Background/Purpose: Colchicine is recommended to prevent gout flares in patients initiating and increasing uric acid lowering therapy until serum uric acid is ≤ 6 mg/dL. Many patients, however, are prescribed colchicine without adequate urate lowering therapy or remain on colchicine after uric acid targets have been met. The recent dramatic increase in colchicine cost in the United States has made it even more important to examine current prescribing practices, identify variables that influence these practices, and promote appropriate colchicine use.

Methods: Pharmacy identified 193 patients at a VA medical center with active outpatient colchicine prescriptions on 11/4/2011. Electronic medical record review revealed 126 patients prescribed colchicine for ≥ 30 days for prophylaxis of gout flares. Colchicine prescribing was defined as inappropriate if 1) no concurrent urate lowering therapy was prescribed, 2) uric acid was not at goal and urate lowering therapy had not been initiated or increased in the past 3 months, or 3) uric acid goals were met for > 1 year and flares had resolved in the absence of tophi. Demographic and clinical variables in appropriate and inappropriate groups were compared.

Results: Of 126 patients prescribed prophylactic colchicine, 34 (27.0%) were prescribed no urate lowering therapy, 50 (39.7%) were not at uric acid goal and had not had urate lowering therapy increased in the prior 3 months, and 9 (7.1%) were at uric acid goal for more than one year with no flares or tophi. Colchicine use was considered appropriate in 33 patients (26.2%) – 20 (15.9%) with urate lowering therapy initiated or increased in the past 3 months, 12 (9.5%) at uric acid target for < 1 year, and 1 (0.8%) at uric acid target for > 1 year but with continued flares. Patients appropriately prescribed colchicine were younger, had shorter time on colchicine, and were more likely to have been seen by Rheumatology as opposed to being managed solely by primary care.  Allopurinol dose and allergy, uric acid level, and renal function were similar in the two groups (see table).

Conclusion: Our results demonstrate a high incidence of what we considered inappropriate prophylactic colchicine use, driven largely by failure to prescribe concurrent urate lowering therapy or adequately increase these medications. Rheumatology consultation was associated with improved colchicine prescribing. Increased education of primary care physicians about current standards of care is needed to avoid unnecessary colchicine exposure and excessive health care system costs.

Comparison of Patients Appropriately and Inappropriately Prescribed Prophylactic Colchicine
	Appropriate (N=33)	Inappropriate (N=93)	P Value
Age, yrs	65 [33-89]	70 [37-89]	0.01
Male, no. (%)	33 (100.0)	92 (98.9)	1.0
Colchicine daily dose, mg	0.6 [0.3-1.2]	0.6 [0.3-1.2]	0.57
Time on colchicine, yrs	1.12 [0.07-17.4]	3.26 [0.05-14.1]	0.0002
Allopurinol dose, mg	200 [100-400]	200 [100-400]	0.34
Allopurinol allergy, no. (%)	1 (3.0)	7 (7.5)	0.36
Crystal confirmed, no. (%)	33 (42.4)	37 (39.8)	0.79
Uric acid level, mg/dL	6.7 [4.2-14.2]	7.4 [3.6-13.2]	0.36
Creatinine, mg/dL	1.29 [0.8-2.3]	1.24 [0.7-2.9]	0.93
GFR, mL/min/1.73m2	64 [37-126]	67 [27-144]	0.87
Rheumatology visit ≤ 1 yr, no. (%)	19 (57.6)	20 (21.5)	< 0.0001
Rheumatology visit ever, no. (%)	25 (75.8)	51 (54.8)	0.04
Skewed data expressed as median [range]. Percentages may not add up to 100 because of rounding.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/evaluating-appropriate-use-of-prophylactic-colchicine-and-urate-lowering-therapy-in-gout/