Clinical
Pharmacy Practice News • October 2020
3
Pain Medicine
ED Patients With Gout Flares Too Often Receive Opioids
P
atients with gout flares presenting to the emergency department (ED) are often given opioids or discharged with opioids, even though the pain relievers are not recommended in treatment guidelines, New Jersey researchers report. Reviewing 214 patient records from the ED with gout at Robert Wood Johnson University Hospital in Somerset, investigators found that 51 patients (24%) were discharged on opioids, and that about 82% of patients had their first encounter with opioids due to this visit. In the ED, opioids (28%) were used second only to nonsteroidal anti-inflammatory drugs (NSAIDs; 41.6%). At discharge, opioids (23.9%) were the third most common medication prescribed, after NSAIDs (37%) and steroids (34.6%), the investigators reported at the American College of Clinical Pharmacy’s 2020 virtual poster symposium (poster 348). Best practices for gout flare management in the ED are urgently needed, said senior author Luigi Brunetti, PharmD, an associate professor of pharmacy practice and administration at Rutgers University’s Ernest Mario School of Pharmacy, in New Brunswick. Dr. Brunetti said he had been collaborating with rheumatologist Naomi Schlesinger, MD, on a few gout-related projects when they noted patients being discharged from the ED on opioids and decided to study it further. “That’s when
we identified these trends in drug use that had us scratching our heads,” Dr. Brunetti said. “It’s one thing if you have a patient coming in on an opioid, perhaps for another indication. But we had a significant percentage of patients that were sent home on an opioid who previously were not prescribed one.” The study pulled records from all patients visiting the ED with a primary diagnosis of gout from Jan. 1, 2016, through July 1, 2019. They used a comparative analysis to determine differences between patients who were or were not discharged on opioids, and multivariable logistic regression to identify factors associated with an opioid prescription upon discharge from the hospital. Moreover, 12% of patients were discharged on opioids without anti-inflammatory drugs, and a history of opioid use (odds ratio [OR], 3.3; 95% CI, 1.3-8.6; P=0.14) and gastroesophageal reflux disease (OR, 3.5; 95% CI, 1.09-10.9; P=0.035) was associated with opioid prescription upon discharge. Medications prescribed in the ED and upon discharge were NSAIDs, corticosteroids, opioids, acetaminophen and colchicine. “There’s a good frequency of inappropriate prescribing of opioids for gout flares, and it’s good the authors have statistics to make a case for better education of gout management,” commented Cortney Mospan, PharmD, an assistant
professor of pharmacy at Wingate University Levine College of Health Sciences, in Wingate, N.C. Dr. Mospan co-authored a recent continuing education article on the pharmacist’s role in managing gout and hyperuricemia (bit.ly/2UD554C).
What the Guidelines Say This spring, the American College of Rheumatology released the 2020 Guideline for the Management of Gout, Dr. Mospan said. There are three foundational drugs recommended for flares: NSAIDs, corticosteroids and colchicine. A gout flare indicates that uric acid has elevated to the point that it exceeds the ability to be absorbed, and crystals start to form, she noted. The body recognizes these crystals as foreign substances, which activates the immune system to attack and eliminate them. “When you look at treatment options recommended by the guidelines, those are all anti-inflammatory medications as opposed to a pain medication like opioids, because what we need to be doing in that acute gout flare—even though there is a tremendous amount of pain—is to decrease that inflammatory response,” Dr. Mospan said. “That will result in pain relief and subside that acute gout flare.” There’s another reason to treat that inflammation, she added. Studies have shown a connection between elevated uric acid and cardiovascular disease,
EDITORIAL BOARD
including hypertension ion and diabetes (N Engl ngl J Med 2008;359[17]: 7]: 1811-1821). Prescribing opi-oids is problematic not only because the drugs do noth-ing for the underlying ng inflammation; opioids ds also can introduce ce patients—who haven’t n’t been exposed before— e— to the addictive painnkillers, Dr. Mospan an said. Moreover, leftover pills could be diverted by the patient or a visitor to the home, increasing the supply of illicit opioids in the community. Pharmacists can play a key role in gout treatment, Dr. Mospan said, including educating patients on medication benefits and side effects and the importance of adherence. They also can help prescribers adhere to treatment recommendations. Based on the Rutgers study, such help is sorely needed. Aside from the high percentage of opioid prescriptions, the investigators also found that about 30% of patients were prescribed acetaminophen, which is not recommended and will not help with pain. —Karen Blum The sources reported no relevant financial relationships.
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