276. Out-Patient Management of Gout by UK Rheumatologists: The BSR National Gout Audit

Abstract

Background: Gout is predominantly managed in primary care, where management is frequently suboptimal. Little is known about gout management in rheumatology clinics. This national audit on behalf of the BSR/BHPR standards, audit and guidelines working group compared out-patient management of gout by rheumatologists against national and international guidelines. Method(s): All new out-patients seen with gout between 6 May 2013 and 28 June 2013 in UK rheumatology units were eligible. Using a web-based form housed on a secure server, data collected included reason for referral, how gout was diagnosed, clinical characteristics, current urate-lowering therapy (ULT), initiation/changes to ULTs, target serum urate (SUA) levels, prophylaxis against acute attacks, changes to diuretics, and follow-up. Audit standards pertaining to diagnosis (AS1, AS2), indications for ULT (AS3), diuretic cessation (AS4), target SUA levels (AS5), allopurinol starting dose (AS6, AS7), prophylaxis (AS8), uricosuric/febuxostat use (AS9), and febuxostat use in patients with heart disease (AS10) were derived from the BSR/BHPR and EULAR gout management guidelines and the NICE febuxostat technology appraisal. Result(s): 434 patients were recruited from 91 rheumatology units. Mean age was 59.8 years (S.D. 15.1); 356 (82%) were male. The most frequent reasons for referral were diagnostic uncertainty (234, 54%), failure to respond to primary care management (122, 28%), and complex comorbidity (107, 25%). Rheumatology follow-up was arranged for 279 (64%). AS1/AS2: Gout was diagnosed on clinical grounds in 362 (83%) and by microscopic crystal identification in 57 (13%). 108 (25%) had tophi. AS3: Of 382 with at least one indication for ULT, ULT was continued/initiated in 291 (76%). AS4: Of 106 taking a diuretic, this was reduced/stopped in 30 (29%). AS5: Of 356 with SUA>360 mumol/l, the letter to GP specified a target SUA level <300 mumol/l in 150 (42%); and was not specified in 121 (34%). AS6/AS7: Of 158 who started allopurinol, the starting dose was 50mg daily in 10 (6%), 100mg in 129 (82%), and 300mg in 9 (14%). In those with eGFR<60 ml/min, the highest starting dose was 100 mg. AS8: Of 199 who started a new ULT, prophylaxis was prescribed for 190 (98%). AS9: Of 50 started on a uricosuric/febuxostat, 42 (84%) had taken allopurinol previously. AS10: Of 44 commenced on febuxostat, 8 (18%) had a history of ischaemic heart disease/cardiac failure. Conclusion(s): Use of ULTs, allopurinol starting dose, use of prophylaxis, and use of allopurinol first-line before uricosurics/febuxostat concords well with national and international guidelines. It appears that use of febuxostat conflicts with NICE guidance in one in five people. Areas for improvement include requirement for a crystal-proven diagnosis, possibly reflecting available expertise and current rheumatology training, and diuretic cessation. Prospective data are required to assess achievement of target SUA levels.