medwireNews: Supported self-management improves attainment of urate targets in people with gout, research suggests.
This feasibility study looked at the potential benefit of urate self-testing via the GoutSMART smartphone app alongside direct advice from clinicians on the escalation or lowering of urate therapy in a treat-to-target approach.
“[F]eedback suggests that the self-monitoring approach was accepted by most and was enthusiastically endorsed by many,” report Philip Riches (Western General Hospital, Edinburgh, UK) and colleagues in The Lancet Rheumatology.
The study included 60 patients with gout who had a serum urate level of 0.36 mmol/L or higher and had a physician recommendation to initiate or escalate urate-lowering therapy. Before being randomly assigned to a self-monitoring or usual care group, the participants were offered a gout management plan. This included advice to start allopurinol at a dose of 100 mg once a day or to increase their current dose by 100 mg, with further titration recommended until the urate target of 0.30 mmol/L was reached.
Forty patients were randomly assigned to the self-monitoring group and were taught to self-test their serum urate levels every 2 weeks if their levels were above target and monthly intervals if they were on target and prompted to maintain a diary of their levels in the GoutSMART app. Self-reported urate levels were monitored by the study team who advised escalation of allopurinol by 100 mg/day if levels were above target and a switch to febuxostat once the maximum allopurinol dose had been reached.
The remaining 20 patients received usual care, which involved a limited version of the same app. Patients were prompted to record gout flares and keep quality-of-life diaries. If patients requested treatment advice, they were referred back to their general practitioner.
At 24 weeks, a significantly higher proportion of patients in the self-monitoring group achieved the urate target of 0.30 mmol/L or less compared with those in the usual care group, at 73% versus 15%. This translated to a significant risk difference of 0.58 in favor of self-monitoring.
The authors note that there were also fewer flares within the first 24 weeks of the trial among those in the self-monitoring group than the usual care group, at a mean 2.03 versus 3.00 flares per person in the respective groups. This was a nonsignificant difference.
By week 52, however, the difference in the incidence of flares was significant, at a mean of 0.81 flares per person in the self-management group and 2.06 in the usual care group.
The researchers were “surprised to find a reduction in flare frequency,” and say that it “could be a chance finding influenced by participants in the usual care group with high flare rates.”
They add: “The difference in flare frequency does not appear to be explained by differential use of regular colchicine,” which at 24 weeks was taken by 27% and 32% of participants who underwent self-monitoring and usual care, respectively.
Riches et al conclude: “Future studies are needed to establish the cost-effectiveness of such models, and to evaluate clinical outcomes stratified by the urate levels reached.”
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Lancet Rheumatol 2022; doi:10.1016/S2665-9913(22)00062-5