Guideline Concordance and Documentation of Allopurinol Initiation Across Clinical Specialties: A Three-Year Retrospective Evaluation

Background/Objectives: To assess guideline concordance and indication documentation of new allopurinol prescriptions and whether these differed across clinical specialties. Methods: A retrospective study at a tertiary academic center in Riyadh, Saudi Arabia, included adults with a first institutional allopurinol dispensation between January 2022 and November 2024. Prescriptions were guideline-concordant if issued for gout meeting 2020 American College of Rheumatology initiation criteria, tumor lysis syndrome management, or recurrent nephrolithiasis; documented non-guideline-concordant if another indication was recorded; and undocumented otherwise. Specialty associations were assessed using logistic regression, age- and sex-adjusted Firth models, and Fisher’s exact tests. Results: Among 707 patients, 105 (14.9%) prescriptions were guideline-concordant, 452 (63.9%) were documented non-guideline-concordant, and 150 (21.2%) were undocumented; asymptomatic hyperuricemia accounted for 47.0%. Relative to Rheumatology, Primary Care (OR 92.57, 95% CI 32.89–260.57) and Nephrology (OR 24.69, 95% CI 7.01–86.90) had higher odds of documented non-concordance, persisting after adjustment. Cardiology had the highest undocumented rate (35.4%). Conclusions: Non-guideline-concordant initiation was common, and the type of quality gap differed by specialty. These observational associations may partly reflect case mix and should not be attributed to specialty alone, but they support specialty-tailored stewardship.