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Supported self-management approaches have been shown to benefit patients with chronic health conditions, including gout.
Improved urate targets were seen in patients with gout receiving supported self-management, via the GoutSMART app, when compared with usual care, according to a study published in The Lancet.1
“Improved outcomes for patients with gout are associated with the control of urate levels; yet, less than 40% of patients in the UK are currently offered urate lowering therapy, and it is typically offered without titration to target,” investigators stated. “Supported self-management has been shown to benefit patients with chronic health conditions.”
A randomized controlled feasibility study analyzed adult patients with gout and a clinician-recommended initiation or escalation of urate-lowering therapy at Western General Hospital, NHS Lothian, in Edinburgh, United Kingdom, enrolled between April 5, 2019 and March 19, 2020. Patients were identified via the Scottish Health Research Register (SHARE). Investigators randomized patients in a 2:1 ratio of either supported self-management, via GoutSMART, or usual care. Patients entered quality of life and disease severity into the app once a month and reported any flares.
Those placed in self-management received a urate self-testing meter as well as direct advice from their clinicians. Patients with a urate level of more than 0.30 mmol/L tested levels every 2 weeks and were given reminders to do so each day.
Patients in the usual care group were only able to use the app as a health diary and their management plan was implemented by their general practitioner. All patients were encouraged to start 100 mg allopurinol once daily or increase their dosage by 100 mg.
The primary outcome was the percentage of patients who were able to achieve a urate target of 0.20 mmol/L or less by the 24-week mark.
Of the 60 patients included in the study, the mean age was 52.8 years, 93% of participants were male, and 97% were White. Demographics were balanced at baseline between both groups.
At 24 weeks, the urate target goal was achieved by 73% (n = 29) of patients in the self-management cohort compared with only 15% (n = 3) of patients in the usual care group (RR 4·83 [95% CI 1·67–13·96]). At 52 weeks, the 0·30 mmol/L target had been reached by 80% (n = 32) participants in the self-monitoring group and by 45% (n = 9) participants in the usual care group (RR 1·78 [95% CI 1·07–2·96].
During the 24-week period, flares were reported less frequently in the self-monitoring group (2.03) when compared with the usual care group (3.00) group (rate difference –0·97 [95% CI –1·88 to –0·07]).
A total of 90% of participants completed the study, with no significant differences in adverse events or drop-pout rates across both groups.
Generalizability was limited because patients who refused to participate skewed older and those who did participate were recruited from secondary care. Further, the percentage of women and minority groups analyzed in this study were less than initially expected. As excluded patients averaged 9 years older than participants, investigators hypothesized that the app approach was preferred by younger patients. Lastly, those without access to a smartphone were excluded. However, this number may decline over time as more patients purchase smartphones.
“We accept that larger trials of our approach are needed, and we hope that such trials will clarify whether the unexpected, rapid improvements in clinical outcomes observed in this study were a result of chance or were driven by the patient population or the high use of flare prophylaxis,” investigators concluded. “It would be helpful for future studies to explore outcomes in populations stratified by baseline urate or presence of tophi, and similarly, the controversy over whether to choose a urate target of 0·30 mmol/L or 0·36 mmol/L will not be resolved until these two strategies are directly compared.”
Philip L Riches, Debbie Alexander, Barbara Hauser, Barbara Kuske, Amrey Krause, Evaluation of supported self-management in gout (GoutSMART): a randomised controlled feasibility trial, The Lancet Rheumatology, 2022. ISSN 2665-9913. https://doi.org/10.1016/S2665-9913(22)00062-5.