Lana Pine is the editor of HCPLive Rheumatology. She is an experienced editor and technical writer with a demonstrated history of working in the banking and publishing industries. In her free time, she enjoys cooking, yoga, listening to podcasts, and drawing. She can be reached via email at LPine@mjhlifesciences.com.

Lana Pine

 care was linked to a higher uptake of and adherence to urate lowering therapy (ULT) compared with usual care, according to a study published in 

“Currently, gout management, particularly ULT, is often suboptimal,” wrote a team of investigators led by Claus Rasmussen, MD, associated with the Department of Rheumatology, North Denmark Regional Hospital in Hjorring, Denmark. “Nurses successfully manage various diseases including gout. As gout prevalence is rising, and rheumatologists and general practitioners face shortages, a new approach is imperative.”

Despite the established recommendations for ULT, less than half of patients are prescribed ULT and treatment adherence is generally poor. Further, the doses are often fixed without titration, which hinders a patient’s ability to obtain target plasma urate (p-urate) concentrations.

In the real-life prospective cohort study, investigators assessed the effectiveness of a nurse-led care program that used a treat-to-target strategy for the management of gout over a span of 2 years.

Patients with clinically confirmed gout diagnosed between June 2017 and June 2021 who were treated at the Clinic of Rheumatology in the North Denmark Regional Hospital were recruited into the study. The nurse-led management program provided a structured treatment plan including consultations, patient leaflets, laboratory monitoring, and telephone contacts. Patients were required to have had ≥ 1 visit or telephone call with the nurse-led clinic and nurses were given specialized training in gout management, with a focus on overcoming established barriers to treatment.

At the 1-year mark, patients were cared for in general practice for the remainder of the trial. The primary endpoint was obtaining target p-urate levels, defined as < .36 mmol/L, at 2 years. Other endpoints were treatment adherence and the achievement of target p-urate levels among specific subgroups. These results were compared with patients diagnosed with gout in the same clinic but receiving usual care.

A total of 114 patients with gout were recruited into the nurse-led group and 172 patients received usual care.

Among the nurse-led cohort, 82% (n = 92/112) achieved target p-urate levels and 98% continued treatment with ULT. Results were comparable among patient subgroups. Most (90%, n = 101/112) patients received allopurinol treatment with an average daily dosage of 308 mg. Conversely, only 44% (n = 63/144) of patients in the usual care group obtained target p-urate with insufficient doses of allopurinol (67%, n = 97/144), with a mean daily dosage of 235 mg. Additionally, fewer patients (73%) in this group continued ULT. The nurse-led care averaged 2 visits and 3 telephone calls over a 336-day period.

The overall mortality rate at the end of 2 years was 15%, with 4% (n = 4/114) in the nurse-led group compared with 23% (n = 39/172) in the usual care group (95% confidence interval [CI] .1547 [.04 — .43], 

Investigators mentioned limitations including selection bias and a lack of alternative comparison groups. However, by examining and comparing the nurse-led and usual care groups, they were able to obtain valuable insights regarding treatment efficacy and could better understand potential trends and associations that may impact future research and clinical practice.

“Our study demonstrates that a low-cost nurse-led gout clinic, primarily based on telephone interventions for 1 year, can be highly successful in achieving a clinically relevant reduction in p-urate levels,” investigators concluded. “This reduction significantly decreases the risk of disease progression, complications and potentially even mortality rates.”

Rasmussen C, Larsen JW, Christensen HM, et al. Optimising gout treatment: insights from a nurse-led cohort study. 

. 2024;10(2):e004179. Published 2024 Apr 24. doi:10.1136/rmdopen-2024-004179

Bavanendrakumar M, Robinson PC. Management of patients with gout and achievement of target serum Urate levels at a tertiary rheumatology service in Australia. Intern Med J 2020;50:337–41. doi:10.1111/imj.14445

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Among the nurse-led cohort, 83% of patients with gout achieved target p-urate levels and 98% continued treatment with urate lowering therapy.

Nurse-Led Gout Care Linked to Better Medication Adherence 

An automatic electronic health record (EHR)-based 

 register was proven to be a feasible and valid option for assessing and improving gout management, according to a study published in 

 During the analysis, investigators also noted a substantial under-reporting and underdiagnosis of the disease since the beginning of the COVID-19 pandemic.

Although guidelines for the management of gout and how to treat acute flares or chronic gouty arthritis are readily available, previous research has shown the disease remains undertreated. For example, a recent study reported only 30% — 50% of patients with gout are prescribed urate lowering therapy and fewer than half of these patients adhere to their medication.

“Despite the high prevalence of this disease, existing gout registers predominantly come from rheumatology settings which do not fully capture the disease’s spectrum,” wrote a team of investigators led by Nils Bürgisser, MD, associated with the Division of Rheumatology at Geneva University Hospitals (HUG) in Switzerland. “One of the barriers to create larger gout registers is their labor-intensive nature, requiring manual data collection by healthcare professionals. Furthermore, administrative datasets, a common source for research studies, often lack relevant clinical information such as laboratory data and specific patient-centered outcomes.”

The EHR collected information from all adult patients aged > 18 years from HUG, a French-speaking tertiary academic hospital, between January 2013 and December 2022. Gout diagnosis was based on 6 criteria: urate-lowering therapy prescription, monosodium urate crystals in joint aspiration, the International Classification of Diseases 10 (ICD 10) gout diagnosis, and gout-related terms in the problem lists, clinical reports, or imaging reports. The team evaluated the positive predictive value (PPV) and negative predictive value (NPV) of the query by the chart reviews.

Among a total of 2,110,902 patients, 10,289 exhibited ≥ 1 criteria for gout. A combination of joint aspiration or diagnostic in the problem list or ≥ 2 other criteria created a subcategory of 5138 patients. Of this register, 92.4% had a PPV (95% confidence interval [CI] 88.5% — 95.0%) and 94.3% had a NPV (95% CI 91.9% — 96.0%). The PPV and NPV were comparable among inpatients and outpatients.

The incidence was 2.9 per 1000 patient-years, which dropped by 30% at the beginning of the COVID-19 pandemic.

Patients with a gout diagnosis were predominantly male (76.5%), overweight (69.5%), had several comorbidities, and had an average age of 71.2 years. The most common comorbidities were hypertension (69.4%) and cardiovascular and ischemic disease (53.0%). Over half (57.4%) were prescribed a urate lowering therapy, 6.7% had either ≥ 2 flares within a year or were hospitalized due to gout, and 32.9% received a consultation from a rheumatologist.

Investigators noted selection bias as a main limitation of the study, which could also hinder generalizability. Additionally, the EHR could not evaluate any patients who consulted with clinicians in private clinics or practices and those who did not ultimately seek medical attention. However, HUG provides free care to the majority of the regional population, including inpatient and outpatient care to more vulnerable patients. Other important limitations were the use of a single hospital for the register, the possibility of misdiagnosis, and the chance that some patients with gout went undiagnosed due to missing information within the EHR.

“The automatic nature of the query makes this register inexpensive and sustainable, facilitating the assessment of the adequacy of gout management, the monitoring of indicators following quality improvement projects, and the detection of gout patients to be included in new studies or trials,” investigators summarized. “Also, the decline of gout diagnoses since 2020, especially evident in inpatient settings, prompts questions about how the pandemic may have affected healthcare access, patient behaviors and diagnostic approaches.”

Bürgisser N, Mongin D, Mehouachi S, et al. Development and validation of a self-updating gout register from electronic health records data. 

. 2024;10(2):e004120. Published 2024 Apr 24. doi:10.1136/rmdopen-2024-004120

Dehlin M, Jacobsson L, Roddy E. Global epidemiology of gout: prevalence, incidence, treatment patterns and risk factors. Nat Rev Rheumatol 2020;16:380–90. doi:10.1038/s41584-020-0441-1

The incidence of gout was 2.9 per 1000 patient-years, which dropped by 30% at the beginning of the COVID-19 pandemic. 

EHR-Based Gout Register May Improve Disease Management

Recent research demonstrated transient elastography was a reliable and superior method to detect liver fibrosis among a cohort of Chinese patients with 

 being treated with methotrexate compared with the total cumulative dose of methotrexate (≥ 3.5 g) method.

Therefore, a liver biopsy should be reserved for high-risk patients or those with liver stiffness of ≥ 11.7 kilopascals (kPa) on transient elastography, according to a study published in the 

Although methotrexate is an effective, safe, and cost-effective immunosuppressive drug for patients with PsO and 

, prolonged use may cause liver fibrosis and fatty changes without altering liver enzymes. These changes might be due to the production of extracellular adenosine.

 As liver biopsy—a gold standard for detecting liver injury among this patient population—is risky and invasive, transient elastography could be a safer option.

“Transient elastography is a non-invasive method for assessing liver ‘hardness’ or stiffness that involves measuring the velocity of a vibration wave (ie, a shear wave) when travelling to a particular depth inside the liver, based on the principle that the wave velocity is greater in fibrotic tissue than in normal liver tissue,” wrote a group of international investigators predominantly associated with the University of Hong Kong. “This technique has been used as a screening tool for liver cirrhosis in various conditions. In contrast to liver biopsy, transient elastography allows the simultaneous assessment of a larger sampling area, is easily reproducible, and has low inter-observer variability and a low failure rate (<5%).”

Investigators evaluated the performance of transient elastography in methotrexate-induced liver fibrosis compared with liver biopsy in a cohort of adult Chinese patients with clinically diagnosed PsO. Liver stiffness was measured using transient elastography. Exclusion criteria included conditions that could influence transient elastography performance, positive viral hepatitis carrier status, and known liver cirrhosis. Biopsy was conducted when liver stiffness was ≥ 7.1 kPa or if the total cumulative dose of methotrexate was ≥ 3.5 g.

A total of 228 patients were ultimately recruited for the study, of which 34 met the inclusion criteria. Of these, approximately one-fourth (26.5%) had significant liver fibrosis. The area under the receiver operating characteristic curve was .76 (95% confidence interval [CI] = .59 — .93; 

= .021), which demonstrated the satisfactory performance of transient elastography in detecting liver fibrosis.

Using a cut-off value of 7.1 kPA for liver stiffness, results yielded 100% sensitivity and 68% specificity among this patient population. Although liver fibrosis was significantly correlated with obesity and diabetes status, as defined by a body mass index of ≥ 30 kg/m2, waist circumference ≥ 138 cm, and glycated hemoglobin level ≥ 7.8%, it was not linked with the total cumulative dose of methotrexate or the duration of methotrexate use.

Investigators noted the small sample size as a limitation of the study. A larger sample size could be beneficial to draw definitive conclusions, despite liver fibrosis being generally uncommon in patients with PsO receiving methotrexate.

“When considering liver biopsy to rule out the possibility of clinically significant liver fibrosis, transient elastography-based liver stiffness measurements provide superior reference information, compared with the total cumulative dose of methotrexate,” investigators concluded. “Patients with high body mass index, body weight, and abdominal obesity have a higher risk of liver fibrosis. Therefore, these factors should be considered when monitoring methotrexate-related liver fibrosis in psoriasis patients.”

Wong CSM, Mak LLY, Lee VKH, et al. Detection of significant liver fibrosis in Chinese psoriasis patients receiving methotrexate: a comparison between transient elastography and liver histology. 

. 2024;30(2):110-119. doi:10.12809/hkmj2210364

Themido R, Loureiro M, Pecegueiro M, Brandão M, Campos MC. Methotrexate hepatotoxicity in psoriatic patients submitted to long-term therapy. Acta Derm Venereol 1992;72:361-4

Using a cut-off value of 7.1 kPA for liver stiffness, results of the transient elastography yielded 100% sensitivity and 68% specificity among this patient population. 

Transient Elastography Deemed Reliable Method to Detect Liver Fibrosis in Patients with PsO Treated with MTX

, a limited percentage of words (11%) focused on treatment adherence, according to a study published in 

 These findings also showed limited medication adherence coverage coupled with narrow strategies in online gout resource.

Gout adherence is classified into 2 categories—unintentional and intentional—defined as the process by which patients choose not to take their medication based on beliefs and perceptions about their condition or treatment. For example, certain patients may not take their medications based on adverse side effects, while other patients may not adhere to medication due to forgetting to take the drug, challenges regarding refills, or encountering logistical barriers such as travel.

“Recent studies have emphasized the significance of online health information seeking as a potential factor that can impact adherence to prescribed medications,” wrote a group of international investigators led by Yasaman Emad, PhD candidate associated with the Department of Psychological Medicine at the University of Auckland in New Zealand. “The way in which people with gout consume online health information can shape their beliefs surrounding their condition and medication use, ultimately impacting their behaviour and level of adherence to prescribed medications.”

Investigators believe improved adherence portrayal could help to effectively manage gout through comprehensive strategies and clear, easily understood information strategies.

An analysis of how medication adherence is addressed among online gout resources was performed using data from 6 countries. They evaluated how often adherence was referred to, the strategies to improve patient adherence, and the types of non-adherence that were targeted. The readability of adherence material was also assessed.

A total of 151 online gout resources from medical and health organizations were included from predominantly English-speaking countries. The analysis used coding for adherence-promoting strategies and non-adherence, and Flesch-Kinacid Reading Ease scores and word count were collected.

Of the websites included, 77 discussed medication adherence (51%), with results demonstrating intentional non-adherence was more prevalent than unintentional non-adherence. A total of 67 websites focused on different types of non-adherence, citing drug-specific concerns (50%), misconceptions regarding gout curability and medication necessity (16%), forgetfulness (16%), and other barriers (5%).

Strategies designed to promote medication adherence were found in only 1 out of 3 websites, with medication education being the most prevalent strategy (17%), followed by engagement from healthcare providers (13%), and memory aid strategies (6%).

Overall, about 11% of the words (89.27, standard deviation [SD] = 76.35) in the entire document were focused on medication adherence among this patient population. Difficult reading comprehension was reported in approximately one-fifth of adherence-related sites.

Investigators noted limitations including analyzing predominantly English-speaking countries, which may hinder generalizability to patient websites from other countries. Currently, there are no guidelines for what types of material on non-adherence should be focused on within patient websites, which could account for the variability in material. Future work should focus on this. Additionally, readability cannot indicate the quality or comprehensiveness of the information alone. Lastly, the study did not include an analysis of resources for healthcare providers including the management guidelines or reference texts. Future research should include an evaluation of gout management guidelines regarding adherence optimization recommendations.

“The study showed that around half of websites providing patient information on gout did not cover adherence or provide any strategies to help patients keep to their medication regimen,” investigators concluded. “Websites could also be improved with greater attention to unintentional factors such as forgetting and through improving readability to help patients with lower health literacy.”

Emad Y, Derksen C, Petrie KJ, Dalbeth N. A content analysis of medication adherence material in patient educational resources about gout. 

. 2024;8(2):rkae042. Published 2024 Mar 19. doi:10.1093/rap/rkae042

Penner LS, Armitage CJ, Thornley T et al.Non-adherence to medicines: not solved but solvable. J Health Serv Res Policy 2009;14:1–61.

Strategies designed to promote medication adherence were found in only 1 out of 3 websites. 