Implementing treat-to-target urate-lowering therapy during hospitalisations for gout flares

Mark D Russell; Louise Ameyaw-Kyeremeh; Flora Dell'Accio; Heather Lapham; Natalie Head; Christopher Stovin; Vishit Patel; Benjamin D Clarke; Deepak Nagra; Edward Alveyn; Maryam A Adas; Katie Bechman; María A de la Puente; Benjamin Ellis; Corrine Byrne; Rina Patel; Andrew I Rutherford; Fleur Cantle; Sam Norton; Edward Roddy; Joanna Hudson; Andrew P Cope; James B Galloway

doi:10.1093/rheumatology/kead574

Implementing treat-to-target urate-lowering therapy during hospitalisations for gout flares

Rheumatology (Oxford). 2023 Oct 31:kead574. doi: 10.1093/rheumatology/kead574. Online ahead of print.

Authors

Mark D Russell¹, Louise Ameyaw-Kyeremeh², Flora Dell'Accio¹, Heather Lapham², Natalie Head², Christopher Stovin¹, Vishit Patel², Benjamin D Clarke³, Deepak Nagra¹, Edward Alveyn¹, Maryam A Adas¹, Katie Bechman¹, María A de la Puente⁴, Benjamin Ellis⁵, Corrine Byrne⁶, Rina Patel⁶, Andrew I Rutherford², Fleur Cantle⁷, Sam Norton¹, Edward Roddy⁸, Joanna Hudson⁹, Andrew P Cope¹, James B Galloway¹

Affiliations

¹ Centre for Rheumatic Diseases, King's College London, London, United Kingdom.
² Department of Rheumatology, King's College Hospital NHS Foundation Trust, London, United Kingdom.
³ Benjamin Clarke, Department of Rheumatology, King's College Hospital NHS Foundation Trust, London, United Kingdom.
⁴ Department of Psychology, Health Psychology Section, Institute of Psychiatry, Psychology, & Neuroscience, King's College London, London, United Kingdom.
⁵ Department of Rheumatology, Imperial College Healthcare NHS Foundation Trust, London, United Kingdom.
⁶ Pharmacy Department, King's College Hospital NHS Foundation Trust, London, United Kingdom.
⁷ Department of Emergency Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom.
⁸ School of Medicine, Keele University, Keele, United Kingdom.
⁹ Department of Psychology, Health Psychology Section, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom.

PMID: 37929968
DOI: 10.1093/rheumatology/kead574

Abstract

Objectives: To evaluate a strategy designed to optimise care and increase uptake of urate-lowering therapy (ULT) during hospitalisations for gout flares.

Methods: We conducted a prospective cohort study to evaluate a strategy that combined optimal in-hospital gout management with a nurse-led, follow-up appointment, followed by handover to primary care. Outcomes, including ULT initiation, urate target attainment, and re-hospitalisation rates, were compared between patients hospitalised for flares in the 12 months post-implementation and a retrospective cohort of hospitalised patients from 12 months pre-implementation.

Results: 119 and 108 patients, respectively, were hospitalised for gout flares in the 12 months pre- and post-implementation. For patients with 6-month follow-up data available (n = 94 and n = 97, respectively), the proportion newly initiated on ULT increased from 49.2% pre-implementation to 92.3% post-implementation (age/sex-adjusted odds ratio (aOR) 11.5; 95% confidence interval (CI) 4.36-30.5; p < 0.001). After implementation, more patients achieved a serum urate ≤360 micromol/L within 6 months of discharge (10.6% pre-implementation vs. 26.8% post-implementation; aOR 3.04; 95% CI 1.36-6.78; p = 0.007). The proportion of patients re-hospitalised for flares was 14.9% pre-implementation vs. 9.3% post-implementation (aOR 0.53, 95% CI 0.22 to 1.32; p = 0.18).

Conclusion: Over 90% of patients were initiated on ULT after implementing a strategy to optimise hospital gout care. Despite increased initiation of ULT during flares, recurrent hospitalisations were not more frequent following implementation. Significant relative improvements in urate target attainment were observed post-implementation; however, for the majority of hospitalised gout patients to achieve urate targets, closer primary-secondary care integration is still needed.

Keywords: Gout; admissions; allopurinol; crystal arthritis; hospital; urate-lowering therapy.