Amir Qaseem, MD, PhD, MHA; Russell P. Harris, MD, MPH; Mary Ann Forciea, MD; for the Clinical Guidelines Committee of the American College of Physicians (*)
Note: Clinical practice guidelines are “guides” only and may not apply to all patients and all clinical situations. Thus, they are not intended to override clinicians' judgment. All ACP clinical practice guidelines are considered automatically withdrawn or invalid 5 years after publication, or once an update has been issued.
Disclaimer: The authors of this article are responsible for its contents, including any clinical or treatment recommendations.
Financial Support: Financial support for the development of this guideline comes exclusively from the ACP operating budget.
Disclosures: Dr. Barry reports grants and personal fees from the Informed Medical Decisions Foundation and Healthwise outside the submitted work. Dr. Boyd reports royalties from UpToDate outside the submitted work. Authors not named here have disclosed no conflicts of interest. Authors followed the policy regarding conflicts of interest described at www.annals.org/aim/article/745942. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-0570. All financial and intellectual disclosures of interest were declared, and potential conflicts were discussed and managed. Dr. Manaker was recused from voting on this guideline because of an active indirect financial conflict. Dr. McLean was recused from voting on this guideline because of an inactive direct financial conflict. A record of disclosures of interest and management of conflicts of interest is kept for each Clinical Guidelines Committee meeting and conference call and can be viewed at www.acponline.org/about-acp/who-we-are/leadership/committees-boards-councils/clinical-guidelines-committee/disclosure-of-interests-for-clinical-guidelines-committee.
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.
Requests for Single Reprints: Amir Qaseem, MD, PhD, MHA, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Qaseem: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.
Dr. Harris: University of North Carolina School of Medicine, 725 Martin Luther King Boulevard, Chapel Hill, NC 27599-7590.
Dr. Forciea: University of Pennsylvania Health System, 3615 Chestnut Street, Philadelphia, PA 19104.
Author Contributions: Conception and design: A. Qaseem, R.P. Harris, M.A. Forciea, T.D. Denberg, M.J. Barry.
Analysis and interpretation of the data: A. Qaseem, R.P. Harris, M.A. Forciea, M.J. Barry, C. Boyd, N. Fitterman, L.L. Humphrey, D. Kansagara, S. Vijan, T. Wilt.
Drafting of the article: A. Qaseem, R.P. Harris, M.A. Forciea, T.D. Denberg.
Critical revision of the article for important intellectual content: R.P. Harris, T.D. Denberg, M.J. Barry, C. Boyd, R.D. Chow, N. Fitterman, L.L. Humphrey, D. Kansagara, S. Vijan, T. Wilt.
Final approval of the article: A. Qaseem, R.P. Harris, M.A. Forciea, T.D. Denberg, M.J. Barry, C. Boyd, R.D. Chow, N. Fitterman, L.L. Humphrey, D. Kansagara, S. Vijan, T. Wilt.
Statistical expertise: A. Qaseem.
Administrative, technical, or logistic support: A. Qaseem.
Collection and assembly of data: A. Qaseem, R.P. Harris.
Qaseem A, Harris RP, Forciea MA, for the Clinical Guidelines Committee of the American College of Physicians. Management of Acute and Recurrent Gout: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166:58-68. doi: 10.7326/M16-0570
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Published: Ann Intern Med. 2017;166(1):58-68.
Published at www.annals.org on 1 November 2016
The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on the management of gout.
Using the ACP grading system, the committee based these recommendations on a systematic review of randomized, controlled trials; systematic reviews; and large observational studies published between January 2010 and March 2016. Clinical outcomes evaluated included pain, joint swelling and tenderness, activities of daily living, patient global assessment, recurrence, intermediate outcomes of serum urate levels, and harms.
The target audience for this guideline includes all clinicians, and the target patient population includes adults with acute or recurrent gout.
ACP recommends that clinicians choose corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), or colchicine to treat patients with acute gout. (Grade: strong recommendation, high-quality evidence)
ACP recommends that clinicians use low-dose colchicine when using colchicine to treat acute gout. (Grade: strong recommendation, moderate-quality evidence)
ACP recommends against initiating long-term urate-lowering therapy in most patients after a first gout attack or in patients with infrequent attacks. (Grade: strong recommendation, moderate-quality evidence)
ACP recommends that clinicians discuss benefits, harms, costs, and individual preferences with patients before initiating urate-lowering therapy, including concomitant prophylaxis, in patients with recurrent gout attacks. (Grade: strong recommendation, moderate-quality evidence)
Table 1. Pharmacologic Agents for Treatment of Gout
Table 2. The American College of Physicians' Guideline Grading System*
Summary of the American College of Physicians guideline on management of acute and recurrent gout.
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Vanya D. Wagler, DO; Aaron W. Pumerantz, DO
Rheumatology Section, Department of Medicine, William Beaumont Army Medical Center, El Paso, Texas
November 8, 2016
Clinical Practice Guidelines for Management of Acute and Recurrent Gout
We note with interest the newly released clinical practice guidelines for management of gout by Qaseem, et al (1). Given the prevalence of gout, significant disease burden, and the availability of potentially curative therapies, it is imperative that primary care physicians and rheumatologists manage chronic gout skillfully and purposefully. In light of existing clinical practice guidelines by the American College of Rheumatology (2) and the European League Against Rheumatism (3) recommending a “treat to target” approach for chronic urate-lowering therapy, it is surprising to see new ACP guidelines suggesting an alternative “treat to avoid symptoms” paradigm. While the prospect of administering urate-lowering therapy without monitoring serum urate may be alluring, it would be a step backward given our current understanding of gout pathophysiology, as hyperuricemia appears to be directly responsible for causing gout (4). The vast majority of patients with gout can achieve disease remission when an aggressive “treat to target” approach is used; it remains unclear whether an alternative approach would be equally as effective. Benefits of monitoring serum urate during therapy include the potential for dose adjustment based on variabilities in individual response to medication, verifying medication adherence, and the ability to prevent future flares by targeting a specific serum urate goal. Implicit in the “treat to avoid symptoms” approach is the assumption that alleviating symptoms is the primary reason for employing urate-lowering therapy. We would suggest that current symptoms provide only part of the impetus for gout therapy and that other clinical features may be just as compelling. For example, gouty erosions on radiography or a history of tophaceous disease of any kind should be sufficient reason to treat hyperuricemia aggressively, regardless of current symptoms. We also observe that although dramatic symptoms are typical of early gout, chronic gouty arthritis can at times be relatively asymptomatic during intercritical periods even while joint inflammation (as demonstrated by ultrasonography) is ongoing (5). For these reasons, symptom-based therapy alone is inadequate and could well result in increased chronic morbidity from gout due to less aggressive treatment. We agree that future gout research should focus on better establishing optimal serum urate-lowering goals, and should consider the benefits of a symptom-based treatment paradigm, but we believe it is premature to suggest “treat to avoid symptoms” as a viable strategy at this time. 1. Qaseem A, McLean R, Starkey M, Forciea MA; Clinical Guidelines Committee of the American College of Physicians. Diagnosis of acute gout: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2016. [Epub ahead of print]. doi:10.7326/M16-0569. 2. Khanna D, Fitzgerald JD, Khanna PP, et al., American College of Rheumatology. 2012 American College of Rheumatology Guidelines for the management of gout. Part 1: systematic nonpharmacologic and pharmacologic therapeutic approaches to hyperuricemia. Arthritis Care Res (Hoboken) 2012;64:1431–46.3. Richette P, Doherty M, Pascual E, et al., 2016 updated EULAR evidence-based recommendations for the management of gout. Ann Rheum Dis Published Online First. doi:10.1136/annrheumdis-2016-2097074. Schett G, Schauer C,Hoffmann M, et al. Why does the gout attack stop? A roadmap for the immune pathogenesis of gout. RMD Open 2015;1:e000046. doi:10.1136/rmdopen-2015-000046.5. Thiele RG, Schlesinger N. Ultrasonography shows active inflammation in clinically unaffected joints in chronic tophaceous gout. Arthritis Rheum 2009;59(9 Suppl):S1512.
David Erk MD FACP
Sage Primary Care, Casper WY
January 15, 2017
Questions regarding treatment of gout
Question 1: What is the recommendation for duration of initial treatment of a patient with an acute gout flare, if that patient will not be receiving a uric acid lower medication?Question 2: What is the recommendation for the timing of starting a uric acid lowering medication following an acute gout flare?
Gout, Guidelines, Rheumatology.
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