How clinical and research failures lead to suboptimal prescribing: the example of chronic gout

Treatment of chronic gout

Chronic tophaceous gout is the most common inflammatory arthritis in older men and affects about 1-2% of adults in the developed world.1 For most patients, allopurinol—a xanthine oxidase inhibitor that blocks the synthesis of uric acid—is highly effective in preventing recurrent attacks of acute gout and the development of chronic tophaceous gout.2 Allopurinol is easy to administer (generally requiring only a once daily dose), inexpensive, and generally well tolerated aside from the extremely rare, and sometimes predictable, allopurinol hypersensitivity reaction and other more common but generally minor or controllable adverse reactions.3 4 5

It seems, therefore, that allopurinol should be the mainstay for prevention and management of chronic gout and that this condition should be well controlled in the population. But in reality, many patients are prescribed subtherapeutic doses of allopurinol (usually ≤300 mg daily compared with a maximum of 800 mg approved by the US Food and Drug Administration for patients with normal renal function) and fewer than half of patients receive allopurinol for more than a year despite needing continuing prophylaxis.6 7 8 Similarly, there is underuse of probenecid, a uricoscuric that is a safe, inexpensive, and effective alternative to allopurinol for patients who do not have a history of nephrolithiasis or serious renal impairment.9 10 11

There …