Study suggests a clinician-supported phone app could help keep this notoriously non-adherent patient group on track.
Gout is relatively easy to treat, but with notoriously low medication adherence, treating physicians face an uphill battle getting patients to control serum urate levels.
Researchers in Edinburgh have developed a mobile phone app to help gout patients self-manage their condition, in conjunction with a serum urate test kit and health professional input. The results of a randomised controlled feasibility study were published in Lancet Rheumatology.
Led by Dr Philip Riches, consultant rheumatologist at the University of Edinburgh Centre for Genomic and Experimental Medicine, a total of 60 patients were included in the study, with 40 in the intervention arm and 20 in the usual care control group.
Participants were required to have a urate level over 0.36 mmol/L in order to identify patients in greater need of therapy escalation. The primary outcome was the percentage of participants achieving a target urate of 0.30 mmol/L or less at 24 weeks, with 0.30mmol/L being the level recommended by the British Society for Rheumatology.
Patients in the intervention arm were provided with the GoutSMART app and a urate self-testing meter, and after entering data were given direct advice from clinicians on medication escalation. Urate levels were tested and entered every two weeks for patients above the target 0.30 mmol/L level, while patients with urate at target and with no recent flares tested monthly. The patients’ GPs were kept informed of dosage adjustments.
Control group patients receiving usual care had a limited version of the app, which functioned only as a health diary to record flares and quality of life measures. Their gout management plan was implemented by their GP.
At the end of 24 weeks, 73% of the intervention group achieved the 0.30 mmol/L urate target, compared with 15% of the control group.
Target urate at 52 weeks, a secondary outcome, was achieved by 80% of intervention participants, compared with 45% of the control group. Flares were also reduced in the intervention group compared to those receiving usual care, although there was no significant difference in rates of tophaceous disease. The dropout rate over one year was 10% in both groups.
While app support for gout patients is not new, the study authors pointed out that existing apps provide only limited clinician support. This study’s approach differed in that the study team actively monitored the serum urate results and provided instant advice on escalating urate-lowering therapy where appropriate.
“I believe the human input/interaction is important,” Dr Riches told Rheumatology Republic.
“Using self-testing meters does improve patient understanding about how medicines work, but I still received regular messages asking why patients were still suffering flares even when their urate levels were good. So the opportunity to console and reassure patients that things will get better must surely improve adherence,” said Dr Riches.
“Supporting patients to manage their own gout can transform clinical outcomes, and the approach we have developed offers a way of doing this without putting more pressure on an already stretched healthcare service.”
In an accompanying editorial, Professor Lisa Stamp and Associate Professor Angelo Gaffo highlighted limitations of the study, including the younger average age of participants relative to the general gout patient cohort. People with advanced chronic kidney disease were excluded, which “although understandable at this stage of development for this treatment concept … results in the exclusion of 20–24% of individuals with gout who can be difficult to treat and could potentially benefit from this intervention.”
In pointing out that 20% of the intervention group did not achieve target, Stamp and Gaffo wrote “a key challenge in managing gout is to determine which treatment strategy will be best suited to an individual with gout and to identify those for whom more support might be required”.
The study authors suggested larger trials were needed to evaluate the clinical and cost-effectiveness of the approach, while Professor Stamp and Associate Professor Gaffo recommended including a more representative group of patients, including those with significant comorbidities, in future trials.
