Background Gout is one of the few curable conditions in Rheumatology, affecting 1.4% of the adult population in the UK. It is also one of the most frequently presenting conditions, both in and outpatient settings, but yet management of this disease is still overlooked and inadequate.
Objectives Audit of gout management, adhering to BSR and EULAR guidelines
Methods We retrospectively selected 50 random patients that were registered to the Rheumatology department at Basildon Hospital, with a diagnosis of gout in the last 3 years. We then compared our management against the British Society of Rheumatology (BSR) 2007 and European League against Rheumatism (EULAR) 2006 guidelines.
Results Our cohort consisted of predominantly males (82%) with the most prevalent age group being 51-75 years (70%). The most common diagnosis was by clinical means (66%), despite the majority of patients having aspirations, only 6% of patients' aspirate was positive for urate crystals. Furthermore, only 20% of patients had tophi.
For an acute attack, most of the patients received steroids (67%), however, in about 32% (10), colchicine was prescribed; this was mainly in the inpatient setting.
The majority of the initial urate lowering agent (ULA) was commenced after two or more attacks (89.5%). However, in a few circumstances where patients had existing chronic kidney disease (CKD) or tophi, treatment was initiated after a single attack (4%). The general consensus between the consultants was to start allopurinol 100mg following two weeks of a gouty attack (78.3%).
Ninety percent (48/50) were given prophylaxis with NSAIDs or colchicine, but only 50% stated the course duration at the initial visit. For those patients that received prophylaxis and were compliant, only 20% (5/24) had a flare of their gout, whilst 60% (3/5) of patients not on prophylaxis encountered an attack.
Post ULA treatment, only 22% achieved their respective target of <300μmol/L. On review of the target levels by EULAR guidelines, the majority of patients (60%) achieved the target urate level of 360μmol/L.
It was also found that the consultants would discharge patients once target urate levels were achieved, with the exception of tophaceous gout or those with co-morbidities.
Conclusions We are able to demonstrate that ULA can prove to have its benefits, not only when commenced after two weeks of an attack, but also when given after 24 hours following resolution of an attack under special circumstances such as CKD or those with tophi.
Furthermore, we have shown that adjusting the urate target level to that of EULAR, allows the following:
1) A more realistic target to be achieved
2) A reduced number of flares and respectable control of the disease.
Finally, the fundamental finding is that ULA in combination with prophylaxis (usually colchicine) is the most important treatment for reducing the number of gout flares, although seldom incorporated.
Arthritis Research UK. Gout. URL: http://www.arthritisresearchuk.org/arthritis-information/data-and-statistics/gout.aspx. [Accessed 27-01-2014]
Kelsey M et al. British Society for Rheumatology and British Health Professionals in Rheumatology Guideline for the Management of Gout. BSR 2007.
Zhang W et al. EULAR evidence based recommendations for gout. Part II: Management. Report of a task force of the EULAR Standing Committee For International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum 2006; 65: 1312-1324.
Disclosure of Interest None declared