Virtual Gout Clinic

Gout is a chronic and progressive form of arthritis occurring as a result of monosodium urate
deposition in the joints and surrounding tissues. Despite its extremely well known
pathogenesis and the availability of highly efficacious therapies, gout continues to lead to
considerable morbidity and mortality due to poor management and limited therapeutic
adherence. The investigators translational research study will address this deficit in
evidence implementation.

The treatment of chronic gout is based primarily on the use of urate lower therapy (ULT) to
reduce the frequency of, and eventually eliminate, acute flares in addition to reducing the
risk of progressive joint destruction. There are currently four ULT agents approved for the
treatment of gout in the United States (US) including probenecid (a uricosuric), pegloticase
(a biologic therapy approved for treatment-refractory gout), allopurinol, and febuxostat.
Available for more than 40 years, allopurinol remains the most frequently prescribed ULT,
accounting for ~99% of all ULT prescriptions. Many early studies confirmed the robust urate
lowering effect of allopurinol, a treatment also yielding ample improvements in long-term
outcomes including a reduction in gouty flares. A recent 28-week randomized trial examining
fixed dose daily allopurinol revealed a 34% reduction in serum urate concentrations vs. a
decrease of 3-4% for those receiving placebo. There are factors that contribute to
sub-optimal allopurinol administration and likely include, but are not limited to: 1) failure
of prescribers to appropriately titrate allopurinol dose to achieve optimal serum urate
target levels; 2) poor long term patient adherence to therapy; 3) drug intolerance,
recognizing that this affects only a small proportion of patients; 4) limited data regarding
the effectiveness of doses exceeding 300 mg/day; and 5) concerns regarding increased toxicity
with higher doses, particularly in the context of chronic kidney disease (CKD).

To date, there have been no published studies examining the impact of a large scale
intervention implemented to optimize allopurinol administration in gout. Intervention studies
that have been done have universally involved small sample sizes and have been limited to
single centers, substantially limiting the external validity of these efforts. The impact of
these interventions, largely employing prescription audits and performance feedback to
providers, have either gone unreported or have been quite modest in effect. Given the
potential cost-effectiveness of allopurinol in gout treatment compared to alternative ULTs
and the growing number of reports that have consistently characterized its everyday use as
sub-optimal, interventions focused on improving and optimizing allopurinol administration in
the context of 'real-life' gout care are urgently needed.

Inclusion Criteria:

- At least one prior International Classification of Disease (ICD) 9 code for gout
(274.xx)

- Received a new prescription for allopurinol, defined as no prior allopurinol
prescription in the preceding 12 months

Exclusion Criteria:

- No prior ICD9 code for gout (274.xx)

- Did not receive a new prescription for allopurinol, defined as no prior allopurinol
prescription in the preceding 12 months