Risa B. Burns, MD, MPH; C. Christopher Smith, MD; Robert H. Shmerling, MD; Anjala Tess, MD
Acknowledgment: The authors thank the patient for sharing his story.
Grant Support: Beyond the Guidelines receives no external support.
Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-2548.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive 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 Proctor & Gamble, Pfizer, and Johnson & Johnson.
Corresponding Author: Risa B. Burns, MD, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, E/Yamins 102, 330 Brookline Avenue, Boston, MA 02215; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Burns, Smith, Shmerling, and Tess: Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215.
Gout is the most common form of inflammatory arthritis. In 2012, the American College of Rheumatology (ACR) issued a guideline, which was followed in 2017 by one from the American College of Physicians (ACP). The guidelines agree on treating acute gout with a corticosteroid, nonsteroidal anti-inflammatory drug, or colchicine and on not initiating long-term urate-lowering therapy (ULT) for most patients after a first gout attack and in those whose attacks are infrequent (<2 per year). However, they differ on treatment of both recurrent gout and problematic gout. The ACR advocates a “treat-to-target” approach, and the ACP did not find enough evidence to support this approach and offered an alternative strategy that bases intensity of ULT on the goal of avoiding recurrent gout attacks (“treat-to-avoid-symptoms”) with no monitoring of urate levels. They also disagree on the role of a gout-specific diet. Here, a general internist and a rheumatologist discuss these guidelines; they debate how they would manage an acute attack of gout, if and when to initiate ULT, and the goals for ULT. Lastly, they offer specific advice for a patient who is uncertain about whether to begin this therapy.
Burns RB, Smith CC, Shmerling RH, et al. How Would You Manage This Patient With Gout?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Ann Intern Med. 2018;169:788–795. doi: https://doi.org/10.7326/M18-2548
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Published: Ann Intern Med. 2018;169(11):788-795.
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