Preemptive Pharmacist Counseling Can Improve Treatment Adherence in Gout and Pseudogout
Lack of adherence to treatment is a pervasive concern in the health care industry, but it’s especially problematic in patients with gout. The consequences are significant. When patients get early and appropriate treatment—and stick with the program—their prognosis is excellent. Conversely, nonadherence can lead to acute flares and substantial morbidity.
Pharmacists are always essential team members when it comes to motivating adherence. But when your patient has gout or pseudogout, more diligence is required to ensure adherence and optimal treatment. This effort isn’t time-consuming when you understand the issues, yet it can yield impressive improvement in your patients’ health.
Nonadherence to Treatment for Gout
Gout and pseudogout are the two most common crystal-induced arthropathies, afflicting more than 8 million people in the United States. The estimated prevalence is 3.9 percent in the general population, but it rises to 20 percent in people with a family history of gout. While the incidence of pseudogout varies with age, the experts say it may afflict nearly half of adults by the time they’re 80 years old. Other important patient demographics include1:
- Male predominance – Prevalence of gout is about 6 percent in men compared to 2 percent in women, although pseudogout is equally prevalent between the two sexes.
- Uric acid level and onset – In men, uric acid levels rise at puberty and age of onset is 40 to 60 years. In women, uric acid levels rise at menopause and peak onset is 60 to 80 years.
- Early onset – May occur in men in their early 20s if they have a genetic predisposition.
Here’s the bad news about adherence. Nonadherence with prescribed pharmacologic treatment ranges from 50 to 82 percent.2 Looking at the positive side, good adherence, which was defined as purchasing at least 80 percent of the prescribed medication, ranged from 18 to 44 percent. It’s also important to know that more than half of patients with gout use complementary and alternative therapies.3
Issues Related to Variable Treatment and Prescriptions
Patient nonadherence is only one side of the equation. It turns out that only half of patients with gout are prescribed urate-lowering medications. While dietary changes have an important role, medication is usually required to manage levels of uric acid. The lack of prescription medications for half of all gout patients doesn’t bode well for successful disease management considering that the goals are to:
- Treat acute attacks.
- Provide prophylaxis to prevent flares.
- Lower excess stores of urate to prevent flares and deposition of crystals in tissues.
Another treatment concern is the failure to monitor serum urate and titrate the dose accordingly. At least part of the problem depends on whether patients are managed by a rheumatologist, reported the March 2015 issue of The Journal of Rheumatology.4. “Modifiable Factors Associated with Allopurinol Adherence and Outcomes Among Gout Patients in an Integrated Healthcare System,” March 2015, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4922495/] Allopurinol dose escalation is necessary for most patients to achieve serum urate goals—a practice that’s common among rheumatologists, but often not implemented with other providers. This is a vital piece of information because a rheumatologist may not even be available for patients who live in rural areas. And don’t forget there’s a shortage of rheumatologists in the US, so many patients must depend on other providers.4
Some physicians start with a low dose and titrate up, so patients need to know their gout flares may not stop immediately. They’ll also need encouragement to adhere with treatment until they reach the optimal dose. Other providers may initiate treatment at a higher dose to reach urate goals before patients stop taking their medication. Pharmacists should also be aware of a 20009 study which reported that 83 percent of newly diagnosed patients taking allopurinol didn’t get tested for serum uric acid within six months.5 Ask patients if they’ve been tested or experienced a change in symptoms or flares. If they’re worsening and you don’t see dosage adjustments, it’s time to intervene.
Factors That Influence Patient Adherence
If you hope to motivate patients to take their medications, you need to know as much as possible about why they don’t adhere to the regimen. Some roadblocks are obvious, like lack of insurance coverage and inability to pay. It’s also good to know that patients with other chronic conditions like hypertension may be more likely to take their gout medications. Beyond that, here’s some insight from several researchers who have explored the problem as it relates to gout:
- Reliance on anti-inflammatory prophylaxis – Patient who rely on NSAIDs to relieve symptoms are less likely to take urate-lowering medications. When you dispense drugs, be sure to teach them about urate levels and how NSAIDs may relieve symptoms but won’t prevent future flares.
- Acute symptom treatment – Some gout patients prefer to treat their gout acutely with over-the-counter anti-inflammatory medications. As a result, they don’t adhere to pharmacologic therapy. These patients also need to learn about the importance of lowering uric acid levels.
- Preference for dietary changes – At least 16 percent of patients with gout say they prefer to rely on dietary changes—primarily following a low-purine diet and also limiting alcohol and high-fructose drinks. But purine restriction only has a moderate impact on serum levels of uric acid. Diet is important, but may not be sufficient to prevent flares.
- Complementary and alternative therapies – About 40 percent of gout patients prefer non-pharmacological intervention. Vitamin C and cherry extract are often used because they’re associated with lowering uric acid. Daily consumption of cherry juice concentrate may reduce acute gout attacks, although the mechanism of action hasn’t been determined.6
- Gaps in patient education – The more patients know about gout and the role of long-term urate-lowering therapy for preventing painful flares, the more likely they are to adhere to the medication regimen. At the very least, you can encourage them to talk with you or their physician before they stop taking medications. They also need to know about potential adverse effects and what results they can expect from urate-lowering therapy.
Pharmacists Improve Outcomes by Monitoring Medications
Patients with gout and pseudogout—and their physicians—are caught in the middle of another confounding factor—changing and conflicting treatment guidelines. In October 2016, the first international treat-to-target recommendations were released. Then in November 2016, the American College of Physicians published new clinical guidelines that turn away from the treat-to-target emphasis.7 Adding that debate to the existing treatment and adherence issues means it’s even more important for pharmacists to monitor medications, educate patients, and advocate for adequate treatment.
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- “Gout and Pseudogout,” October 2016, http://emedicine.medscape.com/article/329958-overview#a5 ↩
- “Treatment Adherence in Patients with Gout,” October 2011, https://www.ncbi.nlm.nih.gov/pubmed/21724443 ↩
- “A Cross-Sectional Internet-Based Patient Survey of the Management Strategies for Gout,” March 2016, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4774197/ ↩
- “Rheumatology Faces Serious Manpower Shortage,” November 2016, http://www.medpagetoday.com/MeetingCoverage/ACR/61442?xid=fb_o_ ↩
- “Quality of Life and Quality of Care for Patients with Gout,” April 2009, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3855300/ ↩
- “Previously Reported Prior Studies of Cherry Juice Concentrate for Gout Flare Prophylaxis: Comment on the Article by Zhang et al,” March 2013, http://onlinelibrary.wiley.com/doi/10.1002/art.37864/full ↩
- “Gout Doubt: Experts Challenge New ACP Guidelines,” November 2016, http://www.medscape.com/viewarticle/871265 ↩