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Need for Better Management of Gout
San Diego—Gout is the most common inflammatory arthritis in the United States, affecting at least 8 million people. Over the past 20 years, there has been a marked increase in prevalence and complexity of, as well as increasing incidence of, treatment-refractory disease and hyperuricemia.
Gout is a very common disease that a lot of members are dealing with, according to Jeffrey D. Dunn, PharmD, senior vice president, VRx Pharmacy, Salt Lake City, UT, speaking at the AMCP meeting during a satellite symposium on leveraging gout treatment. The event was sponsored by AstraZeneca Pharmaceuticals.
The need to better manage gout is highlighted by data showing the high incidence of comorbidities in people with gout and hyperuricemia, as well as the high cost of inadequately treating gout. Dr. Dunn cited data showing that 55% of costs of gout are due to direct gout-related medical costs with the remainder of costs for managing comorbidities.
While Dr. Dunn said that some gout comorbidities (ie, obesity, diabetes, renal insufficiency) contribute to the devel- opment of hyperuricemia, increasing evidence also suggests that hyperuricemia and/or gout may contribute to several associated comorbidities such as renal insufficiency, hypertension, and myocardial infarction and death.
“Given the common nature of gout in our population,” he said, “we should be more aware of this.”
Impact of Poorly Managed Gout
Highlighting that gout is an inflammatory arthropathy that can cause chronic pain and joint destruction, Robert T. Keenan, MD, assistant professor of medicine, director of the gout and crystal arthopathy clinic, division of rheumatology, Duke University School of Medicine, Durham, NC, provided a summary of current and emerging therapies to treat gout.
“One size fits all management is not adequate,” he said. “Treatment must involve individualized communication, education, and medical management.” Optimal pharmacologic management of gout includes adequate treatment of acute flairs to control pain (ie, nonsteroi- dal anti-inflammatory drugs [NSAIDs], colchicine, glucocorticoids, interleukin (IL)-1 inhibitors), anti-inflammatory prophylaxis (ie, colchicine, NSAIDs, IL-1 inhibitors), as well as treatments to reduce urate burden (ie, allopurinol, febuxostat, probenecid, pegloticase). “We want to treat acute flares and prevent these flares down the road,” Dr. Keenan emphasized.
Currently the American College of Rheumatology (ACR) guidelines recommend the use of xanthine oxidase inhibitors such as allopurinol or febuxostat as first-line therapies to reduce serum urate level (sUA), with the dosage titrated to below sUA target. The ACR also recommends considering combination therapy in patients in whom target sUA is not achieved, as well as screening patients for risk of severe allopurinol sensitivity in patients of select Asian descents.
Dr. Keenan emphasized, however, that management is currently less than optimal with lots of obstacles and short-falls to conquer. “We do not do a great job on managing these patients,” he said, adding, “>10% of patients have a definitive diagnosis and 40% to 80% of patients are not treated to goal.”
Other problems include the many patients who do not have uric acid checked (60%), who experience interruptions in allopurinol dosing (50%), who fail to get prophylaxis when starting urate lowering therapy, and who are still on NSAIDs 2 years after starting allopurinol (80%). In addition, 25% of physicians are noncompliant in adjusting initial allopurinol dose for renal function.
According to Dr. Dunn, other reasons why gout management is generally poor is because of patient noncompli- ance, poor physician understanding of therapeutic objectives, poor communication between physician and patient, complexity of therapy because of comorbidities, intolerance to ULT, and failure of ULT.
Implications for Managed Care
Managed care is in a unique position to improve outcomes for patients with gout through medication therapy management (MTM) programs and care management, coordination with other stakeholders, and through reporting and analytics, according to Dr. Dunn.
Pointing out the management of gout requires a multifaceted approach based on benefit design and drug management (including contracting activities, drug dispensing, utilization management, and coordination of care), he emphasized the important role of MTM services and how to identify patients who will most benefit from MTM. These include identifying patients who have not reached or are not maintaining their intended treatment goal, those who experience medication- related adverse effects, those who do not understand or follow their medication regimen, those who need prophylaxis therapy, and those frequently readmitted to the hospital.
Dr. Dunn emphasized that to improve medication adherence, it is critical that patients be a part of treatment plans. Strategies for improving medication adherence include empowering patients to take part in treatment plans (eg, address issues such as patient’s perception of benefits and consequences, environmental and cultural influences, and state of readiness to change), as well as patient education that addresses barriers to treatment adherence such as financial issues, cognitive issues, and adverse effects of medications. To ensure the effectiveness of strategies for improving medication adherence, Dr. Dunn emphasized the importance of recording and reporting of pharmacy data to first document a baseline of compliance from which changes in compliance can be tracked over time. He also emphasized the importance of tracking both drug and total medical costs, and said that although an increase in drug costs can be expected with a successful program for improving compliance, this should be accompanied by a reduction in total medical costs as outcomes improve.
Finally, Dr. Dunn talked about the importance of integrated programs across the care continuum to improve outcomes. In such programs, pharmacists collaborate with nurse case managers, mental health specialists, and providers in a team approach to care. This simplifies care for patients, he said, and coordinates care back to the clinic providers.—Mary Beth Nierengarten
