EULAR evidence based recommendations for gout. Part II: Management. Report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).
Journal: 2006/November - Annals of the Rheumatic Diseases
ISSN: 0003-4967
Abstract:
OBJECTIVE
To develop evidence based recommendations for the management of gout.
METHODS
The multidisciplinary guideline development group comprised 19 rheumatologists and one evidence based medicine expert representing 13 European countries. Key propositions on management were generated using a Delphi consensus approach. Research evidence was searched systematically for each proposition. Where possible, effect size (ES), number needed to treat, relative risk, odds ratio, and incremental cost-effectiveness ratio were calculated. The quality of evidence was categorised according to the level of evidence. The strength of recommendation (SOR) was assessed using the EULAR visual analogue and ordinal scales.
RESULTS
12 key propositions were generated after three Delphi rounds. Propositions included both non-pharmacological and pharmacological treatments and addressed symptomatic control of acute gout, urate lowering therapy (ULT), and prophylaxis of acute attacks. The importance of patient education, modification of adverse lifestyle (weight loss if obese; reduced alcohol consumption; low animal purine diet) and treatment of associated comorbidity and risk factors were emphasised. Recommended drugs for acute attacks were oral non-steroidal anti-inflammatory drugs (NSAIDs), oral colchicine (ES = 0.87 (95% confidence interval, 0.25 to 1.50)), or joint aspiration and injection of corticosteroid. ULT is indicated in patients with recurrent acute attacks, arthropathy, tophi, or radiographic changes of gout. Allopurinol was confirmed as effective long term ULT (ES = 1.39 (0.78 to 2.01)). If allopurinol toxicity occurs, options include other xanthine oxidase inhibitors, allopurinol desensitisation, or a uricosuric. The uricosuric benzbromarone is more effective than allopurinol (ES = 1.50 (0.76 to 2.24)) and can be used in patients with mild to moderate renal insufficiency but may be hepatotoxic. When gout is associated with the use of diuretics, the diuretic should be stopped if possible. For prophylaxis against acute attacks, either colchicine 0.5-1 mg daily or an NSAID (with gastroprotection if indicated) are recommended.
CONCLUSIONS
12 key recommendations for management of gout were developed, using a combination of research based evidence and expert consensus. The evidence was evaluated and the SOR provided for each proposition.
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Ann Rheum Dis 65(10): 1312-1324

EULAR evidence based recommendations for gout. Part II: Management. Report of a task force of the EULAR Standing Committee For International Clinical Studies Including Therapeutics (ESCISIT)

+12 authors
M Doherty, E Roddy, W Zhang, Academic Rheumatology, University of Nottingham, Nottingham, UK
E Pascual, Sección de Rheumatologia, Hospital General Universitario de Alicante, Alicante, Spain
T Bardin, Fédération de Rhumatologie, Hôpital Lariboisière, Paris, France
V Barskova, Institute of Rheumatology RAMS, Moscow, Russian Federation
P Conaghan, Academic Unit of Musculoskeletal Disease, University of Leeds, Leeds, UK
J Gerster, Service de Rhumatologie, Hôpital Nestlé, CH 1011 Lausanne‐CHUV, Switzerland
J Jacobs, Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Utrecht, Netherlands
B Leeb, Second Department of Medicine, Lower Austrian Centre for Rheumatology, Stockerau, Austria
F Lioté, Fédération de Rhumatologie and INSERM U606, IFR 139, Hôpital Lariboisière, Paris, France
G McCarthy, Division of Rheumatology, Mater Misericordiae University Hospital, Dublin, Ireland
P Netter, U7R7561 CNR‐UHP, Physiopathologie et Pharmacologie Articulaire, Universite Henri Poincare, Vandoeuvre Les Nancy, France
G Nuki, Osteoarticular Research Group, University of Edinburgh, Edinburgh, UK
F Perez‐Ruiz, Sección de Rheumatologia, Hospital de Cruces, Baracaldo, Spain
A Pignone, Departmento Medicina Interna, University of Florence, Florence, Italy
J Pimentão, Rheumatology Unit, Hospital Egas Moniz, Lisbon, Portugal
L Punzi, Rheumatology Unit, University of Padova, Padova, Italy
T Uhlig, Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
I Zimmermann‐Gòrska, Department of Rheumatology, Rehabilitation and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
Correspondence to: Dr W Zhang
Academic Rheumatology, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham NG5 1PB, UK; weiya.zhang@nottingham.ac.uk
Copyright © 2006 BMJ Publishing Group Ltd & European League Against Rheumatism
M Doherty, E Roddy, W Zhang, Academic Rheumatology, University of Nottingham, Nottingham, UKE Pascual, Sección de Rheumatologia, Hospital General Universitario de Alicante, Alicante, SpainT Bardin, Fédération de Rhumatologie, Hôpital Lariboisière, Paris, FranceV Barskova, Institute of Rheumatology RAMS, Moscow, Russian FederationP Conaghan, Academic Unit of Musculoskeletal Disease, University of Leeds, Leeds, UKJ Gerster, Service de Rhumatologie, Hôpital Nestlé, CH 1011 Lausanne‐CHUV, SwitzerlandJ Jacobs, Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Utrecht, NetherlandsB Leeb, Second Department of Medicine, Lower Austrian Centre for Rheumatology, Stockerau, AustriaF Lioté, Fédération de Rhumatologie and INSERM U606, IFR 139, Hôpital Lariboisière, Paris, FranceG McCarthy, Division of Rheumatology, Mater Misericordiae University Hospital, Dublin, IrelandP Netter, U7R7561 CNR‐UHP, Physiopathologie et Pharmacologie Articulaire, Universite Henri Poincare, Vandoeuvre Les Nancy, FranceG Nuki, Osteoarticular Research Group, University of Edinburgh, Edinburgh, UKF Perez‐Ruiz, Sección de Rheumatologia, Hospital de Cruces, Baracaldo, SpainA Pignone, Departmento Medicina Interna, University of Florence, Florence, ItalyJ Pimentão, Rheumatology Unit, Hospital Egas Moniz, Lisbon, PortugalL Punzi, Rheumatology Unit, University of Padova, Padova, ItalyT Uhlig, Department of Rheumatology, Diakonhjemmet Hospital, Oslo, NorwayI Zimmermann‐Gòrska, Department of Rheumatology, Rehabilitation and Internal Medicine, Poznan University of Medical Sciences, Poznan, PolandCorrespondence to: Dr W Zhang
Academic Rheumatology, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham NG5 1PB, UK; weiya.zhang@nottingham.ac.uk
Copyright © 2006 BMJ Publishing Group Ltd & European League Against Rheumatism
Accepted 2006 May 8.

Abstract

Objective

To develop evidence based recommendations for the management of gout.

Methods

The multidisciplinary guideline development group comprised 19 rheumatologists and one evidence based medicine expert representing 13 European countries. Key propositions on management were generated using a Delphi consensus approach. Research evidence was searched systematically for each proposition. Where possible, effect size (ES), number needed to treat, relative risk, odds ratio, and incremental cost‐effectiveness ratio were calculated. The quality of evidence was categorised according to the level of evidence. The strength of recommendation (SOR) was assessed using the EULAR visual analogue and ordinal scales.

Results

12 key propositions were generated after three Delphi rounds. Propositions included both non‐pharmacological and pharmacological treatments and addressed symptomatic control of acute gout, urate lowering therapy (ULT), and prophylaxis of acute attacks. The importance of patient education, modification of adverse lifestyle (weight loss if obese; reduced alcohol consumption; low animal purine diet) and treatment of associated comorbidity and risk factors were emphasised. Recommended drugs for acute attacks were oral non‐steroidal anti‐inflammatory drugs (NSAIDs), oral colchicine (ES = 0.87 (95% confidence interval, 0.25 to 1.50)), or joint aspiration and injection of corticosteroid. ULT is indicated in patients with recurrent acute attacks, arthropathy, tophi, or radiographic changes of gout. Allopurinol was confirmed as effective long term ULT (ES = 1.39 (0.78 to 2.01)). If allopurinol toxicity occurs, options include other xanthine oxidase inhibitors, allopurinol desensitisation, or a uricosuric. The uricosuric benzbromarone is more effective than allopurinol (ES = 1.50 (0.76 to 2.24)) and can be used in patients with mild to moderate renal insufficiency but may be hepatotoxic. When gout is associated with the use of diuretics, the diuretic should be stopped if possible. For prophylaxis against acute attacks, either colchicine 0.5–1 mg daily or an NSAID (with gastroprotection if indicated) are recommended.

Conclusions

12 key recommendations for management of gout were developed, using a combination of research based evidence and expert consensus. The evidence was evaluated and the SOR provided for each proposition.

Keywords: EULAR, gout, guidelines, treatment
Abstract

Despite reasonable understanding of its pathogenesis and the availability of effective treatment, gout is often misdiagnosed or diagnosed late in its clinical course, and even when correctly diagnosed treatment is often suboptimal. For example, a recent cross sectional study showed that the prevalence of predefined mismanagement of gout (no drug treatment, analgesic alone, or urate lowering therapy without prophylaxis) was over two times greater with physician management than with patient self management.1 The risk was adjusted by age, sex, education, comorbidity, and number of attacks and was especially high in the first year of disease (relative risk (RR) = 3.8, p<0.005).1 Other medication errors associated with gout appear to be widespread, especially with respect to colchicines.2 Thus the European League Against Rheumatism (EULAR) gout task force was formed to develop evidence based recommendations on aspects relating both to the diagnosis and to the management of gout. This paper reports the second part of the project: evidence based recommendations for the management of gout.

Acknowledgements

We would like to thank the European League Against Rheumatism for financial support, Helen Richardson for logistic support, Jane Robertson for literature search and database development, and Maggie Wheeler for language translations.

Acknowledgements

Abbreviations

AHS - allopurinol hypersensitivity syndrome

ES - effect size

ESCISIT - EULAR Standing Committee for International Clinical Studies Including Therapeutics

EULAR - European League Against Rheumatism

ICER - incremental cost‐effectiveness ratio

NNT - number needed to treat

NSAID - non‐steroidal anti‐inflammatory drug

QALY - quality of life years

RCT - randomised controlled trial

SOR - strength of recommendation

SUA - serum uric acid

VAS - visual analogue scale

Abbreviations

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