In view of the common observation of variability in the management of gout, these indicators remain quite timely. The authors note that certain factors make the need for these indicators more acute, such as the common use of indomethacin to treat gout, a medication which should be used with great caution in the elderly. The literature has also described significant errors in the use of intravenous colchicine and in the use of allopurinol.
A 10-member gout treatment expert panel reviewed proposed indicators. An indicator was considered valid if the median rating of the panel was = 7 on a 1-9 scale of validity. The panel ultimately agreed on 120 articles for the final reference database, 23 of which were randomized clinical trials.
The quality indicators used included 3 categories: 1) use of urate-lowering therapy, 2) behavioral modifications and 3) use of anti-inflammatory medications. They are reviewed in detail in Table 1. In the article, supporting references for each recommended indicator were provided.
|Table 1: Quality Indicators for Gout Management Rated Valid by Panel|
|Use of uric acid-lowering therapy|
|1||If a patient has renal insufficiency (creatinine = to 2.0 or creatinine clearance = to 50ml/min), the patient should be started on < 300mg/d of allopurinol, because of increased allopurinol toxicity with renal insufficiency.|
|2||If a patient receiving azathioprine or 6-MP is to receive allopurinol, then the dose of azathioprine or 6-MP must be reduced by a minimum of 50%, to avoid potentially toxic increases in azathioprine or 6-MP level.|
|3||If a patient with tophaceous gout is to be started on allopurinol, and the patient has neither renal insufficiency (as defined in #1 above) nor peptic ulcer disease, then she should receive colchicine or NSAID prophylaxis in view of the frequently increased gout attacks which occur early in allopurinol therapy.|
|4||Asymptomatic hyperuricemia should not be treated. Asymptomatic = no gout, tophi, kidney stone, hyperuricosuria or ongoing treatment of malignancy.|
|5||Patients with renal insufficiency (as defined in #1 above) or history of kidney stone should be treated with allopurinol rather than a uricosuric agent.|
|6||Indications for the use of a urate-lowering agent include: 1) tophi, 2) erosive changes on x-ray due to gout, 3) gout attacks = 2 per year.|
|7||If a patient is given allopurinol, serum urate should be checked at least once during the first 6 months, to consider dose adjustment.|
|8||If a patient with gout is obese (BMI = 28) or uses alcohol = 1 drink a day, they should be advised that weight loss and/or decreased alcohol use may be beneficial in therapy of gout.|
|9||If a patient with acute gouty arthritis has neither renal insufficiency (as defined in #1 above) nor peptic ulcer disease, then the patient should be treated with NSAID, ACTH or glucocorticoid (systemic or intra-articular) or colchicine.|
|10||If a gout patient is treated with colchicine at a minimum of 0.5mg daily for 6 months or longer, and has renal insufficiency (as defined in #1 above), then CBC and CPK should be checked at least once q6 months.|
Now, 5 ½ years after these indicators have been published, they still contain many valuable suggestions. Some updates that may be considered are:
It is important to increase consistency in physician practice patterns where the medical literature is clear and consistent, and this is applicable to many of the recommendations in Table 1, and to the updated suggestions above. Where the published literature cannot provide definitive recommendations for specific areas of gout management, the availability of expert consensus opinion is valuable to clinicians. Mikuls TR, MacLean CH, Olivieri J, Patino F, Allison JJ, Farrar JT, Bilker WB, Saag KG: Quality of Care Indicators for Gout Management. Arthritis Rheum, 50:3, 937-943, 2004.