FRI0249 Audit of the management of gout -are we doing it right?
Authors: T.J. Khan, S. Kamath, E. Roddy
Journal: Annals of the Rheumatic Diseases (2018)

<h3>Background</h3> Gout is the most prevalent inflammatory arthritis, affecting 2.5% of adults in the UK. However, management is often inadequate in both primary and secondary care, with only 45% of patients achieving target serum urate (SUA) level &lt;360μmol/L over 12 months in UK rheumatology clinics. A better understanding of how well gout is managed in different areas of our service (discharge to GP, general rheumatology follow-up clinics, and specialist gout clinic) will inform service redesign. <h3>Objectives</h3> To compare the management of gout in the rheumatology service against the 2007 British Society for Rheumatology (BSR) and 2006 European League Against Rheumatism (EULAR) gout guidelines, and the NICE febuxostat technology appraisal (TA164). <h3>Methods</h3> We retrospectively audited all new out-patient referrals with gout seen in our department over a 12 month period (January-December 2015). Data were collected by electronic review of case notes and completion of a structured proforma. Three mutually exclusive groups were compared: those seen once in rheumatology and discharged to GP (group1), followed-up in general rheumatology clinics (group2), or followed-up in a specialist gout clinic (group3). Follow-up SUA levels were specifically compared to EULAR (&lt;360μmol/L) and BSR (&lt;300μmol/L) treatment targets. <h3>Results</h3> 150 new consecutive gout referrals (50 per group) were included in the audit: 83% were male and mean age was 62 years. Gout was diagnosed by monosodium urate crystal identification in 16 (11%) and 25% had tophi. 43 (29%) patients were already on ULT, and 107 (71%) patients were newly commenced on ULT. Prophylactic medications were co-prescribed in 86% (130) cases. 44 patients were taking diuretics; diuretics were advised to be stopped or reduced in 12% cases. Nearly all patients starting allopurinol commenced a daily dose of ≤100 mg (99% cases). Of the patients started on a uricosuric/febuxostat, 92% had taken allopurinol previously. Of the 15 patients commenced on febuxostat, 3 (15%) had ischaemic heart disease (IHD) or cardiac failure. Chronic kidney disease (CKD) stage 3 (group1 28%, group2 22%, group3 34%), CKD stage 4/5 (2%, 2%, 10%), IHD/cardiac failure (30%, 30%, 40%), clinically evident tophi (16%, 18%, 42%) and previous allopurinol intolerance (10%, 14%, 24%) were more common in group 3 than groups 1 and 2. After 12 months, only 90 (60%) patients achieved target &lt;360μmol/L (group1 42%, group2 64%, group3 62%) and 47 (31%) patients achieved target SUA &lt;300μmol/L (group1 20%, group2 34%, group3 36%). <h3>Conclusions</h3> Allopurinol starting dose, use of prophylaxis, and use of allopurinol first-line concorded well with national and international guidelines. We achieved target SUA levels more commonly than the UK national average in a recent national rheumatology audit. Patients discharged to the GP with a management plan prior to achieving a target SUA level achieved target less frequently suggesting that rheumatologists should follow patients in order to ensure treatment is escalated until the target SUA level is achieved. <h3>Disclosure of Interest</h3> None declared