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| Posted: February 14 2006 at 8:08am
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| February, 2006 - CRA Journal Club Review by Dr. CHRISTOPHER PENNEY |
Neogi T. et al. Frequency and Predictors of Inappropriate Management of Recurrent Gout Attacks in a Longitudinal Study. J Rheumatol 2006;33:104-9
Dr. Christopher Penney
M.D., FRCPC |
Editorial:
By Dr. Christopher Penney Gout is an ancient and relatively common rheumatic disease which has been increasing in both incidence and prevalence over the past 30 years. Despite our understanding of the pathophysiology and the availability of effective treatment, gout is frequently mismanaged in the community. We still see tophaceous gout! The reasons for that failure of management are not altogether clear.
The authors of this article explore the inappropriate management of recurrent gout in a novel fashion by employing the internet. They recruited a cohort of 232 subjects with intercritical gout and followed them for an average of 268 days. Of interest, 43 of the participants never consulted a physician for any attack of gout. Thus this study was a rare look at gout in the “real world “in that it included patients who didn’t seek out medical attention.
The results are interesting.
| The risk of having 1 or more attacks of gout in a year is quite high – 69%. Fifty-three participants (26%) had definitely or potentially inappropriate treatment for their recurrent gout. This number is likely an underestimate since the authors did not collect information on drug doses or the details of comorbidities.
What factors are associated with the risk of inappropriate therapy? An increasing number of attacks was associated with a decreased risk of inappropriate therapy. Consulting a physician increased your risk of inappropriate therapy by 2.5-fold. Participants with gout for 1 year or less prior to study entry were also at increased risk when compared with those individuals with longer duration gout. Factors such as age, sex, BMI, race, education, and self-reported comorbidities were not associated with risk.
Presumably patients with repeated attacks get better at self management and that would explain the decreased risk of mismanagement in gout patients having more frequent attacks or longer duration of disease.
Why would seeing a physician increase the risk of mismanagement? The obvious reason is that the treating physician may not know proper management. Less obviously, the physician may err in not effectively communicating the nuances of proper management to the patient. Of course, there is always the possibility that the patient is just noncompliant even when taught well.
In my practice, I have gout patients bring their spouses in order to increase compliance. I give them educational pamphlets and write detailed instructions about what to do between and during attacks. I see them as often as once a month for the first few months just to make sure they are doing OK. I also try to educate the referring physician in my consultation letter. Of course this approach is not evidence based. We need studies to determine whether education of patients and physicians makes a difference in the management of gout.
Objectives:
- To appreciate the high frequency of inappropriate management of recurrent gout.
- To understand the risk factors for inappropriate management.
- To consider how education of both physicians and patients may improve management.
ABSTRACT
Frequency and predictors of inappropriate management of recurrent gout attacks in a longitudinal study. Neogi T, Hunter DJ, Chaisson CE, Allensworth-Davies D, Zhang Y.
Clinical Epidemiology Research and Training Unit, Boston University School of Medicine, Boston, Massachusetts 02118, USA. tneogi@bu.edu
OBJECTIVE: To evaluate the patterns and determinants of medication use during recurrent gout attacks.
METHODS: We followed participants with documented gout in an online prospective case-crossover study. During an attack, subjects were asked if they had consulted a physician for the attack and what medications they were using. Definitely inappropriate therapy was defined as use of allopurinol or a uricosuric agent acutely without having used it as a prophylactic. Potentially inappropriate therapy was defined as use of analgesics alone, alternative remedies, or no medications. We estimated the risk of having >or= 1 attack in 1 year using life table methods. We examined the relation of various risk factors to the risk of inappropriate therapy using Poisson regression.
RESULTS: Among 232 participants (mean age 52 yrs, 81% male) with documented gout, the risk of having >or= 1 attack in a year was 69%. One hundred ten participants consulted a physician for each attack, 49 did so for only some attacks, while 43 never consulted a physician for any attack. Fifty-three participants had definitely (n = 10) or potentially (n = 43) inappropriate therapy for their recurrent attacks. Physician consultation for an attack was associated with increased risk of inappropriate therapy (risk ratio, RR, 2.5, p = 0.006), whereas an increasing number of gout attacks was associated with lower risk of inappropriate therapy (RR 0.8, p = 0.01).
CONCLUSION: Given the high risk of recurrent attacks and the substantial number of persons whose attacks are not appropriately managed, further education about management of gout attacks for both patients and physicians may be warranted.
PMID: 16267879 [PubMed - in process]
Edited by elisia - April 01 2006 at 8:35pm
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CRA Forum : February, 2006 Journal Club Review by Dr. Chris Penney
Topic: Review
