LIVERPOOL, ENGLAND – The rate of emergency hospital admissions for gout in England has seen a 59% increase over the past decade, while that of rheumatoid arthritis has halved, it was reported at the British Society for Rheumatology annual conference.

Over an approximate 10-year period (2006-2017), the incidence rate of unplanned gout admissions increased from 7.9 to 12.5 admissions per 100,000 of the population. This represented an increase from 0.023% to 0.032% of all hospital admissions during the period.

To put that into perspective, unplanned admissions for rheumatoid arthritis (RA), decreased from 8.6 to 4.3 admissions per 100,000 of the population, said Mark D. Russell, MD, a rheumatology registrar at Guy’s and St Thomas’ Hospital in London.

Furthermore, primary care prescriptions for common gout medications have seen a dramatic increase over the same time period in England; allopurinol prescriptions are up 72%, there’s been a 166% increase in colchicine prescriptions, and a 20-fold increase in febuxostat (Uloric) prescriptions since data became available for its in 2010.

“Gout’s very much a treatable condition,” Dr. Russell said, but with 82% of all gout admissions being unplanned, “there’s clearly more to do; this should be a call to arms for rheumatologists to help reduce the in-patient burden of this condition.”

The mean length of hospital stay was estimated at 6.6 days, with the median being 3.2 days. Gout accounted for just under 350,000 hospital bed days from 2006 to 2017, and with the cost of a single gout admission being anything from £850 up to £5,600, it constitutes a significant burden for the country’s National Health Service.

But what can be done? Would a “door-to-needle time campaign” help? So that when patients attend the emergency department they are assessed rapidly and treated accordingly? Dr. Russell queried.

Education could be the key, was the consensus during the discussion following his presentation. Education, and not just of those affected by the condition, but also of the family physicians who seem to have a “knee-jerk reaction” to prescribe medications, and not always appropriately. Even hospital staff may need help in differentiating gout from other emergency presentations, with some admitting patients suspecting infection or wrongly discharging them.

Pharmacist-led gout clinics

Another approach to try to avoid emergency hospital visits could be better management and perhaps setting up specialist gout clinics. Such clinics have already been piloted, and rheumatology pharmacist Jane Whiteman shared her experience of setting up a monthly, pharmacist-led gout clinic in a separate presentation.

Dr. Whiteman, who works at Royal Victoria Hospital, part of the Belfast Health and Social Care Trust in Ireland, presented data on 52 patients who were seen at the clinic between June 2015 and May 2017. The total number of patient visits was 87, with an average of 1.7 visits per patient.

Of 38 patients who were discharged from the clinic, 29 (76%) had met target levels of serum uric acid, which guidelines from the British Society for Rheumatology set at less than 0.3 mmol/L (5 mg/dL) and those from the European League of Rheumatism set at less than 0.36 mmol/L (6 mg/dL).

It is important to reduce serum uric acid levels, Dr. Whiteman explained. “Gout occurs when serum uric acid rises and urate crystals reach their saturation point in the serum and start to crystallize out into the joints and into the tissues,” she said. “It’s a progressive disease that usually starts in one joint, but if the serum uric acid isn’t controlled then it can go on to affect a number of joints,” and cause chronic arthritis, among other potentially serious conditions, and is an independent risk factor for cardiovascular and renal disease.

“Studies across the world have shown that gout is not well looked after; patient adherence to treatment is very poor,” Dr. Whiteman said. “Among all the chronic diseases it has the lowest adherence to treatment,” she added, noting that one study showed just one-fifth of patients remained on gout medication at 1 year.

Patient education is an important part of the clinic’s services, as when people are asymptomatic and between bouts of gout, they perhaps do not realize that they still need to take their medication. Education thus needs to include talking about their diet and lifestyle, providing information on medication, and why it is important to keep their serum uric acid levels in check.

After patients’ initial referral to the clinic, they are followed up by the clinic every month until their serum urate levels are below the 0.3 mmol/L target. They can then be discharged and monitored by their family physician.

Postdischarge, Dr. Whiteman and her colleagues found that 22 (76%) of the 29 patients who had met their target levels of serum uric acid later had serum uric acid tested at least once, showing an average level of 0.29 mmol/L at follow-up. This reassuring result occurred perhaps because of a majority of patients (79%) who were still being prescribed, and presumably taking, urate-lowering therapy. Seven patients did not undergo follow-up serum uric acid testing because they had died (one), were in the hospital (one), were not taking medication because they had made diet or lifestyle changes (three), or had their treatment on hold (two).

“I think the gout clinic has been a success; it has addressed barriers to optimal management through education of the patient,” Dr. Whiteman said.

Both presenters had nothing to disclose.

SOURCE: Russel M et al. Rheumatology. 2018;57[Suppl. 3]:key075.186; Whiteman J, et al. Rheumatology. 2018;57[Suppl. 3]:key075.215.

Emergency gout admission increase is ‘call to arms’