Division of Rheumatology, Department of Medicine, National University Hospital, National University Health System, Singapore.
Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
Int J Rheum Dis. 2020 Aug;23(9):1136-1144. doi: 10.1111/1756-185X.13855. Epub 2020 Jun 1.
Urate-lowering therapy (ULT) is effective in gout, but suboptimal management with wide variability in dose escalation remains widespread. We protocolized dose escalation of ULT to improve gout management. The aim was to reduce time to achieve target serum urate (SU) <360 µmol/L.
Process improvement tools were used to identify underlying causes of prolonged time to target SU. We designed a nurse-led telemedicine intervention for dose escalation of ULT. Patients with gout with SU ≥360 µmol/L meeting indications for ULT at a single institution were recruited. Exclusion criteria were estimated glomerular filtration rate <30 mL/min, pregnancy, cognitive impairment and poor mobility. A nurse-led telemedicine clinic was set up to perform patient education, monitoring of adverse events and drug escalation. We partnered with primary healthcare centers for routine blood tests.
From July 2016 to December 2017, 127 patients were recruited. Median time to target SU was 19.0 weeks (interquartile range [IQR] 11.0-31.0). Median dose of allopurinol was 300 mg/d (IQR 200-400) in normal renal function and lower in renal impairment. Median telemedicine calls required to achieve target SU was 2 (IQR 1-3). No patient was hospitalized for gout flares. Two patients had adverse drug reactions, one required cessation of allopurinol for rash with eosinophilia, the other had self-resolving ulcers and allopurinol was continued. Lower baseline SU and number of gout flares were associated with attainment of target SU.
A nurse-led telemedicine for gout care is effective and safe. Our results affirm the utility of telemedicine in increasing access to care and lower healthcare utilization.
降低尿酸治疗（ULT）对痛风有效，但剂量递增管理不理想，剂量递增差异很大。我们制定了 ULT 剂量递增方案以改善痛风管理。目的是减少达到目标血清尿酸（SU）<360µmol/L 的时间。
使用过程改进工具确定导致达到目标 SU 时间延长的根本原因。我们设计了一种护士主导的远程医疗干预措施来增加 ULT 的剂量。在一家机构中，招募了 SU≥360µmol/L 且符合 ULT 指征的痛风患者。排除标准为估计肾小球滤过率<30ml/min、妊娠、认知障碍和行动不便。设立了一个由护士主导的远程医疗诊所，以进行患者教育、监测不良反应和药物升级。我们与初级保健中心合作进行常规血液检查。
从 2016 年 7 月至 2017 年 12 月，共招募了 127 名患者。达到目标 SU 的中位时间为 19.0 周（四分位距 [IQR] 11.0-31.0）。在肾功能正常的情况下，别嘌呤醇的中位剂量为 300mg/d（IQR 200-400），在肾功能受损时则较低。达到目标 SU 所需的中位数远程医疗次数为 2 次（IQR 1-3）。没有患者因痛风发作住院。有 2 例患者出现药物不良反应，1 例因皮疹伴嗜酸性粒细胞增多而停止使用别嘌呤醇，另 1 例出现自限性溃疡，继续使用别嘌呤醇。较低的基线 SU 和痛风发作次数与达到目标 SU 相关。
护士主导的痛风远程医疗护理是有效和安全的。我们的结果证实了远程医疗在增加获得医疗服务和降低医疗保健利用方面的作用。
