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Research ArticleResearch Briefs

Factors Influencing Allopurinol Initiation in Primary Care

Lorna E. Clarson, Samantha L. Hider, John Belcher, Edward Roddy and Christian D. Mallen
The Annals of Family Medicine November 2017, 15 (6) 557-560; DOI: https://doi.org/10.1370/afm.2137
Lorna E. Clarson
1Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, United Kingdom
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  • For correspondence: l.clarson@keele.ac.uk
Samantha L. Hider
1Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, United Kingdom
2Haywood Academic Rheumatology Centre, Staffordshire and Stoke-on-Trent, Partnership NHS Trust, Haywood Hospital, Burslem, Staffordshire, United Kingdom
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John Belcher
1Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, United Kingdom
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Edward Roddy
1Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, United Kingdom
2Haywood Academic Rheumatology Centre, Staffordshire and Stoke-on-Trent, Partnership NHS Trust, Haywood Hospital, Burslem, Staffordshire, United Kingdom
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Christian D. Mallen
1Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, United Kingdom
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    Table 1

    Sample Characteristics (N = 8,142)

    Allopurinol Prescribed n=3,283Allopurinol Not Prescribed n=4,859
    Male, %, (No.)70.9 (2,327)67.9 (3,300)
    Mean age at diagnosis of gout, ya65.4 (SD 10.2)66.9 (SD 11.1)
    Eligible for allopurinol, %, (n)
     At baseline34.7 (1,139)27.1 (1,320)
     Ever25.4 (835)34.7 (1,684)
    Criteria by which eligible for allopurinol, %, (No.)b
     Not eligible39.4 (1,294)37.7 (1,832)
     CKD2.8 (92)4.1 (197)
     Diuretic therapy40.7 (1,336)47.5 (2,310)
     ≥2 gout attacks in 12 months14.2 (466)7.8 (381)
     Tophi1.3 (41)0.9 (43)
     Urolithiasis1.6 (54)2.0 (96)
    Exposure to alcohol, %, (No.)c
     Never exposed to alcohol11.9 (392)13.2 (641)
     Exposed to alcohol76.3 (2,506)71.6 (3,479)
     Not recorded11.7 (385)15.2 (739)
    BMI, %, (n)
     BMI ≤25kg/mb19.1 (626)24.1 (1,173)
     BMI >25kg/mb64.9 (2,129)56.1 (2,724)
     Not recorded16.1 (528)19.8 (962)
    Charlson comorbidity score at gout diagnosis, mean1.7 (SD 1.9)0.8 (1.2)
    Consultation for gout during follow-up, median No. (IQR)2 (1–11)1 (1–10)
    Consultation for any reason during follow-up, median No. (IQR)42 (4–279)88 (8–440)
    • ACR = American College of Rheumatology; BMI = body mass index; CKD = chronic kidney disease; EULAR = European League Against Rheumatism; IQR = interquartile range; SD = standard deviation.

    • ↵a Cohort older than 50 years.

    • ↵b Eligibility according to the EULAR and ACR guidelines.5,6

    • ↵c Exposure to alcohol measured as ever exposed/never exposed or not recorded closest to the date of diagnosis of gout.

    • View popup
    Table 2

    Adjusted Hazard of Receiving an Allopurinol Prescription

    Hazard Ratio95% CI
    Eligible for allopurinol (ever)
     Not eligible1 [referent]1 [referent]
     CKD3.482.31–5.26
     Diuretic therapy2.492.10–2.94
     ≥2 Consultations for gout in 12 months3.883.22–4.68
     Tophi2.101.10–4.00
     Urolithiasis2.331.44–3.78
    Age at diagnosis of gouta1.000.99–1.01
    Male0.590.51–0.69
    Overweight (BMI >25kg/mb)
     Not overweight (BMI ≤25kg/mb)1 [reference]1 [reference]
     Overweight1.141.02–1.27
     Not recorded0.880.74–1.04
    Exposure to alcohol
     Never exposed1 [reference]1 [reference]
     Ever exposed to alcohol1.070.93–1.24
     Not recorded0.800.65–0.99
    Charlson comorbidity scorea0.840.81–0.88
    Number of consultations for gouta (during entire follow-up)1.051.02–1.08
    Number of consultations for any reason (during entire follow-up)
     Quartile 1 (0–34)1 [reference]1 [reference]
     Quartile 2 (34–64)0.440.37–0.61
     Quartile 3 (65–119)0.200.16–0.24
     Quartile 4 (≥120)0.070.05–0.09
    Time-varying covariatesc
    Male1.0071.004–1.011
    Number of consultations for gouta (during entire follow-up)1.0021.001–1.002
    Number of consultations for any reason (during entire follow-up)
     Quartile 1 (0–34)1 [reference]1 [reference]
     Quartile 2 (34–64)1.0051.001–1.009
     Quartile 3 (65–119)1.0091.005–1.037
     Quartile 4 (≥120)1.0151.012–1.020
    Eligible for allopurinol (ever)
     Not eligible1 [referent]1 [referent]
     CKD0.9900.982–0.999
     Diuretic therapy0.9910.988–0.994
     ≥2 consultations for gout in 12 mo0.9850.980–0.989
     Tophi0.9940.979–1.008
     Urolithiasis0.9900.982–0.999
    • ACR = American College of Rheumatology; BMI = body mass index; CKD = chronic kidney disease; EULAR = European League Against Rheumatism.

    • Note: Model is adjusted for all listed variables and clustering by practice.

    • ↵a Denotes a continuous variable.

    • ↵b Eligibility according to the EULAR and ACR guidelines.5,6

Additional Files

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  • The Article in Brief

    Factors Influencing Allopurinol Initiation in Primary Care

    Lorna E. Clarson , and colleagues

    Background Although medication to reduce uric acid, such as allopurinol, can reduce the complications of gout, it is prescribed for only a minority of gout patients. This study investigates factors associated with time to initiation of allopurinol treatment.

    What This Study Found Managing gout as a chronic, rather than an acute, condition could help prevent recurrences. A study of more than 8,000 medical records found a positive association between starting treatment with allopurinol and recurring doctor visits for the condition. Clinicians may therefore be more likely to offer allopurinol, or patients may be more likely to accept it, after multiple acute gout attacks.

    Implications

    • The authors suggest that more frequent chronic disease reviews to evaluate patients� preferences and eligibility for allopurinol could reduce barriers to successfully treating gout.
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The Annals of Family Medicine: 15 (6)
The Annals of Family Medicine: 15 (6)
Vol. 15, Issue 6
November/December 2017
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Factors Influencing Allopurinol Initiation in Primary Care
Lorna E. Clarson, Samantha L. Hider, John Belcher, Edward Roddy, Christian D. Mallen
The Annals of Family Medicine Nov 2017, 15 (6) 557-560; DOI: 10.1370/afm.2137

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Factors Influencing Allopurinol Initiation in Primary Care
Lorna E. Clarson, Samantha L. Hider, John Belcher, Edward Roddy, Christian D. Mallen
The Annals of Family Medicine Nov 2017, 15 (6) 557-560; DOI: 10.1370/afm.2137
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