Improvement in Gout Management by Non-Rheumatologists Following Introduction of Guidelines

Swan S Yeap, Consultant Rheumatologist,

Other Contributors:

December 21, 2012

Dear Editor,

We read with interest the article by Doherty et al [1] where they lament suboptimal care of patients with gout, as the majority are managed by non-specialists. In 2005, we had surveyed non-rheumatologists on their practices regarding the management of gout [2]. Of the 128 respondents, 52.3% were general practitioners (GPs). A significant proportion of respondents were treating gout sub-optimally; 50% would stop allopurinol during an acute attack, once allopurinol was started, only 54.7% would continue indefinitely and 15% would treat asymptomatic hyperuricemia.
As a result of this, in October 2008, the Malaysian Society of Rheumatology and Ministry of Health, Malaysia, published the Clinical Practice Guidelines on the Management of Gout (Gout CPG) which was made available online [3] and in hard copy. To publicise the CPG, a series of weekend rheumatology workshops were run, where the Gout CPG was a topic. These are the results of a second survey done after the introduction of the Gout CPG.
A cross-sectional self-administered questionnaire survey was carried out among doctors attending these workshops. There were 9 workshops carried out between April 2010 and February 2012. Participation in the survey was voluntary. 366 questionnaires were handed out to the all participants of the workshops on the last day, of which 296 (80.9%) were returned. 291 (98.3%) of respondents stated that they treated gout, whose answers were further analysed. With regards to specialty, 33.8% of the respondents were GPs, 46.7% Medical Officers (studying for post-graduate physician qualifications) and 7.7% were general physicians. With regards to experience, 29.3% had graduated less than 5 years ago, 21.7% between 5-10 years ago and 49% more than 10 years ago. Only 12.5% would stop previously prescribed allopurinol during an acute attack, compared to 50% in the previous study. Once started, 68.0% (compared to 54.7% previously) would continue allopurinol indefinitely. Regarding urate levels while on treatment, 11.3% would be satisfied with levels in the high normal (upper third) range, 24.1% middle (middle third) range, 7.9% low normal (lower third) range and 35.4% anywhere within the normal range. This is very similar to the previous survey. 3.4% (compared to 15% previously) would treat asymptomatic hyperuricemia. There were no significant differences (p>0.05 on Kruskal-Wallis tests) in the above management principles between the different specialties or with regards to their years of experience. As this was a self-administered questionnaire, there may be a variation between theory and practice, but at least more doctors seemed to have the correct theoretical knowledge after this series of workshops. The other weakness is that this questionnaire was administered the day after the lectures, so the information was fresh in the participants' memories but may not be remembered long-term. However, all participants of the workshops went home with a copy of the Gout CPG which they can use for future reference.

We conclude that it is encouraging to note that following the introduction of, and teaching on, the Gout CPG, non-rheumatologists are treating gout more appropriately.

Conflict of Interest:

None declared

Conflict of Interest

None declared