Gout is a common and painful condition that is manageable, and treatment guidelines are available. Despite this, several studies suggest management is suboptimal. A recent survey that explored barriers to optimal care found that patients and general practitioners (GPs) who treat gout want to be better educated about the condition and how best to manage it.
The study also suggested that most GPs are not following all of the guidelines for management of gout. For example, urate-lowering therapy (ULT) is frequently delivered inappropriately, and monitoring of uric acid (UA) concentrations is irregular. In addition, when initiating allopurinol as ULT, many GPs fail to prescribe prophylaxis to prevent another attack–which is a risk when treating an acute attack.
Stigmatization of patients with gout also appears to be a major barrier. The condition is often perceived as the patient's fault, due to an excess of alcohol, unhealthy diet, and obesity/overweight.
"Although guidelines are available, few practitioners are familiar with their existence," noted Stefanie Vaccher, MD, University of New South Wales, Sydney, Australia, first author of this publication. "Our findings identified that false perceptions about gout and its treatment, and behaviors of both patients and GPs, served as barriers to effective management. These factors are recommended as key targets for GP, patient, and community education to substantially improve the management of this prevalent and troublesome condition."
"Understanding the reasons for the failure to achieve effective long-term control of this debilitating condition is needed to prevent not only tophi, bone erosions, and permanent disability, but also pain, disruption of quality of life, and economic disadvantage," wrote Dr Vaccher and colleagues.
The study was based on semistructured interviews with 15 GPs (9 women and 6 men) and 22 patients (3 women and 19 men) in Sydney, Australia. Not all of the patients interviewed were treated by the GPs included in the survey. Discussions during interviews focused on medication adherence, experiences with gout, and education and perceptions around interventions for gout. Interviews were recorded, transcribed, and analyzed for patterns.
Fewer than half of the GPs were aware of management guidelines for gout, and contrary to guidelines, fewer than half of them administered prophylaxis against an acute attack when initiating ULT. Dosing of allopurinol was not well-understood. Most GPs started with 100 mg or less per day, and about half uptitrated the dose.
The survey revealed a disconnect between GPs and patients, related to monitoring UA concentrations during ULT. Although all doctors said they tested UA concentrations in patients on ULT, less than 50% of patients on ULT said their UA levels were tested in the previous year.
Most doctors identified alcohol and dietary excess as risk factors for gout, but rarely mentioned other risk factors such as genetic associations, renal function, or concomitant use of medications such as diuretics. Most of the GPs commented on the link between gout and other lifestyle-associated medical problems, such as diabetes and high cholesterol.
Many doctors felt that they had inadequate education on gout management, and some indicated a lack of confidence in managing it. About 50% wanted to have more resources, including patient education materials and website-based information. Patients also stated that they needed more information, and that they had an inadequate understanding of gout.
The majority of GPs believed that low adherence to medication was a significant barrier to successful treatment. Some cited cultural factors leading to misunderstanding about the need for therapy. Some GPs mentioned stereotypes related to gout. Patients, however, did not perceive adherence as a barrier.
Regarding stigma, one GP said, "It sort of has this Hogarthian view of...very fat English people drinking port with their legs up." Patients' interviews suggested that stigma associated with the illness may lead to denial and prevent seeking care.
The majority of patients with chronic gout reported that they were taking daily allopurinol, with about half noting that their dosage had been modified over time. A small percentage were taking long-term colchicine, either as prophylaxis or with allopurinol or as a standard preventive.
Few GPs or patients were aware of the risk of acute attacks when initiating ULT. Contrary to guidelines, most GPs did not say they would give prophylactic medication against an acute attack. Patients appeared to be unaware of the need for prophylaxis.
There were conflicting responses between GPs and patients about prescribed allopurinol dosages. Whereas most doctors said they started with 100 mg/day or less, most of the literature shows much higher doses are prescribed–around 300 mg/day in Australia, they wrote.
Although the survey was conducted in an urban area of Australia, the authors believe the results are generalizable to other developed countries. They say that studies from other countries are congruent with their findings.
- Vaccher S, Kannangara DRW, Baysari MT, et al. Barriers to care in gout: from prescriber to patient. J Rheumatol. 2016;43(1):144-149.