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Gout education for your team
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<img src="/icons/book-closed_gray.svg" alt="/icons/book-closed_gray.svg" width="40px" /> From Whanganui GOUT STOP programme evaluation report
During this continuous quality improvement (CQI) project, it was also identified that there needed to be a clinical update for GPs/nurses on gout. Best practice treatment and management for gout had changed over recent years and there needed to be a greater understanding of the impact of genetics on gout, especially in younger Māori and Pacific males.
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Clinical knowledge
Talking about gout in a new way includes being up to date with the latest guidance, particularly how genetics affect urate/uric acid levels so this knowledge can be shared with whānau Māori and Pacific peoples with gout and the wider community.
“We realised we know a lot about diabetes because we are dealing with it all the time – what it is, how to treat it, medications, tests, how to talk with patients about it, so much. But we don’t have the same knowledge about gout.”
- Nurse leader (From ProCare Gout Collaborative Practice)
7 key areas of clinical knowledge to cover are:
1. Causes of gout
- Gout is not the fault of the person with gout. Gout is not about self-control or excessive consumption of high purine foods.
- Gout is caused by high levels of urate/uric acid in the body.
- Only 10% of high levels of urate/uric acid in the body is caused by food and drink.
- 90% of high levels of urate/uric acid in the body is caused by genes (particularly for whānau Māori and Pacific peoples) which cause the kidneys to stop excreting urate/uric acid. Higher body weight also impacts the kidney’s excretion of urate/uric acid. However, many eating plans for weight loss may not be suitable for a person with gout, eg, high protein, green leafy vegetables, seafood and so on. So weight loss may be a long-term strategy rather than one to address during a gout attack or while the person is being titrated to the correct dose of uric acid lowering medicine.
- For these reasons, advice about being more active and losing weight should be given once the person has achieved their uric acid treatment goal and is no longer experiencing painful gout attacks.
2. Acute gout attacks
- A person’s urate/uric acid levels usually reduce during an acute attack.
- Up to 40 percent of people will have a normal uric acid level (0.36 mmol/L) during an acute attack.
- Just before a gout attack high levels of urate/uric acid form sharp crystals in a joint. These crystals cause the body to have an inflammatory response resulting in a red swollen painful joint.
- After the pain of the acute gout attack goes away the crystals remain in the joint causing damage to the joints and bones.
- With each new attack the size and number of crystals grow and sometimes can be seen as lumps under the skin (tophi).
- As the crystals grow with each acute attack, they cause damage to joints and bones.
- When people present to primary care with a first gout attack, they are highly likely to have had previous gout attacks without knowing – ask about previous sore joints and injuries that took a long time to settle.
- Gout is a marker for other long-term conditions such as type 2 diabetes and cardiovascular disease.
3. Whānau Māori and Pacific peoples with gout
- Gout is both an equality and equity issue for whānau Māori and Pacific peoples.
- Whānau Māori and Pacific peoples are two to three times more likely to get gout than other ethnicities (equality). More men than women get gout.
- Whānau Māori and Pacific peoples with gout are more likely to get gout at a much earlier age – even in their late teens and early 20s – than other ethnicities (equality issue).
- Whānau Māori and Pacific peoples with gout are five to ten times more likely to be admitted to hospital with severe gout attacks than any other ethnicities (equality).
- Whānau Māori and Pacific peoples with gout are far less likely to be prescribed long term uric acid lowering medicines than other ethnicities (equity).
- Whānau Māori and Pacific peoples with gout are far more likely to be prescribed short-term pain medicines such as NSAIDS than other ethnicities (equity).
- These equity and equality issues mean that whānau Māori and Pacific peoples with untreated gout are much more likely to experience impacts to continued employment, ability to engage with families, participate in community activities and play sport and be active as well as mental and emotional wellbeing issues caused by self-blame and stigma (equity).
- There are strongly held, long-standing beliefs in Māori and Pacific communities that:
- Gout is caused by excessive consumption of certain foods, especially seafood and beer.
- Gout is temporary and goes away when the pain goes away.
- Gout is treated by pain medicine.
- If you get gout you only have yourself to blame.
People with gout suffer stigma and judgment from their communities, employers, and agencies that believe that gout is self-inflicted and caused by a lack of self-control when it comes to the consumption of beer and seafood. People with gout are often subject to ridicule and derision and end up believing they are to blame for their gout.
These longstanding beliefs have been confirmed by some primary care teams (1) continuing to prescribe pain relief for acute attacks and primarily talking about dietary changes without discussing the causes and impacts of gout and benefits of long-term treatment.
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↗️ Learn more from our Gout Guide page on Equity
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4. Impacts of gout on patients and their families
As whānau Māori and Pacific peoples get gout at much younger ages and have the condition for a longer time the impacts are significant.
- Employment - employers often blame employees for gout attacks and a couple of acute attacks will easily use up sick leave entitlements.
- Increased difficulty being active and managing weight.
- Participation in family activities with their children and families.
- Participation in and contributions to community activities – church and so on.
- Mental and emotional wellbeing challenges created by not being able to fully participate in family life, being given inaccurate medical advice leading to self-blame.
- Reinforcement of long held incorrect community beliefs about the causes of, and appropriate treatment for gout.
5. Medicines for pain relief during gout attacks (g****out attack / pain medicines)
- Ongoing prescribing of NSAIDs and similar pain relief medicines can have serious side effects.
- Whānau Māori and Pacific peoples with gout need to be aware of those serious side effects and the dangers of buying these medicines over-the-counter as well as sharing these medicines.
6. Treatment goals
- The treatment goal for a person without tophi is 0.36 mmol/L.
- The treatment goal for a person with tophi is 0.30 mmol/L. This lower treatment goal is to ensure that over time the significant urate/uric acid crystals in the joints dissolve and the damage to joints and bones resolves itself.
7. Uric acid lowering medicines
- The most commonly prescribed uric acid lowering medicine is allopurinol.
- Allopurinol prevents the body from making too much urate/uric acid.
- People start on a low dose which is increased every month until they achieve their treatment goal (uric acid level of 0.36 mmol/L or 0.30 mmol/L if they have tophi).
- People should be advised of the rare but serious side effect of a bad rash after starting allopurinol and to contact your team and stop taking allopurinol if a bad rash occurs.
- The person will usually stay on that final dose of medicine for the rest of their life. This needs to be explained clearly to people before starting allopurinol.
- Before starting on allopurinol patients of Han Chinese ethnicity should be tested for HLA-B*58:01 to check for allopurinol sensitivity.
- Once a person achieves their treatment goal, they should have their uric acid levels checked every 12 months unless they have an acute attack. Any acute attack might indicate the need to increase the dose of allopurinol.
- When starting allopurinol (or any other uric acid lowering medicine) people should be prescribed prophylaxis of colchicine (preventative pain relief) for up to 6 months as well as prescribed a short course of other pain relief in the event the person gets an acute attack.
- Acute gout attacks are common while titrating as the uric acid crystals in the joints dissolve and urate/uric acid is released into the bloodstream. This needs to be explained clearly to people and a short-term pain relief script provided in case of an acute attack.
- The person should keep taking allopurinol during an acute attack – it will not make the attack worse.
- A person can start taking allopurinol during an acute attack although this is not common practice.
- It’s good practice to regularly follow up a person for 12 months after reaching their treatment goal to make sure the person is persisting with taking allopurinol, is not experiencing gout attacks and has continuity of supply.
- If a person stops taking allopurinol, then their urate/uric acid levels will rise quite quickly and they will get a gout attack.
- Depending on how long the person stopped their medicine for, they may have to start the titration process again.
- Young men believe that taking medicines every day in their 20s and 30s can be a sign that they are unhealthy. A comprehensive discussion about the potential impact of their gout, the limited success of diet-controlled treatment and their uncertainty around making changes can help this particular group to see that the benefits of being pain-free might outweigh their reluctance to take medicine every day.
Quizzes
Before any gout education use these quizzes as a pre–assessment to see what you or your team already knows about gout.
After gout education use this quiz to assess your team’s knowledge.
Gout knowledge quizzes
Gout knowledge quiz
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<img src="/icons/book_blue.svg" alt="/icons/book_blue.svg" width="40px" /> Click file to open in a new tab (PDF)
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Post education session – gout knowledge quiz
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<img src="/icons/book_blue.svg" alt="/icons/book_blue.svg" width="40px" /> Click file to open in a new tab (PDF)
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He Ako Hiringa
See He Ako Hiringa gout page for key information about gout
Beyond medicines for gout
Link to page
He Ako Hiringa Quiz
Assessment: Beyond medicines for gout
Link to page
More education for your team
Clinical team members:
[ARTICLE] Managing gout in primary care: Part 1 - BPAC, NZ
[PODCAST] Episode one – initiating new medicines (part 1)
Non-clinical team members such as health coaches, kaiawhina and community support workers
[WEBINAR] Understanding gout : Part 1
Link to PDF of webinar slides:
Link to webinar questions and answers (DOCX:
[WEBINAR] Understanding gout : Part 2
Link to webinar slides (PPTX)
References:
See all Gout Guide References