Gout: Communicating Better is the Key to Good Patient Self-management

Gout, an inflammatory arthritis, is very common and increasing in prevalence with men more likely to develop it than women. The risk of developing gout peaks at around age 75. Experts indicate that gout’s prevalence will probably continue to grow, as it is associated with cardiovascular disease and diabetes (which are also growing in prevalence).

Traditionally, clinicians have considered it an 'old disease' because historians make references to its occurrence over centuries. Alexander the Great, Beethoven, and Charles Dickens all suffered with gout.

Gout develops when the body breaks down purines found naturally in the body and in many foods. The process forms a byproduct, uric acid, which can form urate crystals that accumulate in the kidneys (kidney stones) and in joints (gout). Gout most often develops in the big toe joint, but urate crystals can accumulate in elbows, fingers, wrists, knees, and ankles joints, too. While 21% of the United States population has hyperuricemia, 20% of patients who have hyperuricemia will develop the painful arthritis.

Patients describe accumulation of urate crystals in the joints as an 'attack,' because of the pain that develops in the reddish (but discolored), swollen, and warm-to-the-touch joint. Patients may describe it as feeling like the joint is full of glass shards. Even the weight of a sheet on top of the joint can cause extreme discomfort. After the intense pain ends, soreness can linger. Attacks can last hours or days, and, in some cases, weeks. Some people will never experience a second attack, while others may experience multiple attacks in a year.

Treatment options for acute attacks include colchicine, prescription strength nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and naproxen; and sometimes, corticosteroids. Long-term preventive medications include the xanthine-oxidase inhibitors allopurinol or febuxostat. Approximately half of people who have gout don’t respond completely to allopurinol and may need a trial of febuxostat. A newer option is lesinurad. Its mechanism of action is different, so it is added to allopurinol or febuxostat to reduce uric acid.

A significant hurdle in helping patients manage gout is medication adherence. Many patients either stop taking their medication, or have incomplete relief. Communication patterns between prescribers and patients could be better.

Researchers have found that some patients lacked basic knowledge about gout medications and their safety. In particular, patients needed more information about appropriate NSAID dosing for an acute gout flare. They also had difficulty differentiating NSAID generic and brand names.

Patients appeared to need more discussion about starting allopurinol, and for some patients, that information needs to be provided by multiple healthcare providers at visits that occur over time. In other words, patients forget information, so healthcare providers need to check retention and repeat often.

Patients also seemed reluctant to take a preventive medication long-term. Some patients simply didn’t think they needed the medication. Clinicians need to emphasize diet, exercise, lifetime medication adherence, early treatment of flares, and long-term medication adherence.

Healthcare providers need to discuss gout openly with patients, and take a few minutes to confirm that patients understand. Patients need a sufficient amount of information to buy into a treatment plan and agree to adhere.

References

Morris C, Macdonald L, Stubbe M, Dowell A. "It's complicated"—talking about gout medicines in primary care consultations: a qualitative study.BMC Fam Pract.2018;17(1):114.

Scirè CA, Rossi C, Punzi L, Genderini A, Borghi C, Grassi W. Change gout: how to deal with this 'silently-developing killer' in everyday clinical practice.Curr Med Res Opin. 2018 Mar 19:1-12.