Improved management of acute gout during hospitalization following introduction of a protocol

Aim: To determine whether implementation of a protocol to manage in-hospital acute gout has improved the care of patients by non-rheumatologists. Method: Two systematic case-file reviews were performed to determine the management of acute gout in all episodes occurring in hospitalized patients before (April 2005-December 2006) and after (November 2008-September 2009) introduction of a protocol for acute gout management in a tertiary referral hospital. The protocol targeted non-rheumatologists with primary intentions to continue baseline anti-gout medications on admission, prevent inappropriate prescriptions of colchicine, non-steroidal anti-inflammatory drugs (NSAIDs) and allopurinol in the hospital, encourage invitations for assistance by rheumatology, and promote combination therapy in cases of severe gout. Results: Excluding patients under the primary care of a rheumatologist, 118 cases of acute gout occurring during hospitalization were reviewed before and 89 cases after introduction of the gout protocol. Post-protocol, there was a significant increase in continuation of baseline allopurinol (P=0.01), significantly less inappropriate prescriptions of colchicine (P<0.001) and allopurinol (P=0.02), and a fall in the occurrence of overall adverse events (P=0.01). After protocol introduction, when monotherapy was prescribed, NSAID usage declined and prednisone usage increased (P=0.04), but there was no significant shift toward combination therapy use. Delays from symptom recognition to treatment were significantly reduced (P<0.001), and rheumatology involvement significantly increased from 33.9% pre-protocol to 51.7% post-protocol. Conclusion: Following introduction of a hospital-wide protocol for acute gout management, there have been significant improvements in the management of acute gout by non-rheumatologist clinicians.