Acute gout frequently complicates hospital admissions, but its diagnosis and management can vary widely. A new study reveals how involving rheumatologists in the care of hospitalized patients with acute gout can influence patient outcomes.
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Andrew Teichtahl, MBBS, B.PHYSIO, FRACP, PhD, a research fellow in the Department of Rheumatology at St. Vincent’s Public Hospital in Melbourne, Australia, and colleagues evaluated acute inpatient gout to determine what factors were associated with rheumatology input. They also examined the differences in patient outcome when rheumatology input was sought.
Their prospective study, published online in the July 29, 2014, edition of Internal Medicine Journal, included a review of data coded in the medical records of 58 patients with a diagnosis of gout from a tertiary public university-affiliated hospital between February and October 2012.1
The diagnoses were based on clinical symptoms and/or an analysis of synovial aspirate. A past history of gout or renal impairment was noted based on the comorbidity section of the medical records. Rheumatology input was defined as a formal consultation by the unit registrar and/or consultant, or the placement of the patient under the primary care of the rheumatology unit.
Most of the documented cases came from medical rather than surgical units, and the majority (59%) of acute gout was managed by non-rheumatologists. The investigators found that rheumatology input occurred more often in younger inpatients (68.9 years vs. 78.4 years; P=0.04) with knee joint disease than other inpatients. Having input from a rheumatologist was more likely to lead to a synovial fluid confirmed diagnosis of gout and subsequent appropriate acute management and follow-up plan. Rheumatology opinion was much less likely to be sought if the first metatarsophalangeal joint was involved.
Additional Research, Similar Conclusion
The results of the current study by Teichtahl et al differ from a 2011 Australian study by Gnanenthiran et al that indicated similar baseline characteristics in patients with or without rheumatology involvement.2
Their study identified 134 gout episodes and found that 118 of these were in patients who were not admitted to a rheumatology unit. Baseline anti-gout medications were discontinued for the majority of patients, and in 9% of documented episodes, no pharmacotherapy was prescribed. The authors documented delays in initiation of treatment in approximately one-third of patients. Acute management of gout included antiinflammatory monotherapy or a combination of colchicine, nonsteroidal antiinflammatory drugs and corticosteroids.
The 2011 study differed from the current study by Teichtahl et al in that it did not specifically examine the distribution of joint involvement. Like the current study, however, Gnanenthiran et al did find a great deal of variability in the way that acute gout episodes are investigated in hospitals. In many cases, patients with gout were not optimally managed. The results led the authors to recommend a hospital-wide protocol that would provide a consistent framework for gout investigation, treatment and follow-up.