Q&A: Pharmacist Shares Insight on Treating Gout

A leader of a pharmacist-managed gout clinic has some insight that can help pharmacists improve the management of their patients’ gout.

Vanita Panjwani, BS, PharmD, a clinical pharmacy specialist and adjunct clinical faculty member at Wayne State University College of Pharmacy, helped lead the clinic at the John D. Dingell Veterans Affairs Medical Center as part of the postgraduate second year (PGY-2) ambulatory care pharmacy resident enhancement project.

The pharmacist-led clinic monitored referred patients’ titration of urate-lowering therapy and considered their medication tolerance. The pharmacists also provided medication and lifestyle education in line with guidelines from the American College of Rheumatology (ACR) and the European League Against Rheumatism.

Dr. Panjwani worked as a clinical pharmacy specialist alongside a PGY-2 pharmacy resident. Resident Thanh Lam helped start the clinic in 2012, while former pharmacy resident Margi Shah worked in the clinic and completed a project that examined clinic outcomes.

To gain insight on gout treatment, Pharmacy Times spoke with Dr. Panjwani, who also lectures on gout management to second-year students at Wayne State University School of Medicine.

Q: What are some ways pharmacists helped manage their patients’ gout at the clinic?

A: In the gout clinic, pharmacists explain how prophylactic (anti-inflammatory) and maintenance (urate-lowering) medications work together to reduce gout burden. The importance of getting the uric acid to “goal” is advised to prevent or reduce gout flares and the development of tophi.

During the first 6 months of starting urate-lowering therapy, the chance for flares is higher as the uric acid gets mobilized from the joints. Taking daily prophylactic colchicine overlapped with urate-lowering therapy can help reduce gout flare burden when taken for the first 6 months.

Initially, patients are seen every 6 to 8 weeks to titrate their urate-lowering therapy to achieve goal serum uric acid level, which the ACR defines as <6.0 mg/dl.

After 6 months, by which time the uric acid is usually at goal, we can stop daily colchicine and just give the patients 9 tablets per month to help them in the event that they have an acute gout flare.

Patients are closely monitored for adverse effects, and therapy adjustments are made accordingly.

Once patients are at goal, they are either discharged from the gout clinic or can be followed up with through the gout phone clinic, which was created for quick follow-up as well as to see if daily colchicine could be changed for as-needed use.

Q: What are some important patient education counseling points for patients with gout?

A: We make sure that the patient understands how to take colchicine in the event of an acute gout flare.

Early recognition of a gout flare is crucial as well as timing of the colchicine. If a patient takes 2 colchicine tablets at the first onset of gout flare, and 1 tablet 1 hour later, most of the time, the gout flare can be terminated, reducing unnecessary trips to the emergency room (ER). If patients wait more than 24 to 48 hours, then the colchicine will not work as well, and they could end up going to the ER.

Q: What nonpharmacological treatments can pharmacists inform their gout patients about?

A: Nonpharmacological treatments remain the cornerstone of gout management.

I cannot overemphasize the role dietary factors play in gout management. At every visit, a detailed interview is done to determine if the patients are consuming alcohol, especially beer and liquor.

We also advise patients to limit their intake of beef, lamb, pork, and seafood with high purine content such as shellfish and shrimp. Weight loss can also reduce uric acid levels.

We motivate patients that if they follow the nonpharmacological treatments, they may require a lower dose of gout medication.

Q: What other advice would you give to patients who want to avoid triggers of gout?

A: When a patient is aware of their dietary triggers, they tend to avoid them since they can remember how painful the gout attack may have been in the past.

If the trigger food is consumed, the patient needs to keep colchicine on hand and start the acute gout dosing regimen as soon as they feel the “tingle” or first sign of a flare.