SummaryBackgroundIn the UK, gout management is suboptimum, with only 40% of patients receiving urate-lowering therapy, usually without titration to achieve a target serum urate concentration. Nurses successfully manage many diseases in primary care. We compared nurse-led gout care to usual care led by general practitioners (GPs) for people in the community.MethodsResearch nurses were trained in best practice management of gout, including providing individualised information and engaging patients in shared decision making. Adults who had experienced a gout flare in the previous 12 months were randomly assigned 1:1 to receive nurse-led care or continue with GP-led usual care. We assessed patients at baseline and after 1 and 2 years. The primary outcome was the percentage of participants who achieved serum urate concentrations less than 360 μmol/L (6 mg/dL) at 2 years. Secondary outcomes were flare frequency in year 2, presence of tophi, quality of life, and cost per quality-adjusted life-year (QALY) gained. Risk ratios (RRs) and 95% CIs were calculated based on intention to treat with multiple imputation. This study is registered with www.ClinicalTrials.gov, number NCT01477346.Findings517 patients were enrolled, of whom 255 were assigned nurse-led care and 262 usual care. Nurse-led care was associated with high uptake of and adherence to urate-lowering therapy. More patients receiving nurse-led care had serum urate concentrations less than 360 μmol/L at 2 years than those receiving usual care (95% vs 30%, RR 3·18, 95% CI 2·42–4·18, p<0·0001). At 2 years all secondary outcomes favoured the nurse-led group. The cost per QALY gained for the nurse-led intervention was £5066 at 2 years.InterpretationNurse-led gout care is efficacious and cost-effective compared with usual care. Our findings illustrate the benefits of educating and engaging patients in gout management and reaffirm the importance of a treat-to-target urate-lowering treatment strategy to improve patient-centred outcomes.FundingArthritis Research UK.

ObjectiveOsteoarthritis (OA) is a common chronic condition in older individuals, but its association with other chronic conditions is largely unknown. This study aimed to systematically review the literature on comorbidities in individuals with OA compared to those without.MethodsWe searched 4 databases for observational studies on comorbidities in individuals with OA. Studies of OA only or in comparison with non‐OA controls were included. The risk of bias and study quality were assessed using the Newcastle‐Ottawa Scale. The prevalence of comorbidities in the OA group and the prevalence ratio (PR) and 95% confidence interval (95% CI) between OA and non‐OA groups were calculated.ResultsIn all, 42 studies from 16 countries (27 case‐only and 15 comparative studies) met the inclusion criteria. The mean age of participants varied from 51 to 76 years. The pooled prevalence of any comorbidity was 67% (95% CI 57–74) in individuals with OA versus 56% (95% CI 44–68) in individuals without OA. The pooled PR for any comorbidity was 1.21 (95% CI 1.02–1.45). The PR increased from 0.73 (95% CI 0.43–1.25) for 1 comorbidity to 1.58 (95% CI 1.03–2.42) for 2, and to 1.94 (95% CI 1.45–2.59) for ≥3 comorbidities. The key comorbidities associated with OA were stroke (PR 2.61 [95% CI 2.13–3.21]), peptic ulcer (PR 2.36 [95% CI 1.71–3.27]), and metabolic syndrome (PR 1.94 [95% CI 1.21–3.12]).ConclusionIndividuals with OA are more likely to have other chronic conditions. The association is dose‐dependent in terms of the number of comorbidities, suggesting multimorbidities. Further studies on the causality of this association and clinical implications are needed.

ObjectivesTo compare the efficacy and safety of topical non-steroidal anti-inflammatory drugs (NSAIDs), including salicylate, for the treatment of osteoarthritis (OA).MethodsPubMed, Embase, Cochrane Library and Web of Science were searched from 1966 to January 2017. Randomised controlled trials (RCTs) comparing topical NSAIDs with placebo or each other in patients with OA and observational studies comparing topical NSAIDs with no treatment or each other irrespective of disease were included. Two investigators identified studies and independently extracted data. Bayesian network and conventional meta-analyses were conducted. The primary outcomes were pain relief for RCTs and risk of adverse effects (AEs) for observational studies.Results43 studies, comprising 36 RCTs (7 900 patients with OA) and seven observational studies (218 074 participants), were included. Overall, topical NSAIDs were superior to placebo for relieving pain (standardised mean difference (SMD)=−0.30, 95% CI −0.40 to –0.20) and improving function (SMD=−0.35, 95% CI −0.45 to –0.24) in OA. Of all topical NSAIDs, diclofenac patches were most effective for OA pain (SMD=−0.81, 95% CI −1.12 to –0.52) and piroxicam was most effective for functional improvement (SMD=−1.04, 95% CI −1.60 to –0.48) compared with placebo. Although salicylate gel was associated with higher withdrawal rates due to AEs, the remaining topical NSAIDs were not associated with any increased local or systemic AEs.ConclusionsTopical NSAIDs were effective and safe for OA. Diclofenac patches may be the most effective topical NSAID for pain relief. No serious gastrointestinal and renal AEs were observed in trials or the general population. However, confirmation of the cardiovascular safety of topical NSAIDs still warrants further observational study.