Land Down Under Undertreats Gout

Despite a number of effective medication therapy options, there is international evidence that gout is inadequately treated. Studies in the United States, the United Kingdom, and now Australia, show the same triad of ineffectiveness: low levels of urate-lowering therapy (ULT), infrequent serum urate and renal function testing, and very low rates of achievement of target serum urate levels.

Despite a number of effective medication therapy options, there is international evidence that gout is inadequately treated. Studies in the United States, the United Kingdom, and now Australia, show the same triad of ineffectiveness: low levels of urate-lowering therapy (ULT), infrequent serum urate and renal function testing, and very low rates of achievement of target serum urate levels.

A recent study inThe Journal of Rheumatology estimated the contemporary prevalence of gout in Australia and assessed the quality of gout care in a large general practice population. The study authors used a national general practice dataset to assess gout prevalence, the proportion of allopurinol use, the frequency of serum urate testing, and achievement of the recommended serum urate target.

The Australian health care system is made up of general practitioners (GPs), who provide primary medical care for patients in pediatrics, psychiatry, surgery, and other primary care functions. Visits to GPs are largely subsidized by the federal government through taxation. If a GP recommends additional specialist care, the patient is referred to a specialist, which is also either subsidized by the federal government or paid for entirely. Data were collected for patients over age 20 across Australia from 2008 to 2013, using computer-based point-of-care systems used by GPs as part of their daily practices. The study measured gout care quality by the number of patients prescribed urate-lowering medication, the number who had their serum urate checked, and the number who had a serum urate level below the target 0.36 mmol/l, a target widely recommended consensus guidelines.

In total, there were 22,776 patients meeting the definition of gout. There were 12,208 patients coded as having gout,12,975 patients prescribed allopurinol, and 7,688 patients prescribed colchicine—making gout prevalence 1.54%(CI 1.52-1.56) (1.27% using age standardization, CI 1.00-1.54). Prevalence in Australia is similar to recent figures from a German population study, but much lower than recent studies in the UK (2.5%) and the United States (3.9%). The authors note that this difference might be explained by the fact that the Australian study was a GP study, or it could be explained by individual study design, health-seeking behavior, or even diet. The prevalence was about 5 times higher in men compared to women

In those patients defined as having gout, 57% had an allopurinol prescription at anytime over the 5-year study period. Allopurinol use was higher in and in older patients. Serum urate was tested at any time over the5-year study period in 54.6% of patients with gout. The frequency of serum urate testing was significantlygreater in those who were taking allopurinol (61.5% vs45.6%, < 0.001). In the patients with a serum urate test during the 5-yearstudy period, 41% had a target serum urate level (< 0.36 mmol/) recorded on at least 1 occasion.

“We observed very low levels of achievement of target serum urate concentrations over the 5-year period,” the study authors note. These results were similar to a large US claims study that found that21% of treated patients with gout had serum urate levels below target. The Australian study found that allopurinol was prescribed at a lower rate (57%) than in the UK and Germany studies, but at a higher rate than a similar US managed-care population study (40%).

“Collectively, the results…support previous international research findings that primary care patients with gout are often not treated with urate-lowering therapy and they do not have their serum urate tested as often as recommended by the American College of Rheumatology and primary care gout guidelines,” the authors noted.

The authors also pointed to a potential barrier for effective gout management: the perception among some health care professionals that gout is a trivial, self-inflicted condition that does not require regular therapy. “Contrary to these beliefs, gout is associated with substantial pain, functional disability, significant comorbidity, and reduced quality of life, as well as social stigma,” the researchers concluded. “Recognition that gout is common and poorly managed is the first step toward improving the quality of care for people with gout.”