Intended for healthcare professionals


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

BMJ 2011; 343 doi: (Published 01 December 2011) Cite this as: BMJ 2011;343:d7459
  1. Wendy Lipworth, postdoctoral fellow12,
  2. Ian Kerridge, director 2,
  3. Jonathan Brett, clinical pharmacology and toxicology registrar 3,
  4. Richard Day, professor of clinical pharmacology 3
  1. 1Australian Institute of Health Innovation, University of New South Wales, Sydney, NSW 2052, Australia
  2. 2Centre for Values, Ethics and the Law in Medicine, University of Sydney, Sydney, Australia
  3. 3Clinical Pharmacology and Toxicology, St Vincent’s Hospital, Darlinghurst, Australia
  1. Correspondence to: W Lipworth w.lipworth{at}
  • Accepted 27 October 2011

Despite the existence of several effective drugs for chronic tophaceous gout, management is often neither rational nor effective. Wendy Lipworth and colleagues examine the possible reasons

An evidence based or “rational” approach to prescribing is thought to maximise the benefit and minimise the harm from prescription drugs. Unfortunately, prescribing often does not meet this ideal despite clinicians’ best intentions. We use treatment of chronic tophaceous gout to show how apparently irrational prescribing arises from several interacting “failures” in both clinical practice and drug development.

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 …

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