Quality of Care in Patients with Gout: Why is Management Suboptimal and What Can Be Done About It?

Abstract

Gout is a common inflammatory arthritis. We know a great deal about its etiopathogenesis and have relatively safe and effective therapies for it. Gout, however, remains a poorly managed disease with mistakes made in securing an accurate diagnosis and in using appropriate therapies for acute and chronic stages of the disease. Synovial fluid analysis with polarizing microscopy is the "gold standard" for confirming the diagnosis of gout but has been used in fewer than 10% of all patients diagnosed with gout. The newly adopted European clinical guidelines offer a practical alternative to synovial fluid analysis, but primary care physicians are not well-versed in their use. Other serious errors in the management of gout are related to the use of medications to treat acute and chronic gout. Frequently, the anti-inflammatory drugs used to treat acute symptoms and urate-lowering drugs used to prevent long-term destruction are improperly dosed, leading to dissatisfaction on the part of patients and physicians. Widespread education about evidence-based diagnostic and treatment guidelines is desperately needed.

Effectiveness of a pharmacist-based gout care management programme in a large integrated health plan: results from a pilot study

“…Why, then, is unsuccessful control of sUA so frequent? A number of factors contribute to suboptimal gout management 11 12 14. Adherence to ULT is poor when compared with medication adherence in other chronic conditions 15.…”

“…Both recommend that patients with tophaceous or recurrent gout be treated with urate-lowering therapy (ULT) to a target sUA of <6 mg/dL. Unfortunately, only a minority of patients with gout receives appropriate treatment, including doses of ULT sufficient to achieve this target 11. There are several reasons for this deficiency which have been addressed by other authors 12 13.…”

Overview of Serum Uric Acid Treatment Targets in Gout: Why Less Than 6 mg/dL?

“…degree of uric acid suppression by different medical regimens, and this is the likely explanation for the different outcomes. Although the disease is well understood, with good treatment options available, gout is often poorly managed [28,70]. Challenges of treating and managing gout include physician adherence to recommended guidelines when prescribing, and patient adherence to their prescribed treatment regimens [71,72].…”

Gout Transitions from Medieval Times into the 21 Century

“…Febuxostat, (XOI) has been recently added to the ULT armamentarium. Despite familiarity with these drugs, patient and physician factors lead to sub-optimal usage as summarized in recent reviews [4,5]. The guidelines provide recommendations to avoid common prescribing errors.…”

“…Studies have documented that 97% of non-protocol patients in cohorts never exceed Allopurinol doses of 300 mg per day [4] which is problematic as the mean dose required to lower serum urate < 6 mg/dL has been shown to greater than 370 mg per day [8]. The dose should be titrated up based on serial serum urate results and patient tolerance (e.g., absence of drug rash or hepatic toxicity).…”