Education and non-pharmacological approaches for gout

Education and non-pharmacological approaches for gout Abstract The objectives of this review are as follows: to highlight the gaps in patient and physician knowledge of gout and how this might impede optimal disease management; to provide recommended core knowledge points that should be conveyed to people with gout; and to review non-pharmacological interventions that can be used in gout management. MeSH terms were used to identify eligible studies examining patients’ and health-care professionals’ knowledge about gout and its management. A narrative review of non-pharmacological management of gout is provided. Many health-care professionals have significant gaps in their knowledge about gout that have the potential to impede optimal management. Likewise, people with gout and the general population lack knowledge about causes, consequences and treatment of this condition. Full explanation about gout, including the potential benefits of urate-lowering treatment (ULT), motivates people with gout to want to start such treatment, and there is evidence, albeit limited, that educational interventions can improve uptake and adherence to ULT. Additionally, several non-pharmacological approaches, such as rest and topical ice application for acute attacks, avoidance of risk factors that can trigger acute attacks, and dietary interventions that may reduce gout attack frequency (e.g. cherry or cherry juice extract, skimmed milk powder or omega-3 fatty acid intake) or lower serum uric acid (e.g. vitamin C), can be used as adjuncts to ULT. There is a pressing need to educate health-care professionals, people with gout and society at large to remove the negative stereotypes associated with gout, which serve as barriers to optimal gout management, and to perceive gout as a significant medical condition. Moreover, there is a paucity of high-quality trial evidence on whether certain simple individual dietary and lifestyle factors can reduce the risk of recurrent gout attacks, and further studies are required in this field. gout, treatment, non-pharmacological, diet, lifestyle Rheumatology key messages Misconceptions about gout are prevalent among both patients and doctors. Patient and provider education can improve the management of gout. Other non-pharmacological approaches should be used as adjuncts to urate-lowering treatment in gout. Background Gout is the commonest inflammatory arthritis and the only chronic arthritis that has the potential of being cured with safe, simple and inexpensive pharmacological treatment, provided it is taken at correct doses and in the long term. However, this treatable condition remains untreated or poorly managed in the majority of people with gout, including those who consult their general practitioner (GP) for gout and fulfil recommended national criteria for receiving long-term urate-lowering treatment (ULT) [1–3]. Likewise, once initiated on ULT, adherence and persistence on these drugs is often poor, with the adherence to ULT being among the lowest medication adherence when compared with other chronic illnesses [1, 4–7]. For example, in one community-based study half of all men and women who commenced ULT discontinued treatment by 358 and 379 days, respectively, whereas in another study the 12-month persistence on ULT was even lower, at 22.6% [5, 8]. There are many barriers to care of gout [3], but an important reason for low uptake and poor adherence and persistence with ULT appears to be significant gaps in knowledge about gout and its treatment in people with this condition, both in the general public and in health-care professionals [9–12]. However, when people with gout receive full individualized education about gout, tailored to their own information needs and understanding, 100% want to receive ULT, and persistence is excellent (92%) at 1 year and remains high (91%) at 5 years, with 85% reporting taking ULT on at least 6 days/week 5 years after receiving such education [13, 14]. These findings suggest that optimal individualized education significantly improves gout care in the long term. However, the decision to seek medical help and to offer treatment is influenced by personal and professional knowledge, respectively, and the existing societal attitude to the illness concerned (Fig. 1). Several studies have examined knowledge about gout among patients and physicians and how this influences their decision to initiate and continue on long-term ULT [9–13, 15–32]. In this narrative review, we describe the findings of these studies and highlight common important gaps in patient and physician knowledge of gout and how it might impede optimal management. Based on our experience of treating community-derived people with gout in two studies, we recommend core knowledge points that should be conveyed to the general public, people with gout and the doctors who treat this condition. Finally, we also review non-pharmacological techniques that can be used in the management of gout. Fig. 1 View largeDownload slide Factors affecting care of gout Patients’ perception about their illness, professional knowledge and perception and societal perceptions of gout all act as important determinants of the decision to seek treatment. Fig. 1 View largeDownload slide Factors affecting care of gout Patients’ perception about their illness, professional knowledge and perception and societal perceptions of gout all act as important determinants of the decision to seek treatment. Methods In order to identify studies examining knowledge of gout and its treatment among people with this condition and those who treat it, we searched PubMed from inception to 28 March 2017 using the following terms: ((gout[MeSH Terms] OR gout[All Fields]) AND (education[Subheading] OR education[All Fields] OR educational status[MeSH Terms] OR (educational[All Fields] AND status[All Fields]) OR educational status[All Fields] OR education[All Fields] OR education[MeSH Terms]) AND humans[MeSH Terms]); OR ((gout[MeSH Terms] OR gout[All Fields]) AND barriers[All Fields]) AND humans[MeSH Terms]. We retrieved 290 studies. There were 23 studies examining the current state of understanding of gout among health-care professionals, including rheumatologists, other hospital physicians, primary care providers, practice nurses and GPs [9–12, 15–21], and people with gout [9, 11–13, 20, 22–32], with or without a discussion of its effects on prescription of ULT. We did not perform a systematic search to identify the studies on non-pharmacological management of gout, and provide a narrative review. What do health-care professionals know about gout? As a result of its high prevalence, gout is most frequently treated by GPs, with only cases that are difficult to manage being referred to secondary care. A postal survey of >400 GPs in Yorkshire, UK in 2002 suggested that only 6% would refer a gout patient to secondary care hospitals [21]. Most GPs felt able to diagnose gout accurately and reported confidence in managing it either independently or with occasional input from other GP colleagues [15, 21]. However, despite this high self-rated confidence in managing gout, many primary care physicians have significant gaps in their knowledge of gout, such as not being aware of cut-off levels for hyperuricaemia and the target serum uric acid (sUA) concentration when treating gout with ULT [10, 11]. Likewise, qualitative interview studies from Sydney, NSW, Australia and Nottingham, UK report that GPs and primary care nurses are frequently unaware of management principles reflected in gout treatment guidelines [11, 12]. It is therefore not surprising that the majority of people with gout from France, Germany, UK and the USA do not undergo regular monitoring blood tests or receive advice about improving their lifestyle that can improve gout [16]. Primary care physicians, GP nurses and non-specialist hospital doctors attribute this lack of knowledge to inadequate education and training concerning gout at both undergraduate and postgraduate levels [11, 12]. Health-care professionals participating in one study reported that they depended on needs-based self-directed learning, including from non-scientific sources, to help guide management of gout [11]. Indeed, many patients recalled receiving incorrect information from their health-care provider; for example, lack of information about the risk of gout attacks in those initiating ULT and advice to discontinue ULT during acute attacks [23]. Rheumatologists are more likely to have more accurate knowledge of gout than other physicians [20]. For example, in a study from China only 76% of non-rheumatology hospital physicians were aware that allopurinol lowers sUA (compared with 100% of rheumatologists), and 16% of non-rheumatology hospital physicians thought that colchicine has a sUA-lowering effect (compared with 0% of rheumatologists). Likewise, 44% of non-rheumatology hospital physicians were either unaware of a sUA treatment target or gave a wrong treatment target to aim for when treating with ULT (compared with 0% rheumatologists), and a similar minority of non-rheumatology hospital physicians were aware of the need for life-long ULT (compared with 94% rheumatologists) [20]. However, in another survey, secondary care hospital doctors, including rheumatologists and physicians in other medical subspecialties, demonstrated significant variations from standard accepted practice in their management of gout [17]. The lack of knowledge about gout and its treatment among people who manage this condition is a significant barrier to correct management. However, health-care professionals who receive didactic lectures on gout demonstrated a significant increase in knowledge about the condition [10], and such an approach can be used to improve standards of gout care. What do people with gout know about it? Just like health-care professionals, people with gout also have significant gaps in their knowledge of gout. In a study of 20 people with gout recruited from GP surgeries in and around Nottingham, UK, there was universal lack of knowledge and understanding about the causes and consequence of gout [11]. For instance, people with gout were unaware of the concepts of slow, gradual accumulation of urate crystals and its negative impact on joint health, were unduly focused only on acute attacks, and lacked knowledge about potentially curative ULT [11]. Likewise, lack of information about the safety of ULT, need to persist on ULT initially despite acute attacks and need for life-long treatment reduced persistence and adherence rates on ULT [11]. A study of patients’ knowledge of gout, performed simultaneously in China and the USA, found a lack of knowledge about factors that cause gout attacks, the need for life-long ULT and the target sUA for ULT [32]. In another study, in which the patients had a better understanding of the aetiopathogenesis of gout, with the vast majority of patients knowing that gout was related to high uric acid (89%) and that acute attacks resulted from crystals inducing inflammation in and around joints (80%), only 25% of patients on ULT in the past year were aware that these medications were to be used in the long term, and only 12% knew that initiation of ULT could trigger gout attacks [24]. Even for a medicine such as colchicine, which has a narrow therapeutic index, people who were currently or previously taking this drug did not know its correct dose, and several took higher than prescribed amounts [27]. Thus, people with gout who do not understand the role and effectiveness of pharmacological ULT, do not seek such treatment or are poorly adherent to it [28, 30] and use potentially ineffective alternative medicines [30]. The uptake of ULT is also inhibited by prevalent misconceptions about the self-inflicted nature of gout (a direct result of dietary and alcohol excesses and poor lifestyle), the popular perception that gout affects only men, and that it is a humorous illness brought on by overindulgence [11, 23, 30, 33]. Very few people realize the far higher attributable risk from inheritance than from excessive alcohol or lifestyle (heritability of serum urate is estimated at 45 and 73%) [34–36]. Additionally, people with gout feel stigmatized [25], particularly regarding alcohol consumption [12], which further inhibits them from seeking advice. Cultural and religious perceptions about gout in some traditional societies, for example, the Maori in New Zealand [25], who believe that gout may be a just punishment from the gods, also inhibits people from seeking a cure. Other personality characteristics, such as stoicism and tolerance, also inhibit people with gout from seeking medical attention for this condition [11, 25]. People with gout are keen to be educated about their condition and frequently complain of a paucity of information from trusted sources, and rely upon endorsed and unendorsed websites for detailed information [23]. However, such self-discovered sources of information can be overwhelming and inaccurate [23]. Indeed, previous surveys have found such resources to be of poor quality [37], with only a few patient information resources providing acceptable-quality information [38, 39], and given the plethora of resources available online it can be difficult for people to find reliable information about gout that is easy to understand. Newspaper articles, which serve as a means of societal education, also perpetuate the misconceptions about gout, its pathogenesis and treatment [33]. Thus, it is not surprising that in traditional societies where gout is prevalent, the family may be a major resource for information [30]. Mind the gap! What do health-care providers think about their patients’ knowledge of gout? Health-care providers seem to overestimate their patients’ knowledge of gout [9, 11]. In an interview study of 15 health-care providers and 26 gout patients, the health-care providers felt that their patients had ‘a good understanding regarding the management of gout’, and ‘regarding the need for long-term medication use’. However, the patients were only aware of a regimen to take for acute attacks, and although they were often aware that allopurinol reduces sUA, they had unanswered questions regarding gout aetiology and were unsure about the duration of treatment and the fact that allopurinol could trigger or make gout attacks worse around the time that it is first commenced [9]. However, most health-care practitioners felt that they did not provide sufficient patient education [9, 11] and that a lack of knowledge about gout among gout patients is a significant barrier to its effective management [19]. Bridging the gap Both health-care providers and people with gout agree that patient education is vital to improving the quality of gout care [9]. However, while health-care providers recommend the use of written educational handouts [9, 19], people with gout often request a combination of verbal and printed information. They also suggest that providers tailor their message according to individual needs of patients and provide holistic and honest advice, including alternative treatment modalities and risk of precipitating gout attacks with ULT etc. [9]. Both groups of people agreed that more time for consultations and follow-up visits after initiating treatment will improve gout management, but this is considered very difficult because of high demands on the health-care service [9]. Additionally, although giving a written patient information sheet is time efficient [40], fewer than one in five people with gout are given such handouts. Patient and public education can reduce the stigmatization of gout and break down cultural barriers that prevent gout patients from receiving optimal treatment [18]. The use of recall mechanisms, education about complications of gout and use of group therapy where patients share management techniques has been recommended [19]. Will bridging the gap improve uptake of ULT? Educating about the potential benefits of ULT in reducing attack frequency motivates patients to agree and adhere to ULT [23], and patients who have benefited from ULT often wish they had been started on it earlier [12]. Most patients depend on their practitioner as the first and main source of medical information and advice and feel that better information about gout from a GP who is educated about this condition would greatly improve gout management [12]. The important role of patient, physician and specialist education in improving the quality of gout care has been highlighted previously [41]. This is supported by the findings of a systematic review of randomized controlled trials, which evaluated interventions that improve adherence to medications in people with rheumatic diseases. In this study, all interventions shown to have a positive impact on medication adherence were those that were tailored to the individual and delivered by a health-care provider such as a nurse, pharmacist or rheumatologist [42]. Key points to consider when educating people about gout People with gout should be educated about the pathogenesis, associated co-morbidities and management of gout, including both pharmacological and non-pharmacological management. The use of humorous cartoons that promote negative stereotypes should be discouraged. The key knowledge points around which we recommend educating people with gout are outlined in Table 1 [39]. Table 1 What should I tell my gout patients? Causes and consequences of gout      We know its cause: deposition of urate crystals in and around joints.      Crystals form when sUA concentrations rise above the critical saturation point.      In people with persistently raised sUA concentrations, crystals slowly but continuously accumulate without causing symptoms initially.      When sufficient crystals have formed, some occasionally spill out into the joint cavity, triggering severe inflammation and presenting as an acute attack.      Over many years, acute attacks can increase in frequency and spread to involve other joints.      In addition to acute attacks, continuing crystal deposition might eventually result in hard, slowly expanding lumps of crystals (tophi) that can cause pressure damage to the joints and can appear as lumps under the skin.      In some people, tophi could result in irreversible joint damage and cause regular chronic pain on using the joints.      Reduction and maintenance of sUA concentrations below the saturation point stops production of new crystals and encourages existing crystals to dissolve, so eventually there are no crystals and therefore no gout.  Explanation of risk factors that elevate sUA concentrations above the saturation point      Hereditary factors result in some people having relatively inefficient renal excretion of UA.      High BMI; the majority of UA is made by the cells, and this production increases with obesity.      A purine-rich diet; around one-third of uric acid comes from the diet.      Drugs (e.g. diuretics) can reduce the kidney’s ability to excrete uric acid.      Chronic renal impairment.      Gout is associated with obesity, hypertension, hyperlipidaemia, diabetes, myocardial infarction, chronic renal impairment and kidney stones.  Treatment      Treat acute attacks of gout with colchicine, NSAIDs or CSs, rest and ice-packs.      Explain that ULT can eventually eliminate the crystals and cure gout.      Consider prophylaxis to prevent acute attacks of gout when starting ULT.      There is a need for slow, upward titration of ULT to reduce provocation of attacks.      There is a need for individualized dosing of ULT to achieve the desired sUA concentration (treat to target).      Dietary and lifestyle factors can also reduce urate concentrations, but they are ancillary to ULT.  Causes and consequences of gout      We know its cause: deposition of urate crystals in and around joints.      Crystals form when sUA concentrations rise above the critical saturation point.      In people with persistently raised sUA concentrations, crystals slowly but continuously accumulate without causing symptoms initially.      When sufficient crystals have formed, some occasionally spill out into the joint cavity, triggering severe inflammation and presenting as an acute attack.      Over many years, acute attacks can increase in frequency and spread to involve other joints.      In addition to acute attacks, continuing crystal deposition might eventually result in hard, slowly expanding lumps of crystals (tophi) that can cause pressure damage to the joints and can appear as lumps under the skin.      In some people, tophi could result in irreversible joint damage and cause regular chronic pain on using the joints.      Reduction and maintenance of sUA concentrations below the saturation point stops production of new crystals and encourages existing crystals to dissolve, so eventually there are no crystals and therefore no gout.  Explanation of risk factors that elevate sUA concentrations above the saturation point      Hereditary factors result in some people having relatively inefficient renal excretion of UA.      High BMI; the majority of UA is made by the cells, and this production increases with obesity.      A purine-rich diet; around one-third of uric acid comes from the diet.      Drugs (e.g. diuretics) can reduce the kidney’s ability to excrete uric acid.      Chronic renal impairment.      Gout is associated with obesity, hypertension, hyperlipidaemia, diabetes, myocardial infarction, chronic renal impairment and kidney stones.  Treatment      Treat acute attacks of gout with colchicine, NSAIDs or CSs, rest and ice-packs.      Explain that ULT can eventually eliminate the crystals and cure gout.      Consider prophylaxis to prevent acute attacks of gout when starting ULT.      There is a need for slow, upward titration of ULT to reduce provocation of attacks.      There is a need for individualized dosing of ULT to achieve the desired sUA concentration (treat to target).      Dietary and lifestyle factors can also reduce urate concentrations, but they are ancillary to ULT.  sUA: serum uric acid; ULT: urate-lowering treatment. If there is insufficient time in a face-to-face consultation, this information can be provided in a written information leaflet, but it is important to emphasize that hyperuricaemia, a prerequisite for developing gout, is mainly genetically mediated and should not be a cause of embarrassment or shame, and that gout requires long-term treatment to reduce uric acid concentrations, which then can eliminate the crystals and cure gout (i.e. no further attacks and no crystals to damage the joints). Additionally, that uric acid lowering may cause additional acute attacks in the beginning but will eliminate gout within months to years, depending on the crystal load; and that NSAIDs, glucocorticoids and colchicine only treat acute attacks but do not treat gout or influence uric acid concentrations. Finally, it is important to emphasize that if untreated, the frequency of gout attacks may increase, more joints will be affected, and there is a risk of irreversible joint damage. Non-pharmacological management of gout Non-pharmacological interventions have a role in the management of gout. For instance, rest and topical ice application are important adjuncts to managing acute gout. A small unblinded randomized controlled trial of 19 participants with crystal-proven gout treated with prednisolone 30 mg/day and colchicine 0.6 mg twice a day, and randomized to topical ice application for 30 min four times/day or no such intervention, demonstrated that ice application reduced pain attributable to acute gout at day 7 [43]. The mean reduction in joint pain was 7.7 cm in those treated with topical ice plus colchicine and prednisolone, compared with 4.4 cm in those treated with colchicine and prednisolone alone [43]. Likewise, avoidance of risk factors that are known to trigger acute attacks of gout, such as excessive alcohol or red-meat intake, may reduce attack frequency [44, 45]. It is noteworthy that purines derived from animal meats confer higher risk of recurrent gout attacks than those derived from vegetable sources [44]. Conversely, the consumption of one to three servings of cherry (each serving being 10–12 cherries or half a cup of cherry) or cherry extract (rich in anthocyanins) in a 48 h period reduced the risk of recurrent gout attacks by 35–45% [46]. Likewise, consumption of skimmed milk powder enriched with dairy fractions, glycomacropeptide and G 600 milk fat extract also reduces the frequency of gout attacks [47]. Also, avoidance of exposure to low temperatures and dehydration, factors believed to mediate the nocturnal risk of gout attacks, may prevent recurrent attacks [48]. Dehydration may also explain the increased risk of incident gout in summer (April–September) months in England and Wales [49]. Omega-3 fatty acids also reduce monosodium urate crystal-induced inflammation, and low concentrations of omega-3 fatty acids associated with frequent acute attacks of gout in a retrospective observational study [50]. However, further research is required before omega-3 fatty acids, cherry supplements and other dietary manipulation can be recommended to prevent acute attacks of gout. Non-pharmacological interventions may also be used as adjuncts to ULT. People with gout should be advised to reduce excessive intake of red meat, fish, shellfish and alcohol, especially those rich in added purines, such as beer, lager and whiskey [51]. However, such advice is only relevant to people who regularly consume undue amounts of these foods and drinks; there is no need to eliminate them, but to aim for a balanced and varied diet. Clearly, in an individual patient excessive alcohol consumption needs to be tackled in its own right as does being overweight or obese, even if the patient is treated appropriately with ULT. There is a lower risk of incident gout with increasing vitamin C intake above 500 mg/day owing to its uricosuric effects, with larger impact at higher doses [52], and a negative association between intake of soy protein, non-soy legumes, fresh fruits (⩾2 portions/day) and incident gout [51, 53]. Thus, these changes can be recommended as dietary and lifestyle adjuncts to ULT. However, vitamin C at a dose of 500 mg/day had minimal impact on sUA compared with allopurinol [54], underlining the need to emphasize the key role of ULT when managing gout. Likewise, consumption of four or more cups of coffee (including decaffeinated coffee) [55] reduced sUA, whereas consumption of sugar-sweetened soft drinks, including fruit juices (but not sugar-free diet carbonated soft drinks or fresh fruit intake), increased sUA concentrations, and people with gout can be advised to reduce their intake of sugar-sweetened soft drinks if applicable [56]. In a study of >28 000 male runners, physical fitness and running speed reduced the risk of incident gout [51]. Apart from specific dietary interventions, there is increasing evidence to suggest that weight loss because of dietary modifications, and bariatric surgery when indicated, reduces sUA [57–61]. For instance, a 16-week dietary intervention comprising a low-calorie diet (n = 13, mean BMI 30.5 kg/m2) resulted in a mean weight loss of 7.7 kg and achieved a clinically meaningful mean reduction in sUA of 100 µmol/l and a reduction in the frequency of gout attacks [57]. Similar findings were reported in studies of bariatric patients undergoing surgical weight-loss treatment. For instance, in a study from New Zealand, in which 60 people with type 2 diabetes and BMI ⩾35 kg/m2 underwent laparoscopic sleeve gastrectomy, the sUA reduced by 80 µmol/l [58]. Both weight loss and bariatric surgery can reduce the incidence of gout, as shown by the Health Professional Follow-up Study [61] and the Swedish Obese subjects Study [60]. However, weight loss of <5 kg may not have a significant effect on sUA. For instance, in the Multiple Risk Factors Intervention Trial, a weight loss of 1–4.9, 5–9.9 and ⩾10 kg resulted in mean (95% CI) sUA reduction of 7 (6–9), 19 (17–20) and 37 (35–40) μmol/l compared with no weight change on multivariate analysis [59]. Summary and conclusion Individualized patient education (that addresses illness perceptions regarding causation, consequences and management options), together with involvement of the patient in management decisions, is recommended best practice for all chronic conditions, including gout. Furthermore, patient education should not be given only once around the time of diagnosis; it should be reinforced and expanded or updated as required at every subsequent encounter and opportunity. Unfortunately, however, such individualized education and involvement of patients in shared decision-making is often not undertaken. In light of the published evidence, there is a pressing need to improve the knowledge of gout and its management among primary care health-care providers so that they can educate their gout patients correctly and manage gout according to recommended best practice. This will require a greater emphasis on teaching about gout and its associated co-morbidities in undergraduate medical education, during postgraduate training and in continued professional development programmes. Involvement of nurses, especially in the UK, where practice-based nurses are involved in management of many long-term conditions [62–64], and of pharmacists may also be helpful [65–67] (Fig. 2). Fig. 2 View largeDownload slide Involvement of nurses in patient education and management could optimize the standard of care and improve adherence to ULT Nurses often manage chronic conditions, such as asthma or diabetes, in primary care in the UK. They often have good empathetic communication that provides a positive patient–practitioner interaction. Importantly, nurses are allowed more time with the patient that is feasible for a doctor, and lack of time to provide individualized education is one of the many barriers to care of gout. ULT: urate-lowering treatment. Fig. 2 View largeDownload slide Involvement of nurses in patient education and management could optimize the standard of care and improve adherence to ULT Nurses often manage chronic conditions, such as asthma or diabetes, in primary care in the UK. They often have good empathetic communication that provides a positive patient–practitioner interaction. Importantly, nurses are allowed more time with the patient that is feasible for a doctor, and lack of time to provide individualized education is one of the many barriers to care of gout. ULT: urate-lowering treatment. For example, a telephone-based gout management programme provided by trained pharmacists (with support from a rheumatologist if required) improved the use of ULT in a single-arm observational study, with 82% of participants attaining sUA <360 µmol/l in the short term [67]. Pharmacist-led tele-care of gout also resulted in better sUA control compared with usual care provided by primary care practitioners in an open label randomized controlled trial conducted by the same group [risk ratio (95% CI) for sUA <360 µmol/l in active group was 2.8 (1.1, 7.1) with usual care referent]. However, the absolute impact of such an intervention was significantly lower than in the observational study, with only 35% attaining sUA <360 µmol/l at 26 weeks [66]. Furthermore, pharmacist-assisted care is predominantly focused on improving adherence and achieving target sUA concentrations once the decision to commence ULT has been made, and it requires full patient information from another health professional to reach this stage. In summary, patient education is central to improving the quality of gout care. There is a need to educate health-care professionals, patients and society at large to remove the negative stereotypes associated with gout so that people with gout are not inhibited from seeking medical advice and receiving full and correct information on gout. There is a paucity of high-quality trial evidence on whether certain individual dietary and lifestyle factors can genuinely reduce the risk of recurrent gout attacks, and further studies are required in this field. Supplement: This supplement was supported by an unrestricted grant from Grunenthal. Funding: No specific funding was received from any bodies in the public, commercial or not-for-profit sectors to carry out the work described in this manuscript. Disclosure statement: M.D. has received honoraria for ad hoc advisory boards from AstraZeneca and Grunenthal; AstraZeneca has funded a non-pharmacological Sons of Gout study at Nottingham University. 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Education and non-pharmacological approaches for gout

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© The Author 2018. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oup.com
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Abstract

Abstract The objectives of this review are as follows: to highlight the gaps in patient and physician knowledge of gout and how this might impede optimal disease management; to provide recommended core knowledge points that should be conveyed to people with gout; and to review non-pharmacological interventions that can be used in gout management. MeSH terms were used to identify eligible studies examining patients’ and health-care professionals’ knowledge about gout and its management. A narrative review of non-pharmacological management of gout is provided. Many health-care professionals have significant gaps in their knowledge about gout that have the potential to impede optimal management. Likewise, people with gout and the general population lack knowledge about causes, consequences and treatment of this condition. Full explanation about gout, including the potential benefits of urate-lowering treatment (ULT), motivates people with gout to want to start such treatment, and there is evidence, albeit limited, that educational interventions can improve uptake and adherence to ULT. Additionally, several non-pharmacological approaches, such as rest and topical ice application for acute attacks, avoidance of risk factors that can trigger acute attacks, and dietary interventions that may reduce gout attack frequency (e.g. cherry or cherry juice extract, skimmed milk powder or omega-3 fatty acid intake) or lower serum uric acid (e.g. vitamin C), can be used as adjuncts to ULT. There is a pressing need to educate health-care professionals, people with gout and society at large to remove the negative stereotypes associated with gout, which serve as barriers to optimal gout management, and to perceive gout as a significant medical condition. Moreover, there is a paucity of high-quality trial evidence on whether certain simple individual dietary and lifestyle factors can reduce the risk of recurrent gout attacks, and further studies are required in this field. gout, treatment, non-pharmacological, diet, lifestyle Rheumatology key messages Misconceptions about gout are prevalent among both patients and doctors. Patient and provider education can improve the management of gout. Other non-pharmacological approaches should be used as adjuncts to urate-lowering treatment in gout. Background Gout is the commonest inflammatory arthritis and the only chronic arthritis that has the potential of being cured with safe, simple and inexpensive pharmacological treatment, provided it is taken at correct doses and in the long term. However, this treatable condition remains untreated or poorly managed in the majority of people with gout, including those who consult their general practitioner (GP) for gout and fulfil recommended national criteria for receiving long-term urate-lowering treatment (ULT) [1–3]. Likewise, once initiated on ULT, adherence and persistence on these drugs is often poor, with the adherence to ULT being among the lowest medication adherence when compared with other chronic illnesses [1, 4–7]. For example, in one community-based study half of all men and women who commenced ULT discontinued treatment by 358 and 379 days, respectively, whereas in another study the 12-month persistence on ULT was even lower, at 22.6% [5, 8]. There are many barriers to care of gout [3], but an important reason for low uptake and poor adherence and persistence with ULT appears to be significant gaps in knowledge about gout and its treatment in people with this condition, both in the general public and in health-care professionals [9–12]. However, when people with gout receive full individualized education about gout, tailored to their own information needs and understanding, 100% want to receive ULT, and persistence is excellent (92%) at 1 year and remains high (91%) at 5 years, with 85% reporting taking ULT on at least 6 days/week 5 years after receiving such education [13, 14]. These findings suggest that optimal individualized education significantly improves gout care in the long term. However, the decision to seek medical help and to offer treatment is influenced by personal and professional knowledge, respectively, and the existing societal attitude to the illness concerned (Fig. 1). Several studies have examined knowledge about gout among patients and physicians and how this influences their decision to initiate and continue on long-term ULT [9–13, 15–32]. In this narrative review, we describe the findings of these studies and highlight common important gaps in patient and physician knowledge of gout and how it might impede optimal management. Based on our experience of treating community-derived people with gout in two studies, we recommend core knowledge points that should be conveyed to the general public, people with gout and the doctors who treat this condition. Finally, we also review non-pharmacological techniques that can be used in the management of gout. Fig. 1 View largeDownload slide Factors affecting care of gout Patients’ perception about their illness, professional knowledge and perception and societal perceptions of gout all act as important determinants of the decision to seek treatment. Fig. 1 View largeDownload slide Factors affecting care of gout Patients’ perception about their illness, professional knowledge and perception and societal perceptions of gout all act as important determinants of the decision to seek treatment. Methods In order to identify studies examining knowledge of gout and its treatment among people with this condition and those who treat it, we searched PubMed from inception to 28 March 2017 using the following terms: ((gout[MeSH Terms] OR gout[All Fields]) AND (education[Subheading] OR education[All Fields] OR educational status[MeSH Terms] OR (educational[All Fields] AND status[All Fields]) OR educational status[All Fields] OR education[All Fields] OR education[MeSH Terms]) AND humans[MeSH Terms]); OR ((gout[MeSH Terms] OR gout[All Fields]) AND barriers[All Fields]) AND humans[MeSH Terms]. We retrieved 290 studies. There were 23 studies examining the current state of understanding of gout among health-care professionals, including rheumatologists, other hospital physicians, primary care providers, practice nurses and GPs [9–12, 15–21], and people with gout [9, 11–13, 20, 22–32], with or without a discussion of its effects on prescription of ULT. We did not perform a systematic search to identify the studies on non-pharmacological management of gout, and provide a narrative review. What do health-care professionals know about gout? As a result of its high prevalence, gout is most frequently treated by GPs, with only cases that are difficult to manage being referred to secondary care. A postal survey of >400 GPs in Yorkshire, UK in 2002 suggested that only 6% would refer a gout patient to secondary care hospitals [21]. Most GPs felt able to diagnose gout accurately and reported confidence in managing it either independently or with occasional input from other GP colleagues [15, 21]. However, despite this high self-rated confidence in managing gout, many primary care physicians have significant gaps in their knowledge of gout, such as not being aware of cut-off levels for hyperuricaemia and the target serum uric acid (sUA) concentration when treating gout with ULT [10, 11]. Likewise, qualitative interview studies from Sydney, NSW, Australia and Nottingham, UK report that GPs and primary care nurses are frequently unaware of management principles reflected in gout treatment guidelines [11, 12]. It is therefore not surprising that the majority of people with gout from France, Germany, UK and the USA do not undergo regular monitoring blood tests or receive advice about improving their lifestyle that can improve gout [16]. Primary care physicians, GP nurses and non-specialist hospital doctors attribute this lack of knowledge to inadequate education and training concerning gout at both undergraduate and postgraduate levels [11, 12]. Health-care professionals participating in one study reported that they depended on needs-based self-directed learning, including from non-scientific sources, to help guide management of gout [11]. Indeed, many patients recalled receiving incorrect information from their health-care provider; for example, lack of information about the risk of gout attacks in those initiating ULT and advice to discontinue ULT during acute attacks [23]. Rheumatologists are more likely to have more accurate knowledge of gout than other physicians [20]. For example, in a study from China only 76% of non-rheumatology hospital physicians were aware that allopurinol lowers sUA (compared with 100% of rheumatologists), and 16% of non-rheumatology hospital physicians thought that colchicine has a sUA-lowering effect (compared with 0% of rheumatologists). Likewise, 44% of non-rheumatology hospital physicians were either unaware of a sUA treatment target or gave a wrong treatment target to aim for when treating with ULT (compared with 0% rheumatologists), and a similar minority of non-rheumatology hospital physicians were aware of the need for life-long ULT (compared with 94% rheumatologists) [20]. However, in another survey, secondary care hospital doctors, including rheumatologists and physicians in other medical subspecialties, demonstrated significant variations from standard accepted practice in their management of gout [17]. The lack of knowledge about gout and its treatment among people who manage this condition is a significant barrier to correct management. However, health-care professionals who receive didactic lectures on gout demonstrated a significant increase in knowledge about the condition [10], and such an approach can be used to improve standards of gout care. What do people with gout know about it? Just like health-care professionals, people with gout also have significant gaps in their knowledge of gout. In a study of 20 people with gout recruited from GP surgeries in and around Nottingham, UK, there was universal lack of knowledge and understanding about the causes and consequence of gout [11]. For instance, people with gout were unaware of the concepts of slow, gradual accumulation of urate crystals and its negative impact on joint health, were unduly focused only on acute attacks, and lacked knowledge about potentially curative ULT [11]. Likewise, lack of information about the safety of ULT, need to persist on ULT initially despite acute attacks and need for life-long treatment reduced persistence and adherence rates on ULT [11]. A study of patients’ knowledge of gout, performed simultaneously in China and the USA, found a lack of knowledge about factors that cause gout attacks, the need for life-long ULT and the target sUA for ULT [32]. In another study, in which the patients had a better understanding of the aetiopathogenesis of gout, with the vast majority of patients knowing that gout was related to high uric acid (89%) and that acute attacks resulted from crystals inducing inflammation in and around joints (80%), only 25% of patients on ULT in the past year were aware that these medications were to be used in the long term, and only 12% knew that initiation of ULT could trigger gout attacks [24]. Even for a medicine such as colchicine, which has a narrow therapeutic index, people who were currently or previously taking this drug did not know its correct dose, and several took higher than prescribed amounts [27]. Thus, people with gout who do not understand the role and effectiveness of pharmacological ULT, do not seek such treatment or are poorly adherent to it [28, 30] and use potentially ineffective alternative medicines [30]. The uptake of ULT is also inhibited by prevalent misconceptions about the self-inflicted nature of gout (a direct result of dietary and alcohol excesses and poor lifestyle), the popular perception that gout affects only men, and that it is a humorous illness brought on by overindulgence [11, 23, 30, 33]. Very few people realize the far higher attributable risk from inheritance than from excessive alcohol or lifestyle (heritability of serum urate is estimated at 45 and 73%) [34–36]. Additionally, people with gout feel stigmatized [25], particularly regarding alcohol consumption [12], which further inhibits them from seeking advice. Cultural and religious perceptions about gout in some traditional societies, for example, the Maori in New Zealand [25], who believe that gout may be a just punishment from the gods, also inhibits people from seeking a cure. Other personality characteristics, such as stoicism and tolerance, also inhibit people with gout from seeking medical attention for this condition [11, 25]. People with gout are keen to be educated about their condition and frequently complain of a paucity of information from trusted sources, and rely upon endorsed and unendorsed websites for detailed information [23]. However, such self-discovered sources of information can be overwhelming and inaccurate [23]. Indeed, previous surveys have found such resources to be of poor quality [37], with only a few patient information resources providing acceptable-quality information [38, 39], and given the plethora of resources available online it can be difficult for people to find reliable information about gout that is easy to understand. Newspaper articles, which serve as a means of societal education, also perpetuate the misconceptions about gout, its pathogenesis and treatment [33]. Thus, it is not surprising that in traditional societies where gout is prevalent, the family may be a major resource for information [30]. Mind the gap! What do health-care providers think about their patients’ knowledge of gout? Health-care providers seem to overestimate their patients’ knowledge of gout [9, 11]. In an interview study of 15 health-care providers and 26 gout patients, the health-care providers felt that their patients had ‘a good understanding regarding the management of gout’, and ‘regarding the need for long-term medication use’. However, the patients were only aware of a regimen to take for acute attacks, and although they were often aware that allopurinol reduces sUA, they had unanswered questions regarding gout aetiology and were unsure about the duration of treatment and the fact that allopurinol could trigger or make gout attacks worse around the time that it is first commenced [9]. However, most health-care practitioners felt that they did not provide sufficient patient education [9, 11] and that a lack of knowledge about gout among gout patients is a significant barrier to its effective management [19]. Bridging the gap Both health-care providers and people with gout agree that patient education is vital to improving the quality of gout care [9]. However, while health-care providers recommend the use of written educational handouts [9, 19], people with gout often request a combination of verbal and printed information. They also suggest that providers tailor their message according to individual needs of patients and provide holistic and honest advice, including alternative treatment modalities and risk of precipitating gout attacks with ULT etc. [9]. Both groups of people agreed that more time for consultations and follow-up visits after initiating treatment will improve gout management, but this is considered very difficult because of high demands on the health-care service [9]. Additionally, although giving a written patient information sheet is time efficient [40], fewer than one in five people with gout are given such handouts. Patient and public education can reduce the stigmatization of gout and break down cultural barriers that prevent gout patients from receiving optimal treatment [18]. The use of recall mechanisms, education about complications of gout and use of group therapy where patients share management techniques has been recommended [19]. Will bridging the gap improve uptake of ULT? Educating about the potential benefits of ULT in reducing attack frequency motivates patients to agree and adhere to ULT [23], and patients who have benefited from ULT often wish they had been started on it earlier [12]. Most patients depend on their practitioner as the first and main source of medical information and advice and feel that better information about gout from a GP who is educated about this condition would greatly improve gout management [12]. The important role of patient, physician and specialist education in improving the quality of gout care has been highlighted previously [41]. This is supported by the findings of a systematic review of randomized controlled trials, which evaluated interventions that improve adherence to medications in people with rheumatic diseases. In this study, all interventions shown to have a positive impact on medication adherence were those that were tailored to the individual and delivered by a health-care provider such as a nurse, pharmacist or rheumatologist [42]. Key points to consider when educating people about gout People with gout should be educated about the pathogenesis, associated co-morbidities and management of gout, including both pharmacological and non-pharmacological management. The use of humorous cartoons that promote negative stereotypes should be discouraged. The key knowledge points around which we recommend educating people with gout are outlined in Table 1 [39]. Table 1 What should I tell my gout patients? Causes and consequences of gout      We know its cause: deposition of urate crystals in and around joints.      Crystals form when sUA concentrations rise above the critical saturation point.      In people with persistently raised sUA concentrations, crystals slowly but continuously accumulate without causing symptoms initially.      When sufficient crystals have formed, some occasionally spill out into the joint cavity, triggering severe inflammation and presenting as an acute attack.      Over many years, acute attacks can increase in frequency and spread to involve other joints.      In addition to acute attacks, continuing crystal deposition might eventually result in hard, slowly expanding lumps of crystals (tophi) that can cause pressure damage to the joints and can appear as lumps under the skin.      In some people, tophi could result in irreversible joint damage and cause regular chronic pain on using the joints.      Reduction and maintenance of sUA concentrations below the saturation point stops production of new crystals and encourages existing crystals to dissolve, so eventually there are no crystals and therefore no gout.  Explanation of risk factors that elevate sUA concentrations above the saturation point      Hereditary factors result in some people having relatively inefficient renal excretion of UA.      High BMI; the majority of UA is made by the cells, and this production increases with obesity.      A purine-rich diet; around one-third of uric acid comes from the diet.      Drugs (e.g. diuretics) can reduce the kidney’s ability to excrete uric acid.      Chronic renal impairment.      Gout is associated with obesity, hypertension, hyperlipidaemia, diabetes, myocardial infarction, chronic renal impairment and kidney stones.  Treatment      Treat acute attacks of gout with colchicine, NSAIDs or CSs, rest and ice-packs.      Explain that ULT can eventually eliminate the crystals and cure gout.      Consider prophylaxis to prevent acute attacks of gout when starting ULT.      There is a need for slow, upward titration of ULT to reduce provocation of attacks.      There is a need for individualized dosing of ULT to achieve the desired sUA concentration (treat to target).      Dietary and lifestyle factors can also reduce urate concentrations, but they are ancillary to ULT.  Causes and consequences of gout      We know its cause: deposition of urate crystals in and around joints.      Crystals form when sUA concentrations rise above the critical saturation point.      In people with persistently raised sUA concentrations, crystals slowly but continuously accumulate without causing symptoms initially.      When sufficient crystals have formed, some occasionally spill out into the joint cavity, triggering severe inflammation and presenting as an acute attack.      Over many years, acute attacks can increase in frequency and spread to involve other joints.      In addition to acute attacks, continuing crystal deposition might eventually result in hard, slowly expanding lumps of crystals (tophi) that can cause pressure damage to the joints and can appear as lumps under the skin.      In some people, tophi could result in irreversible joint damage and cause regular chronic pain on using the joints.      Reduction and maintenance of sUA concentrations below the saturation point stops production of new crystals and encourages existing crystals to dissolve, so eventually there are no crystals and therefore no gout.  Explanation of risk factors that elevate sUA concentrations above the saturation point      Hereditary factors result in some people having relatively inefficient renal excretion of UA.      High BMI; the majority of UA is made by the cells, and this production increases with obesity.      A purine-rich diet; around one-third of uric acid comes from the diet.      Drugs (e.g. diuretics) can reduce the kidney’s ability to excrete uric acid.      Chronic renal impairment.      Gout is associated with obesity, hypertension, hyperlipidaemia, diabetes, myocardial infarction, chronic renal impairment and kidney stones.  Treatment      Treat acute attacks of gout with colchicine, NSAIDs or CSs, rest and ice-packs.      Explain that ULT can eventually eliminate the crystals and cure gout.      Consider prophylaxis to prevent acute attacks of gout when starting ULT.      There is a need for slow, upward titration of ULT to reduce provocation of attacks.      There is a need for individualized dosing of ULT to achieve the desired sUA concentration (treat to target).      Dietary and lifestyle factors can also reduce urate concentrations, but they are ancillary to ULT.  sUA: serum uric acid; ULT: urate-lowering treatment. If there is insufficient time in a face-to-face consultation, this information can be provided in a written information leaflet, but it is important to emphasize that hyperuricaemia, a prerequisite for developing gout, is mainly genetically mediated and should not be a cause of embarrassment or shame, and that gout requires long-term treatment to reduce uric acid concentrations, which then can eliminate the crystals and cure gout (i.e. no further attacks and no crystals to damage the joints). Additionally, that uric acid lowering may cause additional acute attacks in the beginning but will eliminate gout within months to years, depending on the crystal load; and that NSAIDs, glucocorticoids and colchicine only treat acute attacks but do not treat gout or influence uric acid concentrations. Finally, it is important to emphasize that if untreated, the frequency of gout attacks may increase, more joints will be affected, and there is a risk of irreversible joint damage. Non-pharmacological management of gout Non-pharmacological interventions have a role in the management of gout. For instance, rest and topical ice application are important adjuncts to managing acute gout. A small unblinded randomized controlled trial of 19 participants with crystal-proven gout treated with prednisolone 30 mg/day and colchicine 0.6 mg twice a day, and randomized to topical ice application for 30 min four times/day or no such intervention, demonstrated that ice application reduced pain attributable to acute gout at day 7 [43]. The mean reduction in joint pain was 7.7 cm in those treated with topical ice plus colchicine and prednisolone, compared with 4.4 cm in those treated with colchicine and prednisolone alone [43]. Likewise, avoidance of risk factors that are known to trigger acute attacks of gout, such as excessive alcohol or red-meat intake, may reduce attack frequency [44, 45]. It is noteworthy that purines derived from animal meats confer higher risk of recurrent gout attacks than those derived from vegetable sources [44]. Conversely, the consumption of one to three servings of cherry (each serving being 10–12 cherries or half a cup of cherry) or cherry extract (rich in anthocyanins) in a 48 h period reduced the risk of recurrent gout attacks by 35–45% [46]. Likewise, consumption of skimmed milk powder enriched with dairy fractions, glycomacropeptide and G 600 milk fat extract also reduces the frequency of gout attacks [47]. Also, avoidance of exposure to low temperatures and dehydration, factors believed to mediate the nocturnal risk of gout attacks, may prevent recurrent attacks [48]. Dehydration may also explain the increased risk of incident gout in summer (April–September) months in England and Wales [49]. Omega-3 fatty acids also reduce monosodium urate crystal-induced inflammation, and low concentrations of omega-3 fatty acids associated with frequent acute attacks of gout in a retrospective observational study [50]. However, further research is required before omega-3 fatty acids, cherry supplements and other dietary manipulation can be recommended to prevent acute attacks of gout. Non-pharmacological interventions may also be used as adjuncts to ULT. People with gout should be advised to reduce excessive intake of red meat, fish, shellfish and alcohol, especially those rich in added purines, such as beer, lager and whiskey [51]. However, such advice is only relevant to people who regularly consume undue amounts of these foods and drinks; there is no need to eliminate them, but to aim for a balanced and varied diet. Clearly, in an individual patient excessive alcohol consumption needs to be tackled in its own right as does being overweight or obese, even if the patient is treated appropriately with ULT. There is a lower risk of incident gout with increasing vitamin C intake above 500 mg/day owing to its uricosuric effects, with larger impact at higher doses [52], and a negative association between intake of soy protein, non-soy legumes, fresh fruits (⩾2 portions/day) and incident gout [51, 53]. Thus, these changes can be recommended as dietary and lifestyle adjuncts to ULT. However, vitamin C at a dose of 500 mg/day had minimal impact on sUA compared with allopurinol [54], underlining the need to emphasize the key role of ULT when managing gout. Likewise, consumption of four or more cups of coffee (including decaffeinated coffee) [55] reduced sUA, whereas consumption of sugar-sweetened soft drinks, including fruit juices (but not sugar-free diet carbonated soft drinks or fresh fruit intake), increased sUA concentrations, and people with gout can be advised to reduce their intake of sugar-sweetened soft drinks if applicable [56]. In a study of >28 000 male runners, physical fitness and running speed reduced the risk of incident gout [51]. Apart from specific dietary interventions, there is increasing evidence to suggest that weight loss because of dietary modifications, and bariatric surgery when indicated, reduces sUA [57–61]. For instance, a 16-week dietary intervention comprising a low-calorie diet (n = 13, mean BMI 30.5 kg/m2) resulted in a mean weight loss of 7.7 kg and achieved a clinically meaningful mean reduction in sUA of 100 µmol/l and a reduction in the frequency of gout attacks [57]. Similar findings were reported in studies of bariatric patients undergoing surgical weight-loss treatment. For instance, in a study from New Zealand, in which 60 people with type 2 diabetes and BMI ⩾35 kg/m2 underwent laparoscopic sleeve gastrectomy, the sUA reduced by 80 µmol/l [58]. Both weight loss and bariatric surgery can reduce the incidence of gout, as shown by the Health Professional Follow-up Study [61] and the Swedish Obese subjects Study [60]. However, weight loss of <5 kg may not have a significant effect on sUA. For instance, in the Multiple Risk Factors Intervention Trial, a weight loss of 1–4.9, 5–9.9 and ⩾10 kg resulted in mean (95% CI) sUA reduction of 7 (6–9), 19 (17–20) and 37 (35–40) μmol/l compared with no weight change on multivariate analysis [59]. Summary and conclusion Individualized patient education (that addresses illness perceptions regarding causation, consequences and management options), together with involvement of the patient in management decisions, is recommended best practice for all chronic conditions, including gout. Furthermore, patient education should not be given only once around the time of diagnosis; it should be reinforced and expanded or updated as required at every subsequent encounter and opportunity. Unfortunately, however, such individualized education and involvement of patients in shared decision-making is often not undertaken. In light of the published evidence, there is a pressing need to improve the knowledge of gout and its management among primary care health-care providers so that they can educate their gout patients correctly and manage gout according to recommended best practice. This will require a greater emphasis on teaching about gout and its associated co-morbidities in undergraduate medical education, during postgraduate training and in continued professional development programmes. Involvement of nurses, especially in the UK, where practice-based nurses are involved in management of many long-term conditions [62–64], and of pharmacists may also be helpful [65–67] (Fig. 2). Fig. 2 View largeDownload slide Involvement of nurses in patient education and management could optimize the standard of care and improve adherence to ULT Nurses often manage chronic conditions, such as asthma or diabetes, in primary care in the UK. They often have good empathetic communication that provides a positive patient–practitioner interaction. Importantly, nurses are allowed more time with the patient that is feasible for a doctor, and lack of time to provide individualized education is one of the many barriers to care of gout. ULT: urate-lowering treatment. Fig. 2 View largeDownload slide Involvement of nurses in patient education and management could optimize the standard of care and improve adherence to ULT Nurses often manage chronic conditions, such as asthma or diabetes, in primary care in the UK. They often have good empathetic communication that provides a positive patient–practitioner interaction. Importantly, nurses are allowed more time with the patient that is feasible for a doctor, and lack of time to provide individualized education is one of the many barriers to care of gout. ULT: urate-lowering treatment. For example, a telephone-based gout management programme provided by trained pharmacists (with support from a rheumatologist if required) improved the use of ULT in a single-arm observational study, with 82% of participants attaining sUA <360 µmol/l in the short term [67]. Pharmacist-led tele-care of gout also resulted in better sUA control compared with usual care provided by primary care practitioners in an open label randomized controlled trial conducted by the same group [risk ratio (95% CI) for sUA <360 µmol/l in active group was 2.8 (1.1, 7.1) with usual care referent]. However, the absolute impact of such an intervention was significantly lower than in the observational study, with only 35% attaining sUA <360 µmol/l at 26 weeks [66]. Furthermore, pharmacist-assisted care is predominantly focused on improving adherence and achieving target sUA concentrations once the decision to commence ULT has been made, and it requires full patient information from another health professional to reach this stage. In summary, patient education is central to improving the quality of gout care. There is a need to educate health-care professionals, patients and society at large to remove the negative stereotypes associated with gout so that people with gout are not inhibited from seeking medical advice and receiving full and correct information on gout. There is a paucity of high-quality trial evidence on whether certain individual dietary and lifestyle factors can genuinely reduce the risk of recurrent gout attacks, and further studies are required in this field. Supplement: This supplement was supported by an unrestricted grant from Grunenthal. Funding: No specific funding was received from any bodies in the public, commercial or not-for-profit sectors to carry out the work described in this manuscript. Disclosure statement: M.D. has received honoraria for ad hoc advisory boards from AstraZeneca and Grunenthal; AstraZeneca has funded a non-pharmacological Sons of Gout study at Nottingham University. 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