Acute Gout in Emergency Admissions - Patient Characteristics and Adherence of Care Processes to Current Guidelines

Abstract

Gout or hyperuricemia are both well known and common diseases. The prevalence of gout is increasing worldwide. Thus, patients with gout are becoming more common. Although there are several published guidelines for the management of gout, actual treatment of gout is inconsistent with these guidelines in many respects. Gout is usually treated by general practitioners (GP) in Germany. The aim of our study was to show which patients present to the emergency department and to record how treatment and clinical diagnostic testing of gout patients is performed in the emergency department of a university hospital in Germany. No such data have been published for Germany. Retrospective analysis of data of patients with ICD Code M10.xx from the emergency department at a university hospital from 05/2013 until 04/2016. 65 patients were treated with acute gout during the study period at the emergency department (age ∅ 53.45 y, 76.9% male, 23.07% female). 42 patients (65%) came outside normal office hours of GPs. In 31 patients, hyperuricemia or gout was known in their medical history, in 22 of these acute gout was known. 48 (73%) of patients came with monoarthritis and therefrom 40 with "classic" gout, such as podagra. 57 (86%) patients were subjected to diagnostic blood analysis and 31 (48%) diagnostic X-ray of the affected joint. We defined the appropriate indications for X-ray in diagnosis of acute gout as: signs of superinfection, prior surgical intervention or uncertain trauma in case history. According to this definition, 67% of the X-rays were performed without the correct indication. Four Patients were given punction of the affected joint to demonstrate monosodium urate monohydrate (MSU) crystals. Twelve patients were admitted as inpatients for surgery and/or antibiotic treatment. 51 (78%) patients received NSAIDs, 7 in combination with steroids and 4 patients received colchicine. Of those patients who received NSAID, 17 had an unknown or impaired renal function. Seven patients received neither pharmacological treatment nor recommendations for further treatment. Ten patients (15%) received a urate-lowering therapy or an existing therapy was increased during acute gout. In 10 patients, a urate-lowering therapy was recommended as further therapy. 63% were given further treatment recommendations such as cryotherapy or diet. Acute gout is seldom presented in the emergency room (< 1‰). This confirms the impression that gout is mainly a disease treated in the outpatient setting. As shown in our study, the pharmacological treatment of acute gout was largely consistent with the guideline recommendations; nevertheless observance of renal function before treatment with NSAIDs should be emphasised. Furthermore, we identified overuse of diagnostic procedures. Current guidelines recommend diagnosing acute gout with clinical scores. In conclusion, our study shows that those clinical diagnostic scores should be implemented in clinical practice, in order to avoid unnecessary diagnostic procedures.