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ACP issues clinical recommendations for acute gout

The ACP recently released evidence-based clinical practice guidelines for diagnosing and managing acute gout in Annals of Internal Medicine.

A systematic review of randomized, controlled and observational studies published between January 2010 and March 2016 served as the basis of the ACP’s recommendations for managing gout. In these studies, researchers assessed clinical outcomes such as pain, joint swelling and tenderness, daily routine activities, patient global assessment, recurrence, intermediate outcomes of serum uric acid levels and harms.

The ACP made four essential recommendations for clinicians managing patients with acute or recurrent gout based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method:

• corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs) or colchicine should be used to treat acute gout;
• colchicine should be prescribed in low doses;
• long-term uric acid-lowering therapy should not be initiated following a patient’s first gout attack or in patients with sporadic attacks; and
• benefits, harms, costs, and individual preferences should be discussed with patients who have frequent gout attacks prior to initiating uric acid-lowering therapy such as concomitant prophylaxis.

“Physicians should consider using corticosteroids first in patients without contraindications because they are one of the most effective anti-inflammatory medications available and they are as effective as NSAIDs for managing acute gout but have fewer adverse effects,” Nitin S. Damle, MD, MS, MACP, president of ACP, said in a news release about the guidelines. “Although a generic formulation of colchicine is now available, it is more expensive than NSAIDs or corticosteroids. This is an important consideration for patients, especially as prescription drug prices continue to increase.”

In addition, the ACP developed a guideline for diagnosing gout based on a systematic review of prospective and cross-sectional studies published through February 2016. Those studies included in the review evaluated outcomes such as accuracy of test results, serum uric acid and synovial fluid crystal analysis, radiographic or ultrasonography changes, clinical decision-making, patient-centered outcomes and adverse effects of the tests.

The ACP made one essential recommendation for clinicians to diagnose patients with gout based on the GRADE method:

• Patients with possible acute gout should be tested using synovial fluid analysis to confirm gout diagnosis.

“While joint aspiration with synovial fluid analysis for uric acid crystal analysis is the reference standard for diagnosing gout, most patients are seen initially by their primary care physician or an [ED] physician where synovial fluid analysis is less frequently and less easily performed,” Damle said in the release. “In certain situations, physicians should use clinical judgement so that patients can begin treatment if gout is suspected.”

The ACP stressed the importance of prompt, accurate gout diagnosis to avoid unnecessary surgery, hospitalization, delays in adequate treatment such as antibiotics for septic joints and prescribing long-term treatment unnecessarily.

In an accompanying editorial, Tuhina Neogi, MD, PhD, of Boston University School of Medicine, and Ted R. Mikuls, MD, MSPH, of University of Nebraska Medical Center, argue that the “treat-to-avoid-symptoms” approach with urate-lowering therapy that the ACP recommends has not been adequately tested. Implementing this approach would be “a disservice to our patients and primary care colleagues,” they wrote.

“A clear understanding of the pathophysiology of gout provides a strong foundation for rational recommendations while we await clarity on these important issues,” Neogi and Mikuls wrote.

In a second editorial, Robert M. McLean, MD, member of the ACP Clinical Guidelines Committee, points to evidence as the directive of developing their guideline recommendations for managing and diagnosing gout.

“Specifying clinical options when evidence is lacking is the role of expert consensus panels or best-practice statements, but these documents must not masquerade as the type of evidence-based guidelines defined by the [Institute of Medicine],” he wrote. “As we try to provide our patients with the best possible care, we must be clear about when the best clinical decision is defined by high-quality evidence and when it is suggested by consensus.” – by Alaina Tedesco

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Disclosure: The ACP operating budget supported the development of these new guidelines. McLean reports receiving personal fees from Takeda Pharmaceuticals speakers’ bureau prior to 2015. Please see full studies or editorials for a complete list of all other authors’ relevant financial disclosures.