Gout Admissions Escalate in the U.K.

LIVERPOOL -- Hospital admissions for gout are on the rise in England, reported Mark D. Russell, MBBS, of King's College London during a "hot topics" session at the annual conference of the British Society for Rheumatology (BSR) here.

From April 2006 to March 2017, there were 56,664 admissions for gout recorded in the National Health Service's digital data. This represented an increase in the incidence rate of unplanned admissions for gout of 59%, from 7.9 to 12.5 admissions per 100,000 population. In addition, gout increased as a proportion of all hospital admissions from 0.023% to 0.032%.

In comparison, unplanned admissions for patients with rheumatoid arthritis declined by 50% during the same period, from 8.6 to 4.3 admissions per 100,000 population.

Gout is the most common inflammatory arthritis, and its incidence is increasing in the U.K., Russell said. In a recent paper, there was a 64% increase in prevalence in gout from 1997 to 2015, which likely reflects the increasing burden of the metabolic syndrome in the West. But it's also a curable condition with effective treatments available. In that paper, only 27% of patients received urate lowering therapy within 12 months of the diagnosis in 2012, he noted.

Since that time there have been updated guidelines on gout treatment from both BSR and the European League Against Rheumatism, resulting in a concerted effort to encourage the prescription of urate lowering therapy and using a treat-to-target approach.

The aim of the study was to describe trends in unplanned hospital admissions for gout in adults, as well as to examine prescribing trends for commonly used specific gout medications.

Since 2006, there have been on average 14.9 million annual all-cause admissions, as well as 4,230 annual emergency admissions for gout.

A total of 82% of hospital admissions for gout were unplanned -- in contrast with rheumatoid arthritis where fewer than 3% were unplanned.

The mean length of stay for patients hospitalized for gout was 6.6 days, which was "pretty long," he said, and that has remained unchanged since 2006. and cumulatively, gout accounted for 349,768 bed-days. The current overall cost has ranged from £852 to £5,662 depending on length of stay and patient comorbidities. Most gout admissions are among men, and the number increases exponentially with older age.

There also has been an increase in prescriptions for allopurinol by primary care physicians, from 7,387 per 100,000 to 12,697 per 100,000, which represented a 72% increase, while colchicine prescriptions increased from 394 to 1,046 per 100,000, which was a 166% increase.

In addition, there has been a 20-fold increase in prescriptions for febuxostat (Uloric) since data became available in 2010, from 15 to 300 per 100,000 for colchicine.

These data suggest that there has been an improvement in the accuracy of diagnostic coding following the introduction of payment by results in 2006, he noted.

"A limitation of the study is that we can describe trends but are unable to infer directionality. It's very likely that allopurinol prescriptions are rising because of the increasing incidence of gout, but we can't exclude the possibility that more allopurinol is being prescribed with inadequate prophylaxis and this may have precipitated admissions," Russell pointed out. When urate lowering therapy with allopurinol is being initiated, there is an increase in acute attacks, and oral colchicine is the usual first-line agent for prophylaxis in this situation.

In addition, these data don't differentiate between first presentations and readmissions, which he and his colleagues plan to look into.

"So as rheumatologists we are getting better at initiating urate lowering therapy but still not quite as good at dose titration and treat-to-target. There's clearly more to do and this should be a call to arms for rheumatologists to reduce the inpatient burden of disease," he concluded.

Russell was the recipient of a BSR Young Investigator Award for this work.