contributing to poor adherence to ULT and discusses potential interventions to achieve improved gout-related outcomes. These interventions include initiation of prophylactic anti-inflammatory medication when starting ULT, frequent follow-ups, regular serum urate monitoring and improved patient education, which can be achieved through pharmacist- or nurse-assisted programs. Interventions such as these could improve adherence to ULT and, ultimately, result in optimal gout-related outcomes.

Review of gout clinic in a tertiary hospital setting

“…Furthermore, allopurinol is often ineffectively utilised as a ULT, due to failure to titrate the dose in line with recommendations to achieve sustained serum urate levels less than 0.36 mmol/L, 10,15 or 0.30 mmol/L for severe or tophaceous gout. 14 This second phase takes months to years to achieve.…”

“…15,16 Patients who are not armed with this information and a strategy to manage acute flares usually cease ULT due to the misconception that it should have eased their pain, but instead resulted in worsening of their gout. 15,16 Patients who are not armed with this information and a strategy to manage acute flares usually cease ULT due to the misconception that it should have eased their pain, but instead resulted in worsening of their gout.…”

“…Many published guidelines reinforce this approach; 6,7 however, these are predominantly found in rheumatology journals. Furthermore, allopurinol is often ineffectively utilised as a ULT, due to failure to titrate the dose in line with recommendations to achieve sustained serum urate levels less than 0.36 mmol/L, 10,15 or 0.30 mmol/L for severe or tophaceous gout. Our audit showed that adherence to these guidelines resulted in greater than half of patients with gout achieving serum target urate levels within a year.…”

“…Patient education is an important part of gout management at each encounter, particularly as there is a tendency for gout flares during the first 12 months of ULT. 15,16 Patients who are not armed with this information and a strategy to manage acute flares usually cease ULT due to the misconception that it should have eased their pain, but instead resulted in worsening of their gout.…”

Impact of Lesinurad and allopurinol on experimental Hyperuricemia in mice: biochemical, molecular and Immunohistochemical study

“…UA is primarily excreted through the kidneys in urine (65-75%) and to a lesser extent through the gastrointestinal tract (25-35%) [3,5]. An increase in the level of uric acid in the blood is known as hyperuricemia, and is the cause of gout, which manifests in inflammatory arthritis and painful disabling with acute attacks [6].…”