Primary Care Providers' Knowledge, Beliefs and Treatment Practices for Gout

Results of a Physician Questionnaire

Leslie R. Harrold; Kathleen M. Mazor; Amarie Negron; Jessica Ogarek; Cassandra Firneno; Robert A. Yood


Rheumatology. 2013;52(9):1623-1629. 

In This Article


A total of 838 physicians completed the self-administered questionnaire. The response rate was 41% after excluding physicians who reported not caring for gout patients (n = 51) or whom we were unable to contact due to incorrect addresses (n = 61). Respondents were more likely than non-respondents to be family practitioners as compared with internists (43.5% vs 38.3%, P = 0.01). Respondents and non-respondents were similar in terms of age, gender and region of the country.

The demographics and baseline characteristics for respondents are shown in Table 1. Most were male (64.3%), white (68.4%) and had a mean age of 48 years (±9 s.d.). The majority (94.4%) were board certified and almost two-thirds were in private practice. Slightly more than half had been in practice for >16 years and worked more than 40 h/week in patient care. Sixty-four per cent reported having read more than one gout article in the past year. Most physicians (>80%) stated they referred fewer than 10% of their gout patients to a rheumatologist for management. Overall, only 11.8% reported awareness of gout treatment recommendations (internists 14.4% vs family practitioners 9.6%, P = 0.03).

Management of Acute Gout

The reported management of an acute gout attack in the setting of renal insufficiency is described in Table 2. Most physicians (84.0%) reported that they would not aspirate the inflamed joint acutely, whereas 86.6% would order a serum urate level. For the management of acute symptoms, colchicine was suggested the most (58.8%), followed by NSAIDs (50.5%) and lastly glucocorticoids (45.0%). Most (84.6%) would not initiate a ULT during an acute attack. Approximately three-quarters of physicians counselled their patients to reduce their intake of beef and organ meats, but only half did the same for pork. Only 52.8% of all physicians provided optimal medication treatment, which was defined as avoiding NSAIDs, recommending ≤2.4 mg/day of colchicine or a glucocorticoid for treatment of the acute symptoms and avoiding initiation of a ULT during an acute attack. Internists were significantly more likely to provide the recommended medications than family practitioners (59.5% vs 47.0%, P < 0.001).

Management of Intercritical Gout

For intercritical gout in the setting of renal insufficiency, allopurinol was the most recommended ULT (68.5%) followed by febuxostat (25.3%) and probenecid (4.0%) (Table 3). Appropriate use of ULTs in the setting of renal disease, defined as the initial use of allopurinol at a dose ≤250 mg/day (based on the gout quality indicators)[10] or febuxostat at any dose was recommended by 22.4% of physicians. Additionally, only 21.9% (internists 30.6% vs family practitioners 14.2%, P < 0.001) would use colchicine, likely as prophylaxis, at the recommended doses (≤1.8 mg/day). The majority of providers would titrate the dose of the ULT to a serum urate of ≤6 mg/dl. Recommended medication treatment for intercritical gout was suggested by only 3.4% of physicians and was defined as the use of allopurinol (initial dose of ≤250 mg/day) or febuxostat, with colchicine for prophylaxis (≤1.8 mg/day), with acceleration of ULT dosing until achievement of a serum urate level ≤6 mg/dl. There was no difference between internists and family practitioners.

Management of Tophaceous Gout

The suggested management of tophaceous gout is presented in Table 4. Approximately 80% of physicians recommended a ULT and most (75.3%) would titrate the dosing to a serum urate level ≤6 mg/dl. Only 29.6% recommended prophylaxis when starting a ULT, either colchicine or NSAIDs. Prophylaxis was more commonly recommended by internists than family practitioners (36.2% vs 23.6%, P < 0.0001). Optimal care for tophaceous gout was defined as receiving a ULT (allopurinol, febuxostat or probenecid) and prophylaxis with either an NSAID or colchicine when the ULT was initiated and ULT dosing titrated to a serum urate of ≤6 mg/dl. Only 16.7% of physicians suggested this, with more internists selecting optimal care compared with family practitioners (21.9% vs 12.5%, P < 0.001).