If Treat-to-Target Works for Gout, Who Will Implement It in Primary Care?

To the Editor:

We read with great interest the editorial by Singh¹ commenting on the study by Mulqueen et al² that showed similar rates of monosodium urate crystal dissolution in joints and tendons during treat-to-target (T2T) urate-lowering therapy (ULT). Dr. Singh eloquently articulates the compelling pathophysiological rationale for T2T: complete tophus resolution on dual-energy computed tomography within 12 months represents “an impressive notable finding” that is “uncommon or rare in chronic medical conditions.”¹ We share his enthusiasm for this evidence but wish to raise a critical implementation question: who will deliver T2T care to the millions of patients with gout managed outside rheumatology clinics?

Gout is predominantly managed in primary care settings. Claims-based analyses consistently demonstrate that 70% to 90% of patients receive care exclusively from primary care physicians (PCPs), with fewer than 10% ever consulting a rheumatologist.³ Yet, the evidence supporting T2T, including the studies cited by Dr. Singh,¹ derives almost entirely from trials conducted by rheumatologists in specialized centers. The question is not whether T2T works, but whether it can be implemented where most gout care actually occurs.

Current data suggest a substantial implementation gap. A systematic review found that globally, only 34% of patients on ULT achieve the target serum urate level of < 6 mg/dL.⁴ In primary care specifically, a systematic review of general practice studies found that only approximately 25% of gout patients had serum urate checked regularly.⁵ Adherence to ULT—already among the lowest for chronic conditions—shows 38% nonpersistence at year 1 and 57% by year 5.⁶ A recent survey confirmed that these gaps extend to fundamental knowledge: only 7.9% of PCPs correctly identified appropriate ULT initiation timing, and merely 32% recommended long-term therapy.⁷

Dr. Singh appropriately criticizes the “treat-to-control symptoms” approach⁸ of the American College of Physicians for potentially leading to “suboptimal treatment of the underlying pathology in gout.” However, the existence of conflicting guidelines from major organizations creates confusion that disproportionately affects generalists. A systematic review identified substantial knowledge gaps among providers as a key barrier to optimal gout care, with many PCPs treating gout as an acute rather than a chronic condition.⁹

Encouragingly, Dr. Singh highlights the UK nurse-led program achieving 95% T2T success vs 30% with usual primary care.¹⁰ This dramatic difference underscores both the problem and a potential solution. Similar interprofessional models, including pharmacist-led and nurse-led protocols, offer scalable approaches for resource-limited settings where rheumatology access is scarce.

The pathophysiological evidence for T2T is now unequivocal. The next frontier is implementation science—ensuring that this evidence reaches the settings where patients actually receive care. We propose that future research and guideline updates prioritize simplified decision-support tools and scalable interprofessional interventions. Gout is indeed “curable,” but only if evidence-based care extends beyond specialty clinics to primary care, where the vast majority of patients are managed.

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