Abstract Introduction Number of patients in Brunei Darussalam present to the Primary Health care with the diagnosis of gout

Abstract
Introduction
Number of patients in Brunei Darussalam present to the Primary Health care with the diagnosis of gout. The medical practitioner should be increasingly aware of optimising management of gout, which is aimed at pain relief, preservation of joint function and preventing recurrent attack. Recent guidelines published by British Society of Rheumatology (BSR), have provided clinicians with a framework of achieving these aims.

Aims
To evaluate the management of patients with diagnosis of Gout in in primary health care centre at Kuala Belait Health Centre, KB.

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Methods
All adult patients with the diagnosis of gout seen at Kuala Belait Health Centre, KB in year 2017 were included in the audit. The data was collected using Dx code M10 from BruHIMS. The record of all relevant patients was searched and notes were individually analysed and relevant information were recorded on Performa used for audit.

Results
A total of 200 patients were identified, of which 24 %(n=48) were female and 76%(n=152) were female. Diet and lifestyle advise was documented in 76% (n=153) of the patients. Out of 200 patients diagnosed with gout 35 patients were on allopurinol only. Among those who were on allopurinol 86%(n=31) had their serum uric acid checked regularly, however only 12%(n=4) of patients on allopurinol had their dose adjusted. Comparatively in patients not prescribed allopurinol 15%(n=26) had more than 1 episode of gout in a year, however serum uric acid was monitored in 76%(n=126) of patients not on allopurinol. 44%(n=89) of patients diagnosed with gout had other comorbidities including Hypertension, Diabetes Mellitus and Dyslipidaemias.

Conclusion
Gout management at Kuala Belait Health Centre is not fully concordant to guidelines. Clearly there is a need to improve adherence, particularly in the tight monitoring of serum uric acid levels, medication review, and appropriate use of allopurinol, where indicated and patient follow up.

MANAGEMENT OF GOUT IN PERIMARY HEALTH CARE AT KUAL BELAIT HEALTH CENTRE, KB

BACKGROUND
Gout is a form of inflammatory arthritis. Patients typically have episodes lasting several days when their gout flares and are often symptom free between episodes. The acute episode typically develops maximal intensity within 12 hours. The main features it presents with are
• Pain: this is often very significant
• Swelling
• Erythema
Around 70% of first presentations affect the 1st Metatarsophalangeal (MTP) joint. Attacks of gout affecting this area were historically called podagra. Other commonly affected joints include.
• Ankle
• Wrist
• knee
If untreated repeated acute episodes of gout can damage the joints resulting in a more chronic joint problem.
Radiological features of gout include:
• Joint effusion is an early sign
• Well defined punched out erosions with sclerotic margins in a juxta-articular distribution, often with overhanging edges
• Relative preservation of joint space until late disease.
• Eccentric erosions
• No per articular osteopenia
• Soft tissue tophi may be seen

Gout: predisposing factors
Decrease excretion of uric acid
• Drugs: diuretics
• Chronic kidney disease
• Lead toxicity
Increase production of uric acid
• Myeloproliferative /lymphoproliferative disorder
• Cytotoxic drufs
• Severe psoriasis
Gout: management
Acute management
• NSAIDs
• Intraarticular steroid injection
• Colchicine has a slower onset of action. The main side-effect is diarrhoea.
• Oral steroids may be considered if NSAIDs or colchicine are contraindicated. A dose of prednisolone 15mg/day is usually used.
• If the patient is already taking allopurinol it should be continued.

Allopurinol Prophylaxis
• Allopurinol should not be started until 2 weeks after an acute attack has settled as it may precipitate a further attack if started too early
• Initial dose of 100mg od, with the dose titrated every few weeks to aim for serum uric acid
Of < 300 micromole/l
• NSAID or Colchicine cover should be used when starting allopurinol.

Indications for allopurinol
• Recurrent attacks- the British Society for Rheumatology recommend that in uncomplicated gout uric acid lowering drug therapy should be started if a second attack, or further attack occurs within 1 year
• Tophi
• Renal disease
• Uric acid renal stones
• Prophylaxis if on cytotoxics or diuretics

Life style modifications
• Reduce alcohol intake and avoid during an acute attack
• Lose weight if obese
• Avoid food high in purine e.g Liver. Kidneys, Seafood. Oily fish ( mackerel, sardines) and yeast products

A series of guidelines in the management of Gout has been established by the European League against Rheumatism (EULAR), British Society of Rheumatology (BSR) and American College of Rheumatology (ACR), which emphasizes the importance of titrating urate lowering therapy to achieve a serum urate target below 300 micromole/l.

AIMS & OBJECTIVES

The aim of the audit is to review patients with the diagnosis of Gout seen at Kuala Belait Health Centre in last year (From Jan 2017 to Dec 2017). The standards set by British Rheumatology Society(BRS) for optimal care of Gout was evaluated including screening for co-morbidities, documented advise on life style modification and whether they have achieved target level of Serum uric acid level (300 micromole/l) with optimal dose titration of allopurinol.

CRITERIA

All adult patients with the diagnosis of Gout seen at Kuala Belait Health centre in last 1 year (from 1st January 2017 to 31st December 2017) were included in audit. The audit was done in accordance with guidelines set by British Society of Rheumatology (Table 1) for optimal management of gout.

Table 1 Audit Criteria based on BSR guidelines
Theme Guidelines Criteria
Assessment of Gout patients All patients presenting with acute gout should have their serum uric acid checked after 4-6 weeks Patient recorded serum uric acid 4-6 weeks after diagnosis
Managing and monitoring of chronic gout Allopurinol prescribed and titrated until serum uric acid 2 episodes of gout in a year who were started on allopurinol) should :
• Have serum uric acid level tested since initiation of allopurinol.
• Have allopurinol dose reviewed and titrated.
• Achieve serum uric acid level of 1 attack of gout
16% (26/156)
90% of patients on Allopurinol should
? Achieve a serum uric acid level of < 300micromole/l
? Serum uric acid level monitored
12% (4/36)

86% (32/36)

DUSCUSSION

Gout is a common reason for encounter in General Practice. Hyperuricemia occurs due to combination of genetic and environmental factors. The short term management of Gout is cantered on pain relief and preservation of joint function while long term management targets prevention of chronic attacks and chronic joint damage. Patients presenting with mild gout symptoms are manged with life style modification but for those with moderate to severe attacks, the addition of medication to treat gout is pivotal. Medical treatment includes the usage of non-steroidal anti-inflammatory drugs (NSAIDs), colchicine and corticosteroids. Where indicated the recurrence of gout is controlled by initiating urate lowering therapy (e.g. allopurinol). The patient serum urate level should be monitored regularly and the doses of allopurinol are titrated appropriately until the target urate level is achieved.

Despite the common occurrence of gout, the management of gout in primary health care is still not up to the mark.

Our results revealed that many patients did not have a documented serum uric acid level 4-6 weeks after acute episode. Although serum uric acid level is not a diagnostic marker for gout, it can guide us about further management, especially in deciding whether or not to initiate uric acid lowering therapy.

The audit show that only a handful of patients had their allopurinol dose titrated against the serum uric acid despite of checking their serum uric acid level regularly. British Society of Rheumatology guidelines for allopurinol administration recommend progressive dose titration from a starting dose of 50-100 mg daily with the increments of 50-100 mg daily to a maximum dose of 900 mg daily until target serum uric acid level is achieved. However the common doses of allopurinol prescribed in clinical practice are usually 300mg or less.

In patients who do not receive allopurinol, studies advocated offering allopurinol to patients with either a second episode of gout within a year, renal insufficiency, presence of tophi, uric acid stones or persistent use of diuretics.

Clearly, there is need to improve the prescribing of allopurinol. Our audit demonstrates that many of our patients with a history of more than one episode of gout (one of the indication of allopurinol) were not given allopurinol to control recurrence.

A substantial number of patients (46%) diagnosed with gout had other comorbidities including hypertension, diabetes mellitus, CKD and dyslipidaemias, as these patients are on multiple medicines, the physician should be aware of any drugs interactions while manging these patients.

RECOMMENDATIONS
All patients with Gout should have
• Screening for co-morbid disorders (BP, HbA1c and fasting lipids) recorded within the past five years.
• Documented advice on lifestyle modification ( weight reduction, alcohol intake and dietary adjustment)
• Allopurinol treatment should be titrated to a target serum urate of < 300 micromole/l.
Ongoing monitoring is required to check that serum urate reaches and is maintained at
target level
• All patients with gout should have medication review performed in the past year.

ACTION PLAN
Few suggestions to improve the management of patients with gout are outline in Table 5.

Table 5 Action Plan for management of patients with gout
Issues Action plan
Patients not currently manged according to guidelines • Review gout patients— prescribe allopurinol as appropriate and check serum uric acid level in patients who have not had it.
• Review allopurinol prescription in line with serum uric acid level
Lack of medicine review Create reminders in the system for a medication review in line with serum uric acid level
Neglected advice on life style changes • Patient education
• Hand out leaflets
• Putting posters for awareness at practice
Patient compliance to medication Ensure proper patient education regarding allopurinol therapy before starting therapy
Varying assessment and targets in practice Local guidelines for the management of gout with set standards and targets

CONCLUSION
Primary care centres should be aware of the available guidelines for the appropriate management of gout to ensure uniformity in their care standards. They should be aware of comorbidities associated with gout, such as cardiovascular and renal diseases. A sound understanding of the comorbidities may motivate doctors and patients to achieve good control of patient’s condition.

Although guidelines are readily available and medications have been in use for decades, it is challenge to maintain high standards in the management of gout. In addition clinicians should be able to identify the risk factors and comorbidities which may predispose one to gout flares. Such as obesity and plan their management strategies around these. However, the presence of these comorbidities can also make management difficult and may implicate the efficacy of pharmacological therapy.

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