Adherence to the 2012 American College of Rheumatology (ACR) Guidelines for Management of Gout: A Survey of Brazilian Rheumatologists

<div><p>Objective</p><p>To describe the current pharmacological approach to gout treatment reported by rheumatologists in Brazil.</p><p>Methods</p><p>We performed a cross-sectional survey study using an online questionnaire e-mailed to 395 rheumatologists, randomly selected, from among the members of the Brazilian Society of Rheumatology.</p><p>Results</p><p>Three hundred and nine rheumatologists (78.2%) responded to the survey. For acute gout attacks, combination therapy (NSAIDs or steroid + colchicine) was often used, even in monoarticular involvement, and colchicine was commonly started as monotherapy after 36 hours or more from onset of attack. During an acute attack, urate-lowering therapy (ULT) was withdrawn by approximately a third of rheumatologists. Anti-inflammatory prophylaxis (98% colchicine) was initiated when ULT was started in most cases (92.4%), but its duration was varied. Most (70%) respondents considered the target serum uric acid level to be less than 6 mg/dl. Approximately 50% of rheumatologists reported starting allopurinol at doses of 100 mg daily or less and 42% reported the initial dose to be 300 mg daily in patients with normal renal function. ULT was maintained indefinitely in 76% of gout patients with tophi whereas in gout patients without tophi its use was kept indefinitely in 39.6%.</p><p>Conclusion</p><p>This is the first study evaluating gout treatment in a representative, random sample of Brazilian rheumatologists describing common treatment practices among these specialists. We identified several gaps in reported gout management, mainly concerning the use of colchicine and ULT and the duration of anti-inflammatory prophylaxis and ULT. Since rheumatologists are considered as opinion leaders in this disease, a program for improving quality of care for gout patients should focus on increasing their knowledge in this common disease.</p></div

Management of urate-lowering therapy (ULT) during an acute gouty attack and anti-inflammatory prophylaxis of gout attacks.

<p>¹Answers in agreement with the 2012 ACR gout guidelines</p><p>²participants who answered not to prescribe anti-inflammatory prophylaxis when initiating ULT were excluded from the other questions concerning this topic.</p><p>CI: confidence interval; NSAID: nonsteroidal anti-inflammatory drug.</p><p>Management of urate-lowering therapy (ULT) during an acute gouty attack and anti-inflammatory prophylaxis of gout attacks.</p

Multivariate-adjusted predictors of concordance between reported urate-lowering therapy management and the 2012 ACR gout guidelines.

<p>ACR: American College of Rheumatology; OR: odds ratio; CI: confidence interval; BSR: Brazilian Society of Rheumatology; CrCl: creatinine clearance. OR lower than 1 represents a reduced chance of concordance with the 2012 ACR gout guidelines.</p><p>Multivariate-adjusted predictors of concordance between reported urate-lowering therapy management and the 2012 ACR gout guidelines.</p

Acute gout management: first choice drug(s) to treat an acute gouty attack in different scenarios (N = 309).

<p>¹Healthy besides gout</p><p>²chronic kidney disease, defined here as creatinine clearance ≤60 ml/min</p><p>³colchicine 0.5 mg/hour until symptom resolution or side effect</p><p>⁴colchicine ≤2 mg/day. CI: confidence interval</p><p>NSAID: nonsteroidal anti-inflammatory drug; PO: <i>per os</i>; IM: intramuscular; IA: intra-articular.</p><p>Acute gout management: first choice drug(s) to treat an acute gouty attack in different scenarios (N = 309).</p

Flow diagram of participants’ selection.

<p>1: Practicing rheumatologists, members of the Brazilian Society of Rheumatology; 2: Random sample, stratified proportionally to the number of rheumatologists in each Brazilian geographic region.</p

Urate-lowering therapy (ULT).

<p>¹Answers in agreement with the 2012 American College of Rheumatology gout guidelines</p><p>²participants who reported not to adjust ULT for patients with tophaceous gout based on the SUA level were excluded from other questions that were based on the concept of a target SUA level</p><p>³this question was offered only to those who answered that they would wait for the resolution of the acute gouty attack to initiate ULT.</p><p>CI: confidence interval; CKD: chronic kidney disease; SUA: serum uric acid; CrCl: creatinine clearance.</p><p>Urate-lowering therapy (ULT).</p