Background/Purpose: ACR guidelines exist for the management of gout including the use of uric acid-lowering therapy.  ACR guidelines recommend routine monitoring of uric acid levels and dose titration to achieve a uric acid goal of <6.0 mg/dL as well as regular drug safety monitoring in patients receiving uric acid lowering therapy.  This study assesses the adherence of rural VA primary care providers with these ACR clinical guideline recommendations. 

Methods: Patient records were examined from rural primary care provider panels. To be included in the analysis, patients were required to have been seen by their primary care provider within a one year observation period from November 1, 2013 until Oct 31, 2014 and to have been prescribed allopurinol or febuxostat. The following information was obtained for each patient: the number of uric acid determinations, the uric acid blood values, and the clinical actions that were taken if uric acid was above 6.0 mg/dL, or if the AST and ALT serum values were ≥ 2 times the upper limit of normal (74 U/L for AST and 154 U/L for ALT).  If uric acid level was not at goal, or elevated AST or ALT noted, the patients’ medical record was reviewed.  Clinical action was considered to be appropriate for a uric acid ≥ 6.0 mg/dL if 1) an upward dose titration was documented in clinic notes or pharmacy records, 2) uric acid-lowering therapy was initiated, or 3) compliance counseling was documented in cases of suspected non-compliance. In the case of AST or ALT values ≥ 2 times the upper limit of normal, a clinical action was considered appropriate if a dose decrease or discontinuation of allopurinol or febuxostat was documented.

Results: There were 17,458 patients that had at least one primary care provider visit within the one year observation period and 772 (4.4%) of these patients had been  prescribed  either allopurinol or febuxostat. Of these 772 patients receiving allopurinol or febuxostat, 392 (51%) had at least one uric acid level documented during the observation period, and 738 (96%) patients had AST and/or ALT  determinations. Among the 392 patients that had a uric acid level checked, 130 (33%) had a uric acid level ≥6 mg/dL.  In this group of 130 patients with hyperuricemia (≥6 mg/dL), 73 (56%) had an appropriate clinical action taken.  Among the 738 patients with AST and/or ALT lab determinations, 6 patients (0.8%) had an elevated AST and 1 had an elevated ALT level ≥ 2 times the upper limit of normal, and no dose adjustments or discontinuations of uric acid-lowering therapy were documented in clinical notes or pharmacy records.

Conclusion: Among rural V.A. primary care provider panel patients prescribed uric acid- lowering therapy only 51% of patients had a uric acid level checked within a year while 96% had routine AST and ALT monitoring.   When the uric acid was above the goal of 6.0 mg/dL, defined appropriate action was documented in 56% of patients. There were 0.8% of patients with elevations of AST and 0.1% ALT ≥ 2 times the upper limit of normal, all of which lacked a documented adjustment of uric acid-lowering therapy.  These findings suggest the need for better education for rural VA primary care providers in the management of uric acid-lowering therapy in gout patients.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/uric-acid-lowering-therapy-management-among-rural-veterans-affairs-primary-care-providers/