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PEER REVIEW: GOUT
Closing the Gap: Improving Pharmacist Knowledge of Gout Management Written by Dr. Emma Dorris (Scientist, UCD), Mariosa Kieran (Pharmacist, Mater Misericordiae University Hospital), Professor Nicola Dalbeth (Consultant Rheumatologist, University of Auckland) and Professor Geraldine McCarthy (Consultant Rheumatologist, Mater Misericordiae University Hospital/UCD) MSU crystals. The goal of urate lowering therapy is to reduce serum urate to a therapeutic target level, thereby permitting MSU crystals to dissolve, in addition to preventing further crystal formation and deposition.
Dr. Emma Dorris (Scientist, UCD)
Professor Geraldine McCarthy (Consultant Rheumatologist, Mater Misericordiae University Hospital/UCD)
Mariosa Kieran (Pharmacist, Mater Misericordiae University Hospital)
Professor Nicola Dalbeth (Consultant Rheumatologist, University of Auckland)
Gout is the most common form of inflammatory arthritis in adults. The incidence of gout is rising. People with gout have an increased risk of cardiovascular disease, and gout is associated with a number of comorbidities including diabetes and renal impairment. The increased incidence of gout together with increased cardiovascular risk and comorbidities is a significant public health challenge.
Unlike other common rheumatic diseases, the underlying cause of gout is well understood. Gout is caused by hyperuricaemia, too much uric acid in the body. This can occur due an underexcretion and/or overproduction of urate, which leads to monosodium urate (MSU) crystal formation and deposition in joints and tissues in susceptible individuals (figure 1). Acute gout flares occur as an inflammatory response to the
AUGUST 2022 • HPN | HOSPITALPROFESSIONALNEWS.IE
An important issue in urate lowering therapy is that paradoxically, initiation of urate lowering therapy can actually induce a gout attack. This happens because the urate lowering therapy causes MSU crystals to be shed from the articular cartilage into the joint space, resulting in acute inflammation. To prevent this, a low dose of anti-inflammatory prophylaxis, such as colchicine, is recommended for at least the first three to six months following initiation of urate lowering therapy. Community pharmacists are the most easily accessible members of a patient’s health care team. Pharmacists are often a key source of information on disease management and patients have confidence in them. Pharmacists act as a critical resource for effective management of disease, particularly when chronic such as gout. Thus, open communication and education between the pharmacy and prescriber communities is essential to provide the most up-to-date and appropriate patient care. However, pharmacists frequently report a lack of patient treatment plan information and clinical connection to other healthcare professionals as barriers to providing optimal care to patients. The use of low dose colchicine as a prophylaxis is an example of this gap in knowledge translation. Colchicine use in gout is most commonly used in the treatment of acute gout flares in a strictly time limited fashion. Legacy prescribing, whereby short or intermediate-term medications are
not appropriately discontinued, is prevalent. Patients, and indeed pharmacists, can be unsure whether the prescribed colchicine is intended as a prophylaxis or is a legacy prescription that was previously prescribed in case of flare. This confusion can be magnified by lack of clear, definitive statements on updated best practices from national bodies and the time lag in incorporating professional body recommendations into readily accessible drug information sources, e.g. the product Summary of Product Characteristics, the British National Formulary. Pharmacists have reported that the advice on use of colchicine as a prophylaxis in their typical reference manuals is poorly defined in comparison to its use for acute flares. This can lead to conflicting advice being given to patients from their pharmacists and rheumatologists about gout management, particularly in relation to colchicine use. This prompted research into the pharmacist knowledge of gout management, leading to the development of an educational intervention for pharmacists. Our research showed that pharmacist-knowledge of gout management in Ireland was not in line with current European (EULAR) gout management guidelines. However, we also demonstrated that pharmacists do not typically use disease management guidelines as standard sources of information. As such, there is a knowledge gap in the most up to date recommendations for gout management. Given the wide number of conditions encountered on a daily basis in community pharmacy, this is somewhat understandable. As such, a dedicated effort must be made by prescribers and professional societies to communicate treatment standards to pharmacists.
