Something new is being tried to improve gout outcomes in the United States: Pharmacists are being recruited to help manage patients.
People with too-high serum urate levels who agree to extra help are being referred to pharmacists empowered to order blood tests and allopurinol. Pharmacists contact patients by mail or phone, at first, and then maybe automated messages or emails, and educate them about why they need to lower their urate and how to do it. Pharmacists monitor lab results and titrate allopurinol as needed to hit serum urate levels of 6 mg/dL or less. The tune-up usually takes a year, at which point physicians resume ongoing management. The referring doctor is in the background to make sure everything goes okay.
Dr. Kimberly Low
It’s a simple, inexpensive approach that seems to help patients with a serious but notoriously undertreated condition. “It gives them the extra personal attention they might need. They appreciate the extra nudge most of the time,” said Kimberly Low, PharmD, the ambulatory pharmacist in an ongoing study of the approach at Kaiser Permanente Southern California in Pasadena (Contemp Clin Trials. 2016 Jul 20;50:106-15. doi: 10.1016/j.cct.2016.07.019).
“We need to deliver gout care in a more efficient way that doesn’t put it all on primary care,” where almost all gout is managed. “Pharmacy is a possible way to do that,” said Ted Mikuls, MD, a rheumatology professor at the University of Nebraska in Omaha, and senior investigator on the project. Results will be published soon.
The only randomized trial so far was published recently by Kaiser Permanente Northern California. The chance of hitting the 6-mg/dL mark at 6 months almost tripled when a pharmacist was involved. “The next step is to try to get a large-scale program funded using this model” at Kaiser, said lead investigator Robert Goldfien, MD, chair of the Chiefs of Rheumatology for the Permanente Medical Group in Richmond, Calif (Perm J. 2016 Jul 1;20[3]. doi: 10.7812/TPP/15-234).
Dr. Ted Mikuls
Other places are turning to pharmacists, too, even when there isn’t a study involved. One of them is the San Diego Veterans Affairs Medical Center. It’s a “huge help; otherwise our clinic would be flooded with gout patients,” said rheumatologist Robert Terkeltaub, MD, who oversees the program.
Patients there are happy to have fewer flares and not to have to drive to the San Diego VA for blood draws; they go to a nearby clinic instead, and “we mail them their medications. We’ve had tremendous success” with pharmacists, and their “charges are affordable. We have treated hundreds of patients this way,” Dr. Terkeltaub said.
There doesn’t seem to be a downside. The only issue is how reimbursements will work. That’s not much of a problem when everyone is in the same health system and on the same electronic health record, with paychecks coming from the same place. Perhaps not surprisingly, large health systems are where the model is taking hold. How it could work with smaller practices and community pharmacists is unclear.
An obvious need
Dr. Robert Goldfien
It’s no secret that gout care isn’t very good in the United States, or, really, anywhere else. Gout is a curable or at least imminently manageable condition with the right drugs for flares and lowering urate, but emergency department visits are up; hospitalizations for gout attacks have surpassed rheumatoid arthritis; and allopurinol dosing is routinely too low, if it’s prescribed at all.
Meanwhile, hyperuricemia has been linked to cardiovascular disease and other problems. Some now consider it part of the metabolic syndrome.
There are a lot of reasons why gout care is subpar, but one of them is that primary care providers are just too busy managing diabetes, hypertension, and other problems that seem more important in 10-minute office visits; that’s where pharmacists come in.
“They understand medications, drug-drug, and drug-herb interactions in a way that I don’t,” and also “have access, hopefully, to a more accurate picture of what patients take. I am all thumbs up for any involvement with pharmacists,” said Reid Blackwelder, MD, a recent president of the American Academy of Family Physicians and a family practice professor at East Tennessee State University in Mountain Home, where pharmacists are embedded in primary care.
Dr. Reid Blackwelder
Gout is a natural fit for pharmacy. Although the pharmacy-gout literature is thin, there have been plenty of reports about pharmacists improving outcomes, saving money, and increasing patient satisfaction when they help family practice and other doctors manage chronic problems. That’s one of the reasons why pharmacists are part of the primary care team in Mountain Home and other places that can afford them. Pharmacist-managed Coumadin clinics are the precedent.