Background/Purpose: The introduction of novel treatment modalities for gout has escalated interest and education on this topic.  Although gout is the most common inflammatory arthropathy encountered, it still remains a diagnostic and therapeutic challenge for many.   We surveyed a large cohort of North American Rheumatologists (Rheums) for their views, practices and treatment of gout.

Methods: 2401 adult Rheums from the USA and Canada (138) were invited (via emails) to partake in an online survey in early 2012. The survey included 39 questions regarding respondent demographics, practice type, diagnosis of gout, choice of therapy and safety concerns.  On-line responses were tabulated using the CSV file downloads to Excel spreadsheets and verify data combing for outliers.

Results: There were 318 respondents (13.2% response), 78.8% male; with a mean age of 57.7 yrs. Responses came from private practice (56%), academic (31%), government (4%); with an overall mean of 25 years in practice (52% > 25 yrs).  They see an average of 5.3 gout patients per week and follow 86.4 gout patients in their practice, with 62% seen every 3-6 months.   92% can see an acute gout referral in less than 1 week.  Only 8% are followed for asymptomatic hyperuricemia. 22% for acute gout/flare, 70% for intercritical or chronic inactive gout. 78% are PCP referred, 2/3 for acute gout and 24% for hospitalized gout.   37% view gout a metabolic disorder and 34%as a uric acid overload disorder.  For the diagnosis of gout, Crystal ID (98%) and clinical hx (96%) were most important and alcohol and family history (40%) least important. 77%  have a polarizing microscope and 96% routinely follow urate levels. Indications for urate lowering therapy (ULT) included tophi (72%), >2 attacks/yr (71%) or gouty erosions (68%).  Uricosurics were seldom chosen (<20%) and allopurinol therapy predominated (>95%).  Surprisingly 28% felt no allopurinol dose adjustments were needed with creatinine levels of 2.5-3.5mg/dl.   When initiating ULT, prophylaxis with colchicines (90%) was preferred over NSAID (43%) or prednisone (16%). The primary goal of Rx is attack prevention (94%) more so than urate level < 6.0 (66%). However, acute gout is preferably managed with steroids (86%), NSAIDs (82%) over colchicine (65%).  57% use less Colcrys and 47% use more NSAID and prednisone. Febuxostat is indicated with allopurinol failure/intolerance (93%) or sensitivity (82%).  Pegloticase is indicated for allopurinol failure/sensitivity (69%/44%), febuxostat failure/intolerance (65%) or multiple tophi or attacks (58%/46%).  Overall, 76.5% achieve a urate < 6.0 and 23% have tophi.  Most disappointing is patient noncompliance (78%), management by nonrheumatologist (54%) and confusion between hyperuricemia and gout (41%). The greatest safety concerns were for NSAID or colchicine with renal dz (98% or 54%) and allopurinol with azathioprine (86%).  While cherries, febuxostat and allopurinol were ranked as safest, NSAIDs and pegloticase had the most safety concerns.

Conclusion: Tradition continues to dominate Rheum practice standards in gout with the majority relying on MSU crystal ID and clinical features for diagnosis.  Prevention of attacks, targeting urate < 6.0, and reliance on ULT continue to guide management.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/the-diagnosis-and-management-of-gout-in-2012-survey-of-us-and-canadian-rheumatologists/