Background/Purpose: Gout is the most common form of inflammatory arthritis.¹ The cornerstone of treatment for gout is urate-lowering therapy (ULT), which in the U.S. includes the xanthine oxidase inhibitors (XOI) allopurinol or febuxostat. Studies have shown poor adherence to quality indicators in gout, such as monitoring serum uric acid (SUA) and achieving goal SUA. ^1,2

A clinical pharmacist has been a part of the Froedtert & the Medical College of Wisconsin (F&MCW) Rheumatology Clinic since January 2012. A collaborative practice agreement (CPA) for gout management by the pharmacist, reviewed by the rheumatology providers, has been in place since 12/19/14. Under this CPA, providers have had the opportunity to refer patients with gout to the pharmacist. Providers include referral information, such as preferred medications or how to manage flares, or can defer these decisions to the pharmacist. The CPA, updated yearly, guides therapy in relation to ULT including SUA checks every 3 weeks, flare prophylactic therapy, and treatment of acute flares.

The aim of this study is to measure quality of care in subjects with gout co-managed by rheumatology provider(s) and a pharmacist at the F&MCW Rheumatology Clinic.

Methods: This study is a retrospective analysis assessing patients newly starting ULT between January 1, 2015 and November 30, 2017, and followed 6 months after referral. Adults diagnosed with gout by microscopic evaluation or provider clinical assessment were included. Patients were excluded if any non-XOI ULT was used, SUA was <6mg/dL at the time of ULT initiation, or the patient had an active cancer diagnosis.

Results: Thirty patients were included in the study. At baseline, mean age was 64 years, mean SUA was 9.4mg/dL, and 80% were crystal-proven. At the time of referral, 26 patients were started on allopurinol at a mean dose of 152mg/day, and 4 patients were started on febuxostat at a mean dose of 60mg/day. Twenty-two patients (73%) achieved SUA <6mg/dL during management (primary outcome), 4 patients were non-responsive to outreaches, and 4 patients are still being managed. On average, patients reached goal SUA <6mg/dL at 10 weeks, and SUA decreased by 61% to 5.7mg/dL. The mean ULT doses at the end of the study period were allopurinol 296mg/day and febuxostat 80mg/day. The percentage of patients that were prescribed flare prophylaxis was 100%. During management, the pharmacist had 154 encounters with patients, compared to 51 with providers.

Conclusion: Seventy-three percent of patients co-managed by rheumatology providers and a pharmacist were able to achieve SUA <6mg/dL, occurring at a mean of 10 weeks, and 100% were prescribed flare prophylaxis. Team-based gout management including a pharmacist may provide a method of achieving goals of therapy while reducing time required of providers.

References:

1. Hughes JC, Wallace JL, Bryant CL, Salvig BE, Fourakre TN, Stone WJ. Monitoring of urate-lowering therapy among US veterans following the 2012 American College of Rheumatology guidelines for management of gout. Ann Pharmacother 2017;51(4):301-306.
2. Singh JA, Hodges JS, Asch SM. Opportunities for improving medication use and monitoring in gout. Ann Rheum Dis 2009;68:1265-1270.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/quality-of-gout-management-in-a-rheumatology-clinic-using-a-provider-pharmacist-team-based-approach/