Gout - a step closer to the elusive 'cure'
Published on 18 April 2013
Gout, the most common form of inflammatory arthritis, is supposedly easy to treat. But a new study shows that misconceptions of this painful condition are preventing effective treatment. Jane Tadman reports.
Unlike many types of arthritis, gout, although painful and increasingly common, can be effectively treated by currently available drugs.
There are also national and international guidelines in place, that if properly adhered to should actually result in gout being ’cured’.
But in many cases, patients’ and doctors’ misconceptions and lack of knowledge about gout are preventing this from happening, according to new Arthritis Research UK-funded studies.
The prevalence of gout has increased in recent years and currently affects 1.4% of the adult population, making it the most common form of inflammatory arthritis in men and in older women. People with gout also take 4.5 more health-related days off work per year – and incur almost twice the health costs compared to the general population.
Patients who took part in two related studies at the University of Nottingham often believed that their condition was self-inflicted due to over-indulgence and an unhealthy lifestyle, and associated gout with the negative stereotypes portrayed in Victorian cartoons.
Despite the availability of effective treatments, the research highlighted the lack of knowledge about gout and, worryingly, a lack of awareness of the recommended guidelines about how to manage it among many GPs, hospital doctors and practice nurses.
However, the research, published in the Annals of the Rheumatic Diseases, also shows that if the condition is clearly explained to patients and they buy into the need for on-going medication, gout can in fact be effectively treated in nine out of 10 people.
Gout is caused by the formation of sodium urate crystals in and around the joints, as a result of raised urate levels in the body. A combination of diet and drug therapy can reduce urate levels to below the critical ‘saturation point’ at which crystals can form. If urate levels are maintained below this point it prevents further crystals from forming, and dissolves away ones that have already formed, leading eventually to elimination of all the crystals and ‘cure’ of gout.
Unfortunately, recent UK studies have suggested that only a third to a half of gout patients receive urate-lowering therapies such as allopurinol, and of those that do, many are on an insufficient dose to cure the condition.
Mike Doherty, professor of rheumatology at the University of Nottingham, led an observational proof of concept study to test the effectiveness of a treatment package in more than 100 people with gout, delivered largely by a nurse and based in a hospital setting. The package incorporated current guidelines that included patient education, and individualised lifestyle advice (such as losing weight, if obese). It also involved appropriate drug therapy – escalating doses of the drugs allopurinol, febuxostat or benzbromarone rather than a fixed standard dose, for example, to reduce urate levels in those people with gout in whom there were specific indications for urate-lowering drug therapy.
The study showed that after a year, 92% of patients had achieved the therapeutic target of reduced uric acid levels, and the number of acute attacks suffered by patients was fewer than in the previous year.
“The main barriers to treatment are a lack of understanding of gout – what it is and how it can be managed – both by patients and health professionals,” says Professor Doherty. “Many people focus on acute attacks and have no concept of on-going crystal formation that potentially may lead to irreversible joint damage.
“However, if gout is fully explained, patients then understand the need for long-term treatment with urate-lowering therapies when it is indicated.”
A second qualitative study published in the same journal involved face-to-face interviews with 20 gout sufferers and 18 health professionals from 25 Nottingham general practices and Nottingham City Hospital.
Research fellow Dr Karen Spencer, who led the study, says: “Many patients viewed gout as a self-inflicted or part of the aging process, and only focused on managing acute attacks, rather than treating the underlying causes. Some described how the diagnosis was considered as comical by their family, friends, and even their GP.”
“There was also a reluctance among GPs to use rate-lowering therapies until attacks of gout became more frequent and severe.”
Professor Doherty adds: “There are widespread misconceptions and a universal lack of knowledge and understanding of the causes and consequences of gout, and that it can be treated effectively by lifestyle change and, when indicated, by the use of urate-lowering therapy.
“This leads to suboptimal care of the most common inflammatory joint disease, and the only one for which we have a ‘curative’ treatment.”
The research team is now calling for better education of both patients and health professionals about gout.
In a bid to improve the situation, a new one-page guidance sheet has been produced for GPs by the British Society of Rheumatology with the Primary Care Rheumatology Society (PCRS) and Keele University's primary care and health sciences faculty.
BSR President Dr Chris Deighton says: “By making it easier for our primary care colleagues to have ready access to best practice guidelines, we hope to see a major reduction in the burden of the disease, benefiting not just the individuals spared the extreme pain of severe gout, but the wider economy too.”
Professor Doherty’s team is now running a new clinical trial, largely funded by Arthritis Research UK, to examine the effectiveness of a nurse-led package of care for gout patients in a general practice setting. Nurses in primary care already undertake a substantial amount of the successful management of other common conditions such as asthma and diabetes, and it is hoped that nurse-led management of gout will also prove feasible and successful in general practice.
More than 700 people with gout from Nottinghamshire and the East Midlands will take part in the £829,000 trial, which will recruit over the next two years.
“Now that we know that urate acid levels can be effectively reduced when treated in a hospital-based gout clinic, we want to find out if this can also be achieved in the community when the package of care is delivered by nurses, in the GP surgery,” explains trial co-ordinator Helen Richardson. “We also want to find out if this strategy reduces the frequency of gout attacks and improves the quality of life for gout patients.”
If successful, data from the trial could be used to persuade government departments to include gout within their framework for standards of care for GPs, and patients might just find themselves a step closer to that elusive ‘cure’.
Arthritis Today will keep readers up to date with the outcome of the trial.
Arthritis Research UK's booklet on gout is either available to download on our website, or to order a paper copy either contact 0300 790 0400 or firstname.lastname@example.org