Adherence Low for ULT Dosing ACR Gout Guidelines

While rheumatologists self-report high adherence to the 2020 American College of Rheumatology (ACR) Guideline for Gout Management, there are gaps in knowledge and adherence, particularly around dosing of treatment regimens.

Adherence was investigated in a 57-item questionnaire study conducted by lead investigator Naomi Schlesinger, MD, Division of Rheumatology, Spencer Fox Eccles School of Medicine, University of Utah, and colleagues. Investigators administered the questionnaire to a sample of United States rheumatologists. The questionnaire evaluated adherence, based on guideline recommendations reported to be followed in practice; and agreement, based on whether respondents always followed the recommendations.

The investigators found that all 201 rheumatologists approached completed the questionnaire. The mean overall stated adherence score was 11.5 (maximum 15), and the mean overall stated agreement score was 7.7 (maximum 14). Schlesinger and colleagues found that less experienced rheumatologists with up to 8 years of experience (n = 49) were more likely to report adherence (mean stated adherence score, 12.3) to individual ACR recommendations than those with more experience (n = 152; mean stated adherence score, 11.3; P ≤.05).1

Similarly, rheumatologists who reported seeing at most 75 patients with gout in 6 months (n = 66) had a mean stated adherence score of 12.1 compared with 11.2 for those who reported seeing over 75 patients (P ≤.05). Guidelines for initiating urate-lowering therapy (ULT) were reportedly followed by 78% of rheumatologists, with 89% likely to prescribe allopurinol as a first-line ULT. Dosing recommendations were not highly adhered to, with 43% adhering to febuxostat dosing recommendations and 39% adhering to allopurinol dosing recommendations. Furthermore, rheumatologists from academic settings were more likely to prescribe an interleukin-1 inhibitor for gout flares.1

While guidelines were highly adhered to, ULT initiation and especially dosing were not highly adhered to. These findings are notable as proper ULT administration has been shown to improve outcomes in people with gout in multiple ways. For instance, other recent research presented during November’s ACR Convergence found that using the novel ULT to Acute Treatment Ratio (ULTrA) index was linked to reduction in gout-related hospital admissions.

“Gout is sub-optimally managed with under-prescribed ULT leading to frequent flares, increased healthcare utilization, and cost,” lead investigator Manjari Lahiri, MD, an adjunct associate professor of medicine at the National University of Singapore and a senior consultant in the divisions of rheumatology and advanced internal medicine at the National University Hospital, and colleagues wrote.2

Lahiri and colleagues found that in a retrospective study, the ULTrA index was inversely associated with hospitalization for prevalent patients in 2022 (odds ratio [OR], 0.94; 95% CI, 0.93-0.95; P <.001) and for incident patients in 2023 (OR, 0.98; 95% CI, 0.97-0.99; P = .02) after adjusting for age and sex.2

“The ULTrA is an easy-to-measure index which was inversely associated with hospital admissions,” investigators concluded.2 “This is unlikely to be solely explained by the higher number of acute prescriptions in patients who are hospitalized, as the association was weaker in the 2023 incident cohort with more frequent hospitalizations. The impact of real-time visualization of ULTrA on prescriber behavior and hospitalization should be studied.”

REFERENCES

1. Schlesinger N, Pillinger MH, Lipsky PE. Knowledge of and Stated Adherence to the 2020 American College of Rheumatology Guideline for Gout Management: Results of a Survey of US Rheumatologists. J Rheumatol. 2025, 52 (1) 77-86; doi: 10.3899/jrheum.2023-0981

2. Tang M, Tay F, Santosa A, et al. Urate Lowering Therapy to Acute Treatment Ratio (ULTrA) Index – a Novel Quality Indicator Associated with Reduced Hospital Admissions for Gout. Arthritis Rheumatol. https://acrabstracts.org/abstract/urate-lowering-therapy-to-acute-treatment-ratio-ultra-index-a-novel-quality-indicator-associated-with-reduced-hospital-admissions-for-gout/