Gout curable but hampered by poor adherence

3 minute read

The importance of the ‘completely curable’ condition is sometimes under-appreciated, says Professor Richard Day.

Gout is a curable condition, held back by poor adherence to medicine, latest research suggests.

Speaking at this year’s Australian Rheumatology Association (ARA) Annual Scientific Meeting, rheumatologist Professor Richard Day said the importance of gout as the most common inflammatory arthritis among men was sometimes under-appreciated.

Almost half-a-million Australians had gout, and the proportion rose to one in five among men over the age of 70, said the professor of clinical pharmacology at St Vincent’s Hospital in Sydney.

While there was an “epidemic” of gout, Professor Day said, the condition was “completely curable”.

“The problem is adherence to therapy,” he said, pointing to a 2018 meta-analysis indicating the rate of adherence to medicine was less than 50%.

“This is very low for a condition that is so intrusive,” said Professor Day.

Gout adherence scored the worst out of a several other chronic conditions, including hypertension, hyperthyroidism, diabetes and osteoporosis, another study indicated.

“You wonder why this is the case,” he mused.

Ongoing flare-ups should be worrying beyond simply the pain and discomfort among patients, as they can lead to damage to joints and other organs, namely the kidneys.

But poor adherence wasn’t due to patients alone, said Professor Day – it was also down to their clinicians.

He pointed to several patient factors that led to inadequate treatment, including a limited knowledge about the causes and consequences of gout long term, a lack of understanding around long-term therapies and their control of acute attacks, and insufficient appreciation of the long-term importance of adherence.

In 2016, UNSW researchers surveyed patients to understand what the barriers were to treatment. As well as a poor understanding of gout and its treatments, other barriers included medication-related barriers such as forgetting their drugs – which may be more common among males – and stigma, said Professor Day.

Unfortunately, adherence to long-term therapy for gout was demanding, he added, noting that “well above 80%” of patients required daily therapy and missing even a couple of days could trigger an attack.

Another barrier to adequate treatment was that initiating long-term urate-lowering treatment could actually trigger flares.

“This is the only treatment that I know about that causes the condition you say you’re going to control,” he said. “So, a patient who doesn’t know enough about that and isn’t given a strategy to deal with it is likely to say ‘well, it doesn’t work, I’m stopping it’.”

Until recently, patients were also advised to stop therapy if they had a flare and start it again, he said.

Research now also indicated that patients who had higher urate baseline levels needed higher levels of allopurinol to reach targets. “It does say that perhaps one of our biggest problems is that the dose isn’t enough,” he said.

A 2018 study in The Lancet found that patients under nurse-led care did much better than normal – exceeding targets – which the authors attributed to more time with the patients, explaining the condition in an easy and personalised way and having patients involved in the decision making.

To leverage these benefits, without the costs, Professor Day and colleagues had developed a self-management app, which tracked flare-ups and other factors, that was currently being evaluated.

Ultimately, Professor Day said the key steps to eliminating gout were identifying the afflicted; more education of both patients and clinicians; dosing people adequately; personalising their medical care and, perhaps most importantly, making sure people were adherent to medication.

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