Gout - View Improvement Plan

1. IF a gout patient is receiving an initial prescription for allopurinol and has significant renal impairment (defined as a serum creatinine level ≥ 2 mg/dl or measured/estimated creatinine clearance ≤ 50 ml/min), THEN the initial daily allopurinol dose should be < 300 mg/day.

	Gout
	Patients receiving an initial prescription for allopurinolQI
		n	%	Goal
	Patients receiving an initial prescription for allopurinol	14	67
	INITIALLY PRESCRIBED BY YOU:
	Patients receiving an initial prescription for allopurinol	13	62
	Patients receiving an initial prescription for allopurinol having significant renal impairment	3	23
	Patients receiving an initial prescription for allopurinol having significant renal impairment and initial daily allopurinol dose less than 300 mg/day	1	33
	INITIALLY PRESCRIBED BY OTHER PHYSICIAN:
	Patients receiving an initial prescription for allopurinol	1	5
	Patients receiving an initial prescription for allopurinol having significant renal impairment	1	100
	Patients receiving an initial prescription for allopurinol having significant renal impairment and initial daily allopurinol dose less than 300 mg/day	0	0

2. IF a patient with tophaceous gout is given an initial prescription for a urate-lowering medication and lacks both 1) significant renal impairment (a serum creatinine level ≥ 2 mg/dl or measured/ estimated creatinine clearance ≤ 50 ml/min and 2) peptic ulcer disease, THEN a prophylactic agent (colchicine or NSAID) should be given concomitantly.

	Gout
	Anti-inflammatory agents with initiation of urate-lowering agentsQI
		n	%	Goal
	Patients with tophaceous gout	16	76
	Patients with tophaceous gout given an initial prescription for a urate-lowering medication	11	69
	INITIALLY PRESCRIBED BY YOU:
	Patients with tophaceous gout given an initial prescription for a urate-lowering medication	10	0
	Patients with tophaceous gout given an initial prescription for a urate-lowering medication lacking both significant renal impairment and peptic ulcer disease	1	10
	Patients with tophaceous gout given an initial prescription for a urate-lowering medication lacking both significant renal impairment and peptic ulcer disease given a prophylactic agent concomitantly	0	0
	INITIALLY PRESCRIBED BY OTHER PHYSICIAN:
	Patients with tophaceous gout given an initial prescription for a urate-lowering medication	1	0
	Patients with tophaceous gout given an initial prescription for a urate-lowering medication lacking both significant renal impairment and peptic ulcer disease	0	0
	Patients with tophaceous gout given an initial prescription for a urate-lowering medication lacking both significant renal impairment and peptic ulcer disease given a prophylactic agent concomitantly	0	0

3. IF a gout patient has either 1) a history of nephrolithiasis or 2) significant renal insufficiency (defined as a serum creatinine level ≥ 2 mg/dl or measured/estimated creatinine clearance ≤ 50 ml/min) THEN a xanthine oxidase inhibitor should be started as the initial urate-lowering medication rather than a uricosuric agent.

	Gout
	Apropriate urate-lowering agentQI
		n	%	Goal
	Patients with a history of nephrolithiasis OR significant renal insufficiency	15	71
	Patients with a history of nephrolithiasis OR significant renal insufficiency with a xanthine oxidase inhibitor started as the initial urate-lowering medication rather than a uricosuric agent	11	0
	Patients with a history of nephrolithiasis OR significant renal insufficiency with a uricosuric agent started	3	20

4. IF a patient has hyperuricemia and gouty arthritis characterized by any of the following clinical characteristics 1) tophaceous deposits, 2) gouty erosive changes on radiographs, or 3) gout attack of twice or more per year, THEN the patient should be offered therapy with a urate lowering drug unless contraindicated.

	Gout
	Initiation of urate-lowering therapyQI
		n	%	Goal
	Patients with hyperuricemia and gouty arthritis	19	90
	Patients with hyperuricemia and gouty arthritis where a urate-lowering drug is NOT prescribed due to:
	Not Indicated	1	5
	Contraindicated	2	11
	Patient Refused	0	0
	Other Reason	0	0
	Patients with hyperuricemia and gouty arthritis offered therapy with a urate-lowering drug	16	84

1. IF a patient is newly prescribed any of the following drugs: NSAIDs (selective or non-selective), DMARDs, glucocorticoids or narcotics, THEN a discussion with the patient about the risks of the chosen therapy should be documented.

2. IF a patient is treated with 1) a non-selective NSAID or 2) a COX-2 selective NSAID plus aspirin, AND the patient has risk factors for upper gastrointestinal bleeding, THEN the patient should be treated concomitantly with either misoprostol or a proton pump inhibitor unless patient refuses.

3. IF a patient is treated with daily NSAIDs (selective or non-selective) and the patient has risk factors for gastrointestinal bleeding, THEN a hemoglobin or hematocrit should be performed at baseline and during the first year after initiating therapy.

4. IF a patient is treated with daily NSAIDs (selective or non-selective) AND the patient has risk factors for developing renal insufficiency** THEN a serum creatinine should be assessed at baseline, within the first 3 months, and then at least annually thereafter.

6. IF a patient has established treatment with a DMARD or glucocorticoids, THEN monitoring for drug toxicity should be performed. (SEE Table 2)