Long-Term Care Patients With Gout Have Substantial Disease Burden
As gout is not a pre-specified field in the Minimum Data Set (MDS), it may be underrecognzied and undertreated in nursing home residents. To create a clearer clinical profile of nursing home patients with gout, Barbara Zarowitz, PharmD, and Terrence O’Shea, PharmD, Omnicare Inc., conducted a large retrospective analysis, which revealed that nursing home residents with gout have significant cognitive and functional impairment and a high disease burden. The results of their study were published in June in Consultant Pharmacist. The study included approximately 138,000 residents with gout, who were identified using the MDS and prescription claims records served by Omnicare, between October 2009 and September 2010. Gout was defined according to the International Classification of Diseases Ninth Revision, Clinical Modification (ICD-9-CM), with episodes of acute gout defined by a <14-day course of oral nonsteroidal anti-inflammatory drugs (NSAIDs), oral or injectable steroids, or oral colchicine.
Based on these criteria, gout was identified in 1.8% of residents (n=2487); more than half of these residents (n=1420) were aged 80 years or older. In an interview with Annals of Long-Term Care®, Zarowitz said she and her colleague had expected a much higher percentage of residents with gout given that its prevalence increases with age; but this amount is a likely testament to the underreporting of gout. More than three-fourths of the group were white, but men and women were represented equally. Approximately two-thirds of residents with gout required extensive assistance with most activities of daily living, and pain was reported by nearly 69% of residents. The most common comorbidities among this population were hypertension (82.2%), diabetes (46.6%), arthritis (43.7%), and renal failure (22.4%).
Three-fourths of patients with gout were receiving diuretic therapy, and approximately 17% of residents received no treatment at all. Based on clinical practice guidelines, not all patients require ongoing gout treatment; in this study, only those with recurrent gout attacks received suppressive therapy, Zarowitz said. Episodes of acute gout occurred in 38% of residents, more than half of whom (53%) were treated with a short course of an oral or injectable steroid. Treatment for acute gout with oral colchicines and oral NSAIDs were less common (25.2% and 21.8%, respectively). One of the study’s strengths is that “Unlike data from ambulatory adults cited in other studies, nursing home residents do not have access to over-the-counter medications not dispensed by the pharmacy; thus, this study represents a true 17% untreated,” Zarowitz said.
Due to underreporting, clinicians should maintain a high level of vigilance for gout, especially if residents present with unexplained pain, joint swelling, and/or high uric acid levels. Prompt evaluation and intervention are warranted in these patients, the authors concluded. “Unsteadiness and functional impairment can predispose residents with gout to falls, thus fall prevention strategies should be implemented and residents monitored closely,” Zarowitz said. “Modification of drug therapy may be indicated to decrease the recurrence of gouty attacks (ie, diuretics, niacin, carbidopa/levodopa, cyclosporine).”
