Background/Purpose: Because of the large increase in the price of colchicine with the FDA granted market exclusivity the Pharmacy at the Mpls VA HCS asked the Rheumatology Clinic to conduct a QA/QI review related to colchicine prescriptions refillable for up to one year. We intended to evaluate whether the prescribing of colchicine was appropriate related to the certainty of a gout diagnosis or other disorders treated with colchicine. We also evaluated the safety of prescribed colchicine dosing related to renal impairment, control of hyperuricemia in those on chronic colchicine therapy, the presence of co-morbid conditions and potential multiple drug interactions,

Methods: The pharmacy database provided a list of all patients with active, refillable prescriptions for colchicine at the Minneapolis VA HCS. We developed a structured chart review document to gather data from the electronic medical record of those with colchicine prescriptions. Diagnosis of gout was designated as 1) definite gout with urate crystals identified in synovial fluid, tophi, x-ray changes of osseous tophi) 2) probable gout (clinical picture and 6/12 ACR criteria for acute gout), 3) Other diagnoses treated with colchicine included pseudogout, pulmonary fibrosis, pericarditis . 4) Indeterminate reason in the EMR for colchicine yet patient receiving colchicine with/without urate lowering treatment (often in patients co-managed with outside provider 5) No evidence for dx of gout by reported clinical exam, lab tests or x-ray yet taking colchicine. Diagnostic designations 1), 2), 3) were considered appropriate prescribing of colchicine and those with 4) and 5) not appropriate prescribing of colchicine. Laboratory test results, medical history data, x-ray findings, co-morbidities were collected to evaluate the appropriateness of prescribed dosing of colchicine.

Results: 420 patients had prescriptions recorded in the pharmacy database in Nov 2011. The average age was 68.9 yrs (13% <60y; 39% 60-69y; 21% 70-79yr; 25% 80-89y, 3% >90yr) Only 9% of subjects did not have any co-morbidities; 222 had 1 or 2 (53%) and 161 had 3 or 4 (46%). The most common co-morbidities were diabetes, hypertension, chronic kidney disease, and heart failure. 32 patients actually did not have active prescriptions for colchicine and 32 had died before the chart review. Colchicine was designated appropriate in three groups: 1) 128 with definite gout (30%), 87 with probable gout (21%) and 20 with pseudogout and other diagnoses (4.7%). In 134 gout diagnosis was indeterminate (32%) and colchicine prescription was not designated as appropriate. Colchicine dosing was appropriate relative to renal function in 91% of patients. Interestingly concomitant urate lowering therapy was prescribed in only 239 (56.8%) with 170 (40.4%) at target uric acid of <7 and 69 (16.4%) with uric acid >7. Of concern is the lack of urate lowering therapy in 129 (30.7%) of those on chronic colchicine.

Conclusion: Assessment of colchicine prescribing revealed areas of deficient quality of care related to chronic administration of colchicine in nearly one third of patients without a definite or probable diagnosis of gout. These patients may be exposed unnecessarily to risk of adverse drug effects and may be subject to additional costs. There is concern for chronic colchicine treatment to suppress gouty arthritis without treatment of associated hyperuricemia because permanent joint damage may occur. Chart review of the electronic medical record to obtain clinical data presents challenges due to incomplete data recording. There was minimal evidence of ongoing monitoring for potential colchicine side effects. Because of these concerns about quality of gout care, we have set up a Gout management clinic to properly evaluate diagnostic data and to monitor responses and side effects to improve the quality of gout care. Thus far 79 patients came to Gout Clinic, 45 no showed, 64 died before appointment, and 165 declined the appointment. We will continue monitoring the quality of gout care in this new clinic.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/colchicine-prescribing-as-a-parameter-for-qaqi-process-in-gout-care/