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Quality of care indicators for gout

 

Clinical bottom line.

In the absence of overwhelming evidence on gout treatment from randomised trials, a set of 10 quality of care indicators was determined from available evidence and expert opinion.

References


TR Mikuls et al. Quality of care indicators for gout management. Arthritis & Rheumatism 2004 50: 937-943.

Studies

A comprehensive literature review provided a background for treatment of gout. An initial panel reviewed this literature, and set a number of quality indicators based on evidence. A second panel of eight US and one UK experts then discussed and voted on the validity of these indicators. Only when there was a high level of agreement (at least seven of nine concurring) were these accepted.

Results

There were 120 articles in the final database, of which only 23 were randomised trials. For 10 indicators (Table 1) was there a high level of agreement.

Table 1: Quality of care indicators for gout management

 
If
Then
Because
Uric acid lowering therapy
1 If initial prescription for allopurinol AND patient has significant renal impairment (serum creatinine 2 mg/dL or more, or creatinine clearance below 50 ml/min) Initial daily allopurinol dose should be less than 300 mg per day Risk of toxicity is increased in gout patients given higher doses than this
2 If patient has prescription for xanthine oxidase inhibitor with either azothiaprine or 6-mercaptopurine Dose of azothiaprine/6-MP should be reduced by minimum of 50% Concurrent use of xanthine oxidase inhibitor leads to increase in serum level of azothiaprine, increasing risk of toxicity
3 Patient with tophaceous gout has initial prescription for urate lowering medication and lacks both significant renal impairment and peptic ulcer Prophylactic anti-inflammatory agent should be given concomitantly Anti-inflammatory agent reduces risk of rebound gout attacks, which frequently follow initiation of urate lowering therapy
4 Patient has asymptomatic hyperuricaemia with no prior history of gouty arthritis or tophaceous deposits and no prior history of nephrolithiasis or hyperuricosuria and no ongoing treatment of malignancy Urate lowering therapies should not be initiated There is no widely accepted indication for the treatment of asymptomatic hyperuricaemia
5 Gout patient begins urate lowering therapy and has either a history of nephrolithiasis or significant renal insufficiency xanthine oxidase inhibitor should be started as the initial urate lowering therapy rather than a uricosuric agent In contrast to xanthine oxidase inhibitors, uricosuric agents increase renal excretion of urate, enhancing risk of nephrolithiasis, and may have diminished efficacy
6 A patient has hyperuricaemia and gouty arthritis characterised by any of tophaceous deposits, gouty erosive changes on radiographs, gout attack frequency of two or more per year Patient should be offered a treatment with a urate lowering drug Urate lowering drugs have been well tolerated and effective in decreasing attack frequency and disease severity for those with severe gout
7 A gout patient has a prescription for a xanthine oxidase inhibitor A serum urate level should be checked at least once during the fist six months of continued use Periodic serum urate measurements are required for appropriate dose adjustments
Behaviour modifications
8 A patient is diagnosed with gout and has either obesity (BMI 28 or over) or frequent alcohol use (one or more alcoholic drinks a day) As part of their overall therapy patients should be advised on the importance of weight loss and/or decreased alcohol use Weight loss and reduction of alcohol intake may be beneficial aspects of gout therapy
Use of anti-inflammatory agents
9 A patient has gouty arthritis and lack both of the relative indications to gout treatment of significant renal impairment and peptic ulcer disease The patient should be treated with an anti-inflammatory agent to include one of the following: NSAID, ACTH or glucocorticoid, or colchicine Anti-inflammatory agents have been shown to be effective and well tolerated for the short term treatment of acute gout. Patients with renal impairment or ulcer disease are at higher risk for gout medication toxicity
10 A gout patient receives long term prophylactic oral colchicine (a minimum daily dose of 0.5 mg for six months or longer) and has significant renal insufficiency A complete blood cell count and creatine kinase should be done at least once every six months of continued use The risk of colchicine related myopathy and myosuppression appears to be substantially increased with reduced renal function

 

Comment

These seem to be sensible based on the evidence available in the literature. The indicators were set in March 2002, and so do not contain evidence that might have become available more recently.