Two thirds of gout patients do not receive preventative treatment

Only a third of patients with gout in the UK receive urate-lowering drugs within a year of diagnosis despite updated guidelines, a recent study suggests.

Close up image of feet with red protruding big toe joint.
Urate-lowering therapy should be discussed and offered to all people with a diagnosis of gout. | GETTY IMAGES

In 2017, the British Society for Rheumatology (BSR) updated the management of gout guidelines, to encourage the prescribing of urate-lowering therapy for the prevention of gout after a study found that only 27% of patients with gout were receiving preventative treatment.

The current guidelines state that all patients should be initiated on a urate-lowering drug after an acute attack has resolved. Allopurinol is the recommended first-line treatment and should be initiated on a low dose and titrated up every 4 weeks until serum uric acid level is below 300 micromol/L. Treatment is usually lifelong and regular monitoring is required. Clinicians should also provide lifestyle advice. 

New research

Researchers at King College London have recently investigated whether the initiation of urate-lowering therapy has improved since the guidelines were updated. They used the Clinical Practice Research Datalink to evaluate the management of 129,000 adults with a newly diagnosed gout in the UK between 2004 and 2020. 

There was only a modest improvement in the prescribing of urate-lowering drugs over the study period, from 26.8% in 2004, to 36.6% in 2019. There was also a decrease in prescribing in 2020 compared to 2019. The researchers suggest that this may be a reflection of the reduced access to care during the COVID-19 pandemic. 

According to the BSR guideline, when patients are treated with allopurinol, a target serum uric acid level of less than 300 micromol/L (a less stringent levels of less than 360 micromol/L is recommended by the European Alliance of Associations for Rheumatology). However, the researchers reported that only one in six patients were found to achieve this target level. They also found that patients with comorbidities such as chronic kidney disease, heart failure or obesity were more likely to be initiated on urate-lowering therapy but were less likely to achieve the target urate levels.

Straightforward initiation

The authors of the study concluded that the quality and success of gout care in the UK remain poor despite the updated guidelines. They said there is a need to implement strategies to complement the guidelines and encourage the update of treat-to-target urate-lowering therapy by clinicians. 

Lead author Dr Mark Russell, an NIHR Doctoral Research Fellow, said: 'These results were quite surprising as the initiation of treatment is straightforward, and the medications we use to treat and prevent gout have been around for decades, and are cheap. Our data indicate that we have a lot more work to do. Strategies are needed to encourage the prescription of preventative medications in people with gout. For example, educational programmes could help to raise awareness about the importance of medications such as allopurinol in the prevention of recurrent flares and disability due to gout'.

Dr Asim Suleman, a pain management expert for the charity Versus Arthritis, said: 'It’s simply unacceptable that far too few people are receiving the effective treatments they need for this entirely preventable, excruciating, and surprisingly common condition.'

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