Treat-to-target Strategy in Gout Management is Effective

Gout is the most common form of inflammatory arthritis, caused by crystallization of uric acid in the joint. Rheumatologists have long recommended that patients with gout be treated with drugs to lower uric acid in their blood to prevent crystallization. Specifically, rheumatology societies around the world recommend that uric acid should be lowered to below 6mg/dL because that’s below the concentration at which uric acid can crystalize. This strategy is known as “treat-to-target.”

Recently, controversy about this recommendation was raised because the American College of Physicians’ guidelines stated that there were insufficient data to support a treat-to-target strategy, and that a strategy of treating to avoid symptoms may be reasonable.

In a randomized controlled trial published in the Lancet, nurse-led care that included education and engagement of patients as well as a treat-to-target strategy to lower uric acid was compared with usual care by general practitioners (GP). In this trial, the nurse-led care group had more than a three-fold higher achievement of lowering uric acid to below 6mg/dL, had 67 percent lower risk of gout flares and 79 percent lower risk of having any tophi at the end of follow-up at two years compared with usual care. Further, the nurse-led care strategy was projected to be cost saving by five years.

An accompanying Lancet comment led by Tuhina Neogi, MD, PhD, professor of medicine and epidemiology at Boston University Schools of Medicine and Public Health, noted that this trial adds to a growing body of evidence that the treat-to-target strategy in gout management is effective and there is now ample data from randomized trials to support this treatment approach.

“The high adherence, combined with use of higher doses of allopurinol in the nurse-led group contributed to the marked beneficial effects experienced in the nurse-led group. The findings highlight that patients can adhere to treatment when they receive the appropriate information about their disease, adequate support by their healthcare provider with regular follow-up and feedback,” said Dr. Neogi.

According to the authors, this trial provides definitive evidence that a treat-to-target strategy in gout results in better patient outcomes than the usual care provided by GPs.  “While GPs may not have the capacity to see their patients with gout more frequently, other health care professionals can be trained to implement this approach as has been done in other diseases,” she explained. “Highly efficacious and cost-effective gout management can be readily achieved by educating and spending time with patients. Patients with gout can get their disease under control using a treat-to-target approach. This should now be the standard of care for gout management.”

Nicola Dalbeth, MBChB, MD, FRACP, from the Department of Medicine, University of Auckland, Auckland, New Zealand, also contributed to this editorial.

Disclaimer:

TN is involved in a clinical trial of febuxostat compared with allopurinol in gout as a steering committee member funded by a grant from the US Department of Veterans Affairs (VA CSP-594) and the National Institutes of Health.

ND has received grants from Amgen, grants and personal fees from AstraZeneca, and personal fees from AbbVie, Horizon, Takeda, Kowa, Janssen, and Pfizer. ND is supported by the Health Research Council of New Zealand (15/576). In the past 5 years, she has been principal investigator on a clinical trial of febuxostat in early gout (funded by Takeda) and a clinical trial of lesinurad and febuxostat (funded by AstraZeneca) and co-investigator on a clinical trial of allopurinol dose escalation (funded by the Health Research Council of New Zealand).