Clinical Research StudyAdherence and Outcomes with Urate-Lowering Therapy: A Site-Randomized Trial
Section snippets
Study Design, Setting, Randomization, and Participants
RAmP-UP was a large pragmatic site-randomized study that enrolled patients from May 2014 to July 2015. The study involved 116 clinics within Kaiser Permanente Southern California,20 an integrated healthcare system with approximately 4 million members.21 The study was approved by institutional review boards at Kaiser Permanente Southern California and at the University of Alabama at Birmingham. A waiver of informed consent was granted. To minimize contamination, 24 close-proximity clinics were
Results
There were 1551 eligible patients initiating allopurinol with ICD-9 codes for gout (Figure 1): 782 (50.4%) received usual care at 50 clinics, and 769 (49.6%) received care at 51 intervention sites. There were 88 patients not offered an automated call following the second level of randomization, leaving 681 patients in the intervention for analysis (372 [55%] completers, responding to at least 1 automated survey). There were no significant differences in characteristics between the remaining 681
Discussion
Described as potentially “curative,”25, 26 lowering urate is a key tenet of effective gout management. Despite the availability of efficacious and well-tolerated agents, gout management and related outcomes remain suboptimal. This deficiency has been attributed not only to poor patient adherence but also to inadequate prescribing practices.27 Although subspecialty management guidelines support gradual dose titration of urate-lowering agents to achieve a target urate goal,14, 28 this approach is
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Cited by (49)
Achievement of serum uric acid target by rheumatology clinic pharmacists compared with primary care providers in patients with gout
2023, Journal of the American Pharmacists AssociationCitation Excerpt :More recently, the 2020 ACR Guideline for the Management of Gout cites 3 randomized controlled trials published from 2016 to 2019 that compared nurse- or pharmacist-led treat-to-target gout management and usual care.1 The treat-to-target management strategy assessed by these studies, ranging in follow-up duration from 26 weeks to 2 years, was associated with higher rates of achieving target sUA less than 6 mg/dL, improved ULT adherence, decreased incidence of gout flares and tophi, and improved quality of life.8-10 Although more likely to achieve target sUA less than 6 md/dL, patients with gout managed by a rheumatology clinic pharmacist experienced a numerically but not statistically significant increased number of presumed gout flares as compared with patients managed by a PCP.
Palpable tophi and more comorbidities associated with adherence to urate-lowering medical therapy in a Chinese gout cohort
2022, Joint Bone SpineCitation Excerpt :Understanding the consequences of low adherence may motivate the discovery and implementation of strategies to increase the appropriate use of ULT. Past studies using medication possession ratio (MPR), proportion of days adherent, or Compliance Questionnaire on Rheumatology to represent gout adherence, have been limited to only one-year maximum follow-up [10–12]. Thus, our objective was to evaluate the impact of adherence to ULT on subsequent one and two-year gout-related outcomes.
Management of gout following 2016/2017 European (EULAR) and British (BSR) guidelines: An interrupted time-series analysis in the United Kingdom
2022, The Lancet Regional Health - EuropeCitation Excerpt :Financial incentives to encourage ULT prescription and target attainment could be explored, as has been done for other conditions (e.g. the Quality and Outcomes Framework in the UK). New models of care for people with gout may be needed: for example, engaging allied health professionals (e.g. nurses and pharmacists) from primary care or community pharmacies in ULT titration and monitoring, which has been shown to be effective.5,17,18 Point-of-care urate meters are also widely available, providing reliable estimates of urate levels to facilitate remote monitoring,19,20 while empowering patients to be in control of their condition.
New advances in crystal arthritis
2021, Best Practice and Research: Clinical RheumatologyTreatment advances in gout
2021, Best Practice and Research: Clinical RheumatologyCitation Excerpt :A recent site-randomized trial which included 1463 people with gout commencing allopurinol compared pharmacy-led care via automated telephone technology to usual care. At one year, participants who received pharmacy-led care were more adherent to allopurinol (50% vs. 37%, ORunadj 1.68; 95%CI = 1.30, 2.17; p < 0.001) and more likely to achieve a urate <0.36 mmol/L (30% vs. 15%, ORunadj = 2.37; 95%CI = 1.83, 3.05; p < 0.001) compared with those in the usual care arm [51]. However, impact of the pharmacy-led intervention was limited as 63.4% of participants never had an increase in allopurinol dose, 70% failed to achieve serum urate <0.36 mmol/L and only half were adherent with allopurinol therapy.
Gout
2021, The Lancet
Funding: This work is funded by the National Institutes of Health (NIH) / National Institute of Arthritis and Musculoskeletal and Skin Diseases (P50AR060772). TRM receives research support from NIH/National Institute of General Medical Sciences (U54GM115458) and the National Institute on Alcohol Abuse and Alcoholism (R25AA020818).
Conflicts of Interest: The authors have no conflicts of interest to declare.
Authorship: All authors confirm equal access to data and a role in writing the manuscript.
Trial Registration: NCT 02790463 https://www.ClinicalTrials.gov