Allopurinol Decisions Made Early in Primary Care

Nicola M. Parry, DVM

November 15, 2017

Among patients with gout in primary care settings, decisions to initiate allopurinol therapy are made early, a new study shows.

Lorna E. Clarson, PhD, Keele University, Staffordshire, United Kingdom, and colleagues report the results of their study online November 14 in Annals of Family Medicine.

"Those meeting the internationally agreed-upon eligibility criteria for urate-lowering therapy, particularly at diagnosis, were more likely to receive allopurinol," the authors write.

This suggests that "it is not lack of awareness of guidelines which underlies suboptimal prescribing, as has been reported elsewhere."

Data suggest that gout is suboptimally managed in primary care settings, the researchers explain. Studies have shown that 44% of primary care patients with gout meet guideline criteria for allopurinol therapy at diagnosis and that 87% become eligible within 5 years after diagnosis.

Yet only a minority of these eligible patients receive allopurinol therapy.

Dr Clarson and colleagues therefore aimed to investigate factors that influence general practitioners' initiation of allopurinol treatment for patients with gout.

They examined electronic health records for 8142 patients older than 50 years with a diagnosis of gout.

Among this population, the median time to first allopurinol prescription was 8 months (interquartile range [IQR], 0 - 41 months).

Patients who were eligible for allopurinol therapy at the time of gout diagnosis were more likely to receive it (hazard ratio [HR], 1.41; 95% confidence interval [CI], 1.29 - 1.54) than ineligible patients were.

In contrast, patients who became eligible
after their gout diagnosis were less likely to receive allopurinol therapy than those eligible at the time of diagnosis (HR, 0.77; 95% CI, 0.69 - 0.85).

The short median time to allopurinol initiation, a positive association with eligibility at diagnosis, and the negative association with meeting eligibility criteria after diagnosis suggest decisions to start allopurinol treatment are made early, the authors emphasize.

However, they also found the number of consultations for any reason was negatively associated with allopurinol initiation, suggesting that clinicians do not screen patients for other eligibility criteria as part of continuing care.

"Our findings suggest that more frequent chronic disease reviews to revisit patient preferences and eligibility for allopurinol may reduce barriers to successful treatment of gout," the authors conclude.

"Further research should focus on understanding patient and prescriber preferences in allopurinol prescribing and why patients who become eligible for allopurinol after diagnosis do not receive it."

This study was supported by grants from the National Institute of Health Research (NIHR) School for Primary Care Research. Two authors have reported receiving funding from the NIHR. The remaining authors have disclosed no relevant financial relationships.

Ann Fam Med. Published online November 14, 2017. Abstract

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