Problems with treatment adherence in the management of gout Save

Like many chronic illnesses, gout is plagued by poor adherence to the treatment plan. However, the magnitude of non-adherence in patients with gout is striking. Compared to common medical conditions such as hypertension, type 2 diabetes, hyperlipidemia or osteoporosis, where the reported drug adherence rates are between 50% to 70%, the drug adherence for gout is 37%. This makes gout a true outlier when it comes to following “the plan.” 

The problem with gout management is even more profound than these adherence numbers would suggest. It has been estimated that only 60% of all the people in this country with gout receive any directed therapy. And out of that group, less than 10% are prescribed enough urate lowering therapy (ULT) to have an impact on the disease.

Why, you might ask, is there so much failure in the treatment of gout? It is, after all, a rather straightforward disease with tried-and-true ULTs available to us. When used appropriately (i.e., according to the American College of Rheumatology gout management recommendations), drug intolerance and true drug failure are quite uncommon. 

That leaves two plausible explanations for the poor treatment adherence in the management of gout: One is that the gout population has an unusually high percentage of rebellious personalities; the other, and more likely explanation, is that health care providers have done a pretty poor job of curing this most common of all inflammatory arthritides. This is true of both primary care providers and subspecialists, such as nephrologists and rheumatologists.

There are many misconceptions and biases brought to the table by physicians that preclude optimal gout management. These barriers include: a poor understanding of the pathogenesis of gout; a lack of familiarity with internationally accepted gout management guidelines; the misconception that gout is a benign process; an overly restricted allopurinol dosing range; and the widely held myth that gout is a result of poor lifestyle decisions and is self-inflicted.

There are also common misinterpretations brought to the table by the patient. They may have a poor understanding of the pathogenesis of gout. In a recent Gout Education Society survey, more than 60% of gout patients did not know their serum urate level or that it was an important value to follow. Similarly, almost half of the survey patients perceive the two gout drugs, allopurinol and colchicine, as being similar in action and interchangeable. Another factor that impacts our ability to improve the gout-specific health literacy in patients is their feeling of being stigmatized by the negative stereotype surrounding gout. This, in turn, results in the patient withdrawing socially and not having the support of friends, family, or their own physician.

In the end, the gap in gout care is less about the limits of medicine and more about the limits of communication. Until providers confront misconceptions head-on and clearly explain the stakes, adherence will remain the missing link between treatment and relief.

Take home messages

1. Adherence to treatment suggestions is very low, even when compared to that of other chronic illnesses that are generally not symptomatic.
2. Poor adherence to urate-lowering therapy is primarily a failure of the provider to dispel the patient’s misconceptions and myths about gout while presenting a compelling and realistic reason to be on such therapy.