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Nurse-led care ‘significantly more successful than GPs in treating gout’, finds trial

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Nurse-led care with a more patient-centred approach appears to be more effective than GP-led care for successfully treating gout, according to UK researchers.

They found providing nurse-led care for patients with the painful, long-term condition gout could lead to an increase in the number of patients sticking to a beneficial treatment plan.

“Once fully informed almost all patients want urate-lowering treatment and continue to take it regularly”

Michael Doherty

A study, by the University of Nottingham and the University of Sheffield, indicated that keeping patients fully informed and involving them in care decisions was more successful in managing gout.

The study findings, published in The Lancet, also highlighted the importance of individualised patient education and engagement to treat the condition.

Gout, the most common type of inflammatory arthritis, affects around 2.5% of adults in the UK, with attacks usually treated with anti-inflammatories like ibuprofen.

The researchers highlighted that gout was the only form of arthritis that can be “cured” in effect through the use of urate-lowering therapies (ULT).

The ULT dose needs to be adjusted against the blood urate level until a target low level is achieved, which then prevents new sodium urate crystals from forming and slowly dissolves existing ones.

Patients can also make lifestyle changes, such as losing weight, which can help to bring down urate levels and have other general health benefits, noted the study authors.

“The patient-centred approach led by nurses in this study offers a convincing alternative”

Stephen Simpson

However, they said only 40% of gout patients currently ever received ULT, usually at a fixed dose rather than gradually increasing the dose until a target level of urate was reached in the blood. In addition, getting patients to stick to their medication was tricky, they added.

The Nottingham researchers subsequently carried out a two-year trial in the community to directly compare nurse-led care to the usual GP-led care.

More than 500 gout patients were recruited and randomly split between the two methods of management through more than 50 general practices in the East Midlands.

They were followed up at one and two years and assessed for a series of outcomes including the level of urate in their blood, the frequency of gout flare ups and the presence of tophi – firm, white lumps below the surface of the skin caused by a mass of urate crystals.

The research nurses had received training about gout and its management, which reflected current recommendations, and delivered an individualised package of care.

This included a holistic assessment, a discussion of perceptions about the illness, full information about gout, for example its causes, consequences and treatment options, and patient involvement.

The study found that nurse-led care was associated with a much higher take up of ULT, with patients subsequently being more likely to stick to their treatment.

At two years, 96% of the nurse-led group were on ULT, compared to 56% in the usual care group. In addition, 95% of patients had urate levels in the blood below the required target level, compared to just 30% in the GP-led group.

It was also revealed that around 400-500mg of allopurinol per day was the dose needed to achieve the right blood level of urate – more than the top dose of 300mg per day prescribed by most GPs.

The nurse-led care significantly reduced flare-up frequency, reduced tophi and improved quality of life and was more cost effective too, saving the NHS money after five years.

Lead study author Professor Michael Doherty said: “The nurses delivered recommended best practice that includes full patient information and engagement and a treat-to-target strategy for urate-lowering treatment.

“Once fully informed almost all patients want urate-lowering treatment and continue to take it regularly,” he said. “This results in gradual elimination of the urate crystals that cause gout and subsequent clinical improvements.”

He added: “Although nurses delivered this care, the principles of patient education, treat-to-target urate-lowering strategy, and regular follow-up and monitoring are applicable to any health professional who treats people with gout.

The study received funding from the charities Versus Arthritis and Arthritis Research UK.

Stephen Simpson, director of research at Versus Arthritis, said: “We know that many patients fail to receive any clear explanation of the condition or lifestyle advice to prevent recurring attacks, with few even receiving the appropriate drug treatment.

“Currently, constraints on GP’s time mean patients are not fully aware of the benefits that come with taking their treatments,” he said.

“The patient-centred approach led by nurses in this study offers a convincing alternative that will not only help to alleviate problems in the long term but will also improve that person’s quality of life,2 he added.

The Nottingham team, which led the study, said they now planned to examine the feasibility of training practice nurses to see if this results in equally good results.

It is also hoped that the principles used in the study will be incorporated into guidelines on gout management that are being developed by the National Institute for Health and Care Excellence.

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