Inpatient management of gout: we are still failing

Objective Despite effective treatment, gout is poorly managed. The aim of this study was to determine rates of serum urate (SU) testing and allopurinol dose adjustment in patients on allopurinol admitted to Christchurch based hospitals. Methods The hospital electronic prescribing and administration (ePA) system was used to identify patients on allopurinol during hospital admissions from March 2016-March 2023. Demographics, SU, renal function and changes to allopurinol therapy were recorded for each admission. Results were stratified by target SU and renal function. Results Of 18,081 admissions taking allopurinol, SU was measured in 2,950 (16.32%). The mean SU was 0.37 (SD 0.12) mmol/L, with 1,270 (43.05%) above target SU (0.36 mmol/L). Admissions with chronic kidney disease (CKD) stage 3-5 were more likely to have SU above target than CKD1-2 (78.7% vs 21.3% (p<0.001). Of those with SU above target allopurinol was ceased in 148 (11.7%), dose reduced in 44 (3.5%), increased in 92 (7.2%), and unchanged in 986 (77.6%) during the admission. Those above target SU with CKD stage 3-5 were more likely to stop/decrease allopurinol dose compared to those with CKD stage 1-2 (16.4% vs 10.4%; p=0.01). Conclusion More than 80% of hospital admissions did not have SU measured despite the patient receiving allopurinol. Most admissions, acknowledging limitations, had suboptimal management of the allopurinol dose in the context of their SU. These results reflect a missed opportunity to review and optimise gout management.