Concordance of the management of chronic gout in a UK primary-care population with the EULAR gout recommendations

Abstract

Objectives: To assess concordance of the management of chronic gout in UK primary care with the European League Against Rheumatism (EULAR) gout recommendations. Methods: A postal questionnaire was sent to all adults aged .30 years registered with two general practices. Patients with possible gout attended for clinical assessment, at which the diagnosis was verified clinically. Aspects of chronic gout management, including provision of lifestyle modification advice, use of uratelowering therapies (ULT) including dose titration to serum urate (SUA) level, prophylaxis against acute attacks, and diuretic cessation were assessed in accordance with the EULAR recommendations. Results: Of 4249 (32%) completed questionnaires returned, 488 reported gout or acute attacks and were invited for clinical assessment. Of 359 attendees, 164 clinically confirmed cases of gout were identified. Advice regarding alcohol consumption was recalled by 59 (41%), weight loss by 36 (25%) and diet by 42 (29%). Allopurinol was the only ULT used and was taken by 44 (30%); 31 (70%) were taking 300 mg daily. Mean SUA was lower in allopurinol users than non-users (318 vs 434 mmol/l) and was less often .360 mmol/l in allopurinol users (23% vs 75%). Eight patients had recently commenced allopurinol; two of these also were taking prophylactic colchicine or non-steroidal anti-inflammatory drugs. Of 25 patients with diuretic-induced gout, 16 (64%) were still taking a diuretic. Conclusion: Treatment of chronic gout is often suboptimal and poorly concordant with EULAR recommendations. Lifestyle advice is infrequently offered, and allopurinol is restricted to a minority. Persistent hyperuricaemia was often seen in allopurinol non-users, but was also in allopurinol users, suggesting that doses .300 mg are often necessary.

Poorly controlled gout: who is doing poorly?

“…Studies in the primary care setting in the United Kingdom showed that 20% of patients with tophaceous gout and 33% of patients with recurrent attacks were on allopurinol, and only 33% of patients on urate-lowering therapy attained the SUA treatment target. (12,13) Similar results were seen locally: an audit of the rheumatology clinic in a restructured hospital found that only 25% of patients started on allopurinol had achieved their target SUA levels at one-year follow-up. (3) …”

Gout in the elderly

“…Hyperuricemia is a prerequisite for the development of gout, but only 10% of people with hyperuricemia will develop gout 7 . Treatment of hyperuricemia with urate lowering therapy (ULT) has been demonstrated to reduce the frequency of acute attacks 8,9 . This supports a causal association between hyperuricemia and gout.…”

Diet in Gout and Hyperuricemia

“…Кроме того, хотя основные принципы диетотерапии при пода-гре остаются неизменными на протяжении столетий, в последнее время некоторые из них пересмотрены и продолжают изучаться, но далеко не всегда новые данные использу-ются в конкретных рекомендациях, даваемых врачом пациенту. Это происходит, в частно-сти, вследствие низкой осведомленности вра-чей о принципах профилактики и лечения по-дагры, что подтверждено рядом исследований [14][15][16][17].…”