Paul G. Shekelle, MD, PhD; Sydne J. Newberry, PhD; John D. FitzGerald, MD, PhD; Aneesa Motala, BA; Claire E. O'Hanlon, MPP; Abdul Tariq, BS; Adeyemi Okunogbe, MD; Dan Han, MPA; Roberta Shanman, MLS
Disclaimer: The authors of this manuscript are responsible for its content. Statements in the manuscript should not be construed as endorsement by the Agency for Healthcare Research and Quality (AHRQ) or the U.S. Department of Health and Human Services. AHRQ retains a license to display, reproduce, and distribute the data and the report from which this manuscript was derived under the terms of the agency's contract with the author.
Acknowledgment: The authors thank Patricia Smith for her administrative assistance on the project and acknowledge the guidance provided by the key informants and technical expert panel members on the evidence report.
Financial Support: This project was funded under contract 290-2012-00006I from the AHRQ, U.S. Department of Health and Human Services.
Disclosures: All authors report a grant from AHRQ during the conduct of the study. Dr. Shekelle reports personal fees from ECRI Institute outside the submitted work and royalties from UpToDate. Authors not named here have disclosed no other conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-0461.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Reproducible Research Statement:Study protocol: Available at http://effectivehealthcare.ahrq.gov/ehc/products/564/1992/Gout-managment-protocol-141103.pdf. Statistical code: Not applicable. Data set: Available in the full report at https://effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=2195.
Requests for Single Reprints: Paul G. Shekelle, MD, PhD, RAND Corporation, 1776 Main Street, Santa Monica, CA 90401; e-mail, email@example.com.
Current Author Addresses: Drs. Shekelle and Newberry, Ms. Motala, Ms. O'Hanlon, Mr. Tariq, Ms. Han, and Ms. Shanman: RAND Corporation, 1776 Main Street, Santa Monica, CA 90401.
Dr. FitzGerald: David Geffen School of Medicine at the University of California, Los Angeles, Rehabilitation Center, Room 32-59, 1000 Veteran Avenue, Los Angeles, CA 90095.
Dr. Okunogbe: RAND Corporation, 1200 South Hayes Street, Arlington, VA 22202.
Author Contributions: Conception and design: P.G. Shekelle.
Analysis and interpretation of the data: P.G. Shekelle, S.J. Newberry, J.D. FitzGerald, C.E. O'Hanlon, A. Tariq, A. Okunogbe, D. Han.
Drafting of the article: P.G. Shekelle, S.J. Newberry, J.D. FitzGerald, A. Motala, A. Tariq, A. Okunogbe.
Critical revision of the article for important intellectual content: P.G. Shekelle, S.J. Newberry, J.D. FitzGerald, C.E. O'Hanlon, A. Okunogbe.
Final approval of the article: P.G. Shekelle, S.J. Newberry, J.D. FitzGerald, A. Motala, C.E. O'Hanlon, A. Tariq, A. Okunogbe, D. Han, R. Shanman.
Obtaining of funding: P.G. Shekelle.
Administrative, technical, or logistic support: A. Motala.
Collection and assembly of data: P.G. Shekelle, A. Motala, C.E. O'Hanlon, A. Tariq, A. Okunogbe, D. Han, R. Shanman.
Shekelle PG, Newberry SJ, FitzGerald JD, Motala A, O'Hanlon CE, Tariq A, et al. Management of Gout: A Systematic Review in Support of an American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2017;166:37-51. doi: 10.7326/M16-0461
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Published: Ann Intern Med. 2017;166(1):37-51.
Published at www.annals.org on 1 November 2016
Gout is a common type of inflammatory arthritis in patients seen by primary care physicians.
To review evidence about treatment of acute gout attacks, management of hyperuricemia to prevent attacks, and discontinuation of medications for chronic gout in adults.
Multiple electronic databases from January 2010 to March 2016, reference mining, and pharmaceutical manufacturers.
Studies of drugs approved by the U.S. Food and Drug Administration and commonly prescribed by primary care physicians, randomized trials for effectiveness, and trials and observational studies for adverse events.
Data extraction was performed by one reviewer and checked by a second reviewer. Study quality was assessed by 2 independent reviewers. Strength-of-evidence assessment was done by group discussion.
High-strength evidence from 28 trials (only 3 of which were placebo-controlled) shows that colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs), and corticosteroids reduce pain in patients with acute gout. Moderate-strength evidence suggests that low-dose colchicine is as effective as high-dose colchicine and causes fewer gastrointestinal adverse events. Moderate-strength evidence suggests that urate-lowering therapy (allopurinol or febuxostat) reduces long-term risk for acute gout attacks after 1 year or more. High-strength evidence shows that prophylaxis with daily colchicine or NSAIDs reduces the risk for acute gout attacks by at least half in patients starting urate-lowering therapy, and moderate-strength evidence indicates that duration of prophylaxis should be longer than 8 weeks. Although lower urate levels reduce risk for recurrent acute attacks, treatment to a specific target level has not been tested.
Few studies of acute gout treatments, no placebo-controlled trials of management of hyperuricemia lasting longer than 6 months, and few studies in primary care populations.
Colchicine, NSAIDs, and corticosteroids relieve pain in adults with acute gout. Urate-lowering therapy decreases serum urate levels and reduces risk for acute gout attacks.
Agency for Healthcare Research and Quality. (Protocol registration: http://effectivehealth-care.ahrq.gov/ehc/products/564/1992/Gout-managment-protocol-141103.pdf)
Appendix Table 1. Detailed Search Methods
Literature flow diagram.
* The number of included studies for this article differs from the number of included studies in the evidence report (3) because this review did not address all of the key questions addressed in the report.
† Results for this question are not included in this article. See the evidence report (3).
Table 1. Key Trials of Treatments for Acute Gout
Appendix Table 2. Randomized, Controlled Trials of NSAID Versus NSAID for Treatment of Acute Gout
Table 2. Key Trials of Urate-Lowering Therapy in Patients With Gout
Appendix Table 3. Adverse Events of Urate-Lowering Therapy From Selected Randomized, Controlled Trials*
Table 3. Summary of Prior Knowledge, Findings From the Systematic Review, and Strength of Evidence, by Key Question
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