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| Topic | Indicator | Source |
Resources |
| Allopurinol adjustment for renal function |
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.
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CERTs at UAB |
Helpful Hints |
| Anti-inflammatory agents with Initiation of urate lowering agents |
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.
|
CERTs at UAB |
Helpful Hints |
| Appropriate urate lowering agent |
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.
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CERTs at UAB |
Helpful Hints |
| Initiation of urate-lowering therapy |
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.
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CERTs at UAB |
Helpful Hints |
CERTs at UAB = Centers for Education and Research on Therapeutics at the University of Alabama, Birmingham
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| Topic | Indicator | Source |
Resources |
| Informing patients about risks |
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.
| AFQuIP† |
Helpful Hints |
| Prophylaxis for patients at risk for gastrointestinal bleeding |
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.
| AFQuIP†, ACOVE |
Helpful Hints |
| Lab monitoring |
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.
| AFQuIP† |
Helpful Hints |
| 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.
| AFQuIP† |
Helpful Hints |
| 6. IF a patient has established treatment with a DMARD or
glucocorticoids, THEN monitoring for drug toxicity should be
performed.
(SEE Table 2)
| AFQuIP† |
Helpful Hints |
*NSAID = non-steroidal anti-inflammatory drug
† AFQuIP = Arthritis Foundation Quality Indicator Project,
ACOVE = Assessing Care for Vulnerable Elders
‡ Risk factors for gastrointestinal bleeding are defined as any of the following: age ~ 75, peptic ulcer disease, gastrointestinal bleeding, or glucocorticoid use.
** Risk factors for renal insufficiency defined as any of the following: age ~ 75, diabetes mellitus, hypertension, angiotensin converting enzyme (ACE) inhibitor use or diuretic use.
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