Pharmacist-led collaborative gout clinic helps patients achieve serum uric acid goals

A collaborative clinic led by a pharmacist helps patients with gout to attain better clinical outcomes in the management of their condition, even in the presence of renal impairment, reports a Singapore study. The clinic provides safe, stepwise increments of urate-lowering therapy (ULT) in addition to serum uric acid (SUA) monitoring and adherence reinforcement through frequent initial visits.

In this retrospective pre‒post study, the researchers assessed the impact of a pilot shared care model on providing dose titration of ULT, gout education, and patient support to achieve target SUA levels. They compared outcomes in patients treated with either allopurinol or febuxostat in the 24 months prior to (group A: preimplementation) or 33 months following the launch of the collaborative gout clinic (group B: postimplementation). The clinic includes a pharmacist under the supervision of a rheumatologist.

Ninety-eight patients participated in the study, of which 50 were enrolled in group A (all prescribed allopurinol) and 48 in group B (allopurinol: n=29; febuxostat: n=19). [Proc Singap Healthc 2023;doi:10.1177/20101058231152048]

Among participants who achieved the target SUA level (≤360 μmol/L) at 1 year of drug initiation with allopurinol, patients in group B had shorter median time taken to attain target SUA than those in group A (111 vs 293 days; p=0.016).

Fewer patients in group B than in group A experienced gout flare (41.3 percent vs 70.0 percent; p=0.018). In addition, more group B participants achieved the target SUA level (75.9 percent vs 22.0 percent; p<0.001). The mean daily allopurinol dose to achieve target SUA levels was 276 mg.

Dose escalation fear

Evidence from a previous study suggested that inadequate gout management is driven by fear of allopurinol dose escalation in certain patient populations. [Ann Rheum Dis 2013;72:791-793]

“Our program and protocol were designed to overcome this problem by providing close monitoring of repeated measurements of SUA and other relevant blood tests so that timely interventions could be done to help patients achieve target SUAs safely, including those with impaired renal functions,” the researchers said.

The current protocol did not limit the dose of allopurinol according to renal function in line with the Hande criteria, which was considered by previous studies as a barrier to successful gout treatment. [Am J Med 1984;76:47-56; Curr Rheumatol Rep 2009;11:135-140; Arthritis Rheum 2011;63:412-421; J Rheumatol 2006;33:1646-1650]

“Our observations confirmed this: only two (7 percent) patients and one (3 percent) patient, out of those who were taking allopurinol in the postgroup, achieved target with dose of 100 mg/day and 150 mg/day, respectively,” the researchers said.

Singapore experience

The use of collaborative care to achieve better clinical outcomes in the management of gout is not entirely new in Singapore, with nurse-led interventions as the usual standard of care. [Int J Rheum Dis 2020;23:1136-1144; Scand J Rheumatol 2012;41:450-457]

Such interventions comprised a dedicated nurse who performs medication and diet counselling, management of gout flare and adverse effects with doctor-approved refill and dose escalation of ULT. However, some institutions in Singapore may not have specialist nurse services available immediately.

“To our knowledge, our study is the first in Singapore to demonstrate that pharmacists can potentially be trained up to provide similar monitoring and rapid titration programs for gout,” the researchers said. “Pharmacists are ideal for this venture given their training and experience with medications.”