Diagnosing and Managing Gout – 10 International Recommendations

Sivera F, Andrs M, Carmona, L et al., Multinational evidence-based recommendations for the diagnosis and management of gout: integrating systematic literature review and expert opinion of a broad panel of rheumatologists in the 3e initiative. Ann Rheum Dis. 18 July 2013. doi:10.1136/annrheumdis-2013-203325 (Open Access)

An international panel of rheumatologists has issued new recommendations for the diagnosis and management of gout -- hoping to improve often uneven and suboptimal patient care that exists despite numerous care guidelines and new therapies.

The evidence-based recommendations encompass diagnosis, comorbidity screening, acute flares, urate-lowering therapy (ULT), drug choices, and management of asymptomatic hyperuricemia.

They are published online with open access by the Annals of the Rheumatic Diseases and stem from key clinical questions developed by rheumatologists from 14 countries in Europe, South America and Australasia who took part in the 2011 3e (Evidence, Expertise, Exchange) Initiative.

After systematic literature reviews, data analysis, and formal voting by a panel of 78 rheumatologists, 10 recommendations emerged:

•    Monosodium urate (MSU) crystals should be identified for a definite diagnosis of gout. If not possible, diagnosis can be supported by classical clinical features (e.g., podagra, tophi, rapid response to colchicine) and/or characteristic imaging findings.

•    In patients with gout and/or hyperuricemia, renal function should be measured and assessment of cardiovascular (CV) risk factors is recommended.

•    Acute gout should be treated with low-dose colchicine (up to 2 mg daily), NSAIDs and/or glucocorticoids (intra-articular, oral, or intramuscular), depending on comorbidities and adverse event (AE) risks.

•    Patients should be advised about lifestyle modifications such as reducing stress, losing weight, exercising regularly, stopping smoking, and avoiding excess alcohol and sugar-sweetened drinks.

•    First-line ULT should be allopurinol, with alternatives such as uricosurics (e.g., benzbromarone, probenecid) or febuxostat. Uricase as monotherapy should be considered only for patients with severe gout in whom all other forms of therapy have failed or are contraindicated. ULT (except uricase) should be started at a low dose and escalated to achieve a target serum urate.

•    Patient education on the risk and management of flares is essential when introducing ULT. Consider flare prophylaxiswhen prescribing colchicine (up to 1.2 mg daily) or, if it is contraindicated or not tolerated, substitute NSAIDs or low dose glucocorticoids. Duration depends on individual patients.

•    For patients with mild-to-moderate renal impairment, allopurinol may be used with close monitoring for AEs, starting at a low daily dose (50–100 mg) and up-titrated to achieve target serum uric acid levels. Febuxostat and benzbromarone are alternatives that do not require dose adjustment.

•    The treatment target is serum urate below 0.36 mmol/L (6 mg/dL), and the eventual absence of gout attacks and resolution of tophi. Patient monitoring should include serum urate levels, frequency of gout attacks, and tophi size.

•   Treat tophi medically by sustained reduction in serum uric acid, preferably below 0.30 mmol/L (5 mg/dL). Surgery is indicated only in select cases (e.g., nerve compression, mechanical impingement, or infection).

•    Drug treatment of asymptomatic hyperuricemia is not recommended to prevent gouty arthritis, renal disease, or CV events.

The authors caution that since other specialties (e.g., nephrology, primary care), health professionals, and gout patients did not contribute to the recommendations, it’s unclear how applicable or relevant they are in non-rheumatological settings.

The multinational 3e Initiative previously issued recommendations on use of methotrexate in rheumatic disorders and management of inflammatory arthritis.