Nurse-led care involved providing patients with holistic assessment, discussion of illness perceptions, and full information on gout, and encouraged them to share in decision making. First-line treatment was allopurinol, initially 100mg once daily with upwards titration in 100mg increments every 3–4 weeks according to serum urate concentrations, to a maximum of 900mg once per day. Second-line options were febuxostat or benzbromarone, and combination therapy was the last-line option. Those assigned to usual GP-led care were given the gout information booklet from Arthritis Research UK. They were able to discuss treatment of flares with the research nurse at baseline and at yearly assessments, but were referred to their GP for any enquiries about other aspects of disease management.
Nurse-led care was associated with higher use of urate-lowering therapy (97% at 1 year and 96% at 2 years; versus 47% and 56%, respectively, in the usual-care group), with higher mean allopurinol doses (460mg/day versus 230mg/day at 2 years, respectively. The risk of having two or more flares per year in year 2 (RR 0.33, 95% CI 0.19–0.57) or any tophi at the end of follow-up (RR 0·21, 95% CI 0·08–0·52) was lower in the nurse-led group. Nurse-led care was estimated to be associated with a cost per quality-adjusted life-year gained of £5066 at 2 years and was projected to be cost saving by 5 years.
A related comment notes that the study was limited by the lack of blinding, and the lack of uniform assessment of adverse effects in the usual care group meant that comparisons of this aspect were not possible. However the results suggest patients adhere to gout treatment when they receive information on causes, have regular follow-up and feedback, and where a treat-to-target approach is used.