Amir Qaseem, MD, PhD, MHA; Robert M. McLean, MD; Melissa Starkey, PhD; 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 All ACP clinical practice guidelines are considered automatically withdrawn or invalid 5 years after publication or once an update has been issued.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 Informed Medical Decisions Foundation and Healthwise, outside the submitted work. Dr. Boyd reports royalties from UptoDate, outside the submitted work. Dr. Manaker reports personal fees from work as a grand rounds speaker, lecturer, consultant, and expert witness on documentation, coding, billing, and reimbursement to hospitals, physicians, departments, practice groups, professional societies, insurers, and attorneys (defense, plaintiff “qui tam,” U.S. attorneys general, and the Office of the Inspector General); personal fees from work as an expert witness in workers' compensation and medical negligence; dividend income from stock held by his spouse in Pfizer and Johnson and Johnson; and meal and travel expenses for serving on the CMS Hospital Outpatient Panel, the American Medical Association/Specialty Society Relative Value Unit Update Committee, and the Board of Directors of CHEST Enterprises, a subsidiary of the American College of Chest Physicians. 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=M16-0569. All financial and intellectual disclosures of interest were declared, and potential conflicts were discussed and managed. No CGC members were recused from voting on this guideline due to conflicts. A record of disclosures and management of conflicts of interest is kept for each CGC 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: Drs. Qaseem and Starkey: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.
Dr. McLean: Yale University School of Medicine, 46 Prince Street, New Haven, CT 06519.
Dr. Forciea: University of Pennsylvania Health System, 3615 Chestnut Street, Philadelphia, PA 19104.
Author Contributions: Conception and design: A. Qaseem, M. Starkey, M.J. Barry, N. Fitterman.
Analysis and interpretation of the data: A. Qaseem, M. Starkey, M.A. Forciea, M.J. Barry, C. Boyd, L.L. Humphrey, D. Kansagara, S. Vijan, T. Wilt.
Drafting of the article: A. Qaseem, M. Starkey, T.D. Denberg, S. Manaker.
Critical revision for important intellectual content: A. Qaseem, M. Starkey, M.A. Forciea, T.D. Denberg, M.J. Barry, C. Boyd, R.D. Chow, L.L. Humphrey, S. Manaker, S. Vijan, T. Wilt.
Final approval of the article: A. Qaseem, R. McLean, M. Starkey, M.A. Forciea, T.D. Denberg, M.J. Barry, C. Boyd, R.D. Chow, N. Fitterman, L.L. Humphrey, D. Kansagara, S. Manaker, S. Vijan, T. Wilt.
Statistical expertise: A. Qaseem.
Administrative, technical, or logistic support: A. Qaseem, M. Starkey.
Collection and assembly of data: A. Qaseem, M. Starkey.
The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on the diagnosis of gout.
This guideline is based on a systematic review of published studies on gout diagnosis, identified using several databases, from database inception to February 2016. Evaluated outcomes included the accuracy of the test results; intermediate outcomes (results of laboratory and radiographic tests, such as serum urate and synovial fluid crystal analysis and radiographic or ultrasonography changes); clinical decision making (additional testing and pharmacologic or dietary management); short-term clinical (patient-centered) outcomes, such as pain and joint swelling and tenderness; and adverse effects of the tests. This guideline grades the evidence and recommendations by using the ACP grading system, which is based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method.
The target audience for this guideline includes all clinicians, and the target patient population includes adults with joint inflammation suspected to be gout.
ACP recommends that clinicians use synovial fluid analysis when clinical judgment indicates that diagnostic testing is necessary in patients with possible acute gout. (Grade: weak recommendation, low-quality evidence)
Table. The American College of Physicians' Guideline Grading System*
Summary of the American College of Physicians guideline on diagnosis of gout.
DECT = dual-energy computed tomography; MSU = monosodium urate.
Quantum Biophysical Semeiotic Research Laboratory
November 30, 2016
Bedside diagnosing acute gout.
Today acute gout is more frequent than generally admitted. As a consequence, this facinating paper is really usefull, especially fot the GP. A 60 year-long clinical experience allows me to state that in healthy individual, the nail pressure upon the helix brings about the Gastric Aspecific Reflex (in the stomach both fundus and body dilate, while antral-pyloric region contracts) after a Latency Time of 10 seconds precisely. On the contrary, in individual involved by gout constitution, this Latency Time lowers to a number of seconds less than normal, in relation to the seriousness of underlying disorder (1-3). The suggested treatment,according to the Clinical Practice Guide Lines from the America College of Physicians has to be continued as far as the parametric values of above-referred Reflex are returned to normal.References1) Stagnaro Sergio. Biological System Functional Modification parallels Gene Mutation. www.Nature.com, March 13, 2008,http://blogs.nature.com/nm/spoonful/2008/03/gout_gene.html2) Stagnaro Sergio. Single Patient Based Medicine, Therapeutic Monitoring and proper Drugs Prescription. Nature Medicine.com. April, 4, 2008. http://blogs.nature.com/nm/spoonful/2008/04/trust_noone.html#comments3) Stagnaro S., Stagnaro-Neri M., Le Costituzioni Semeiotico-Biofisiche.Strumento clinico fondamentale per la prevenzione primaria e la definizione della Single Patient Based Medicine. Travel Factory, Roma, 2004. http://www.travelfactory.it/libro_costituzionisemeiotiche.htm
no institutional affiliation
May 31, 2017
Gout is an Early Consequence of Sleep Apnea
One aspect of gout which is too often overlooked in guidelines and in practice is that most gout flares are initiated during sleep. The sleep connection has been known at least since Dr. Thomas Sydenham wrote about it in 1683. A recent study by Dr. Hyon Choi  et al confirms Dr. Sydenham's observation. It is a very important clue to the pathogenesis of gout whether symptomatic or not. Many gout flares are a direct result of sleep apnea, and overcoming the sleep apnea can cure the gout. An epidemiologic study in 2015  found that gout was significantly more prevalent in the sleep apnea population than in the general population. Although Kelley's Textbook of Rheumatology  lists respiratory insufficiency as a cause of acidosis leading to hyperuricemia, the hypoxemia of sleep apnea actually has three effects which can lead to an overnight gout flare in short order. Effect #1 is cellular catabolism in which adenosine triphosphate degradation is accelerated, leading to nucleotide turnover which culminates irreversibly in the transient cellular generation of excess uric acid fed into the blood [4,5], faster than any food would cause. Effect #2 is transient hypercapnia and acidosis, so that the blood can hold less uric acid in solution. Effect #3 is a long term deterioration of the kidneys' glomerular filtration rate  so that removal of uric acid from the blood is slowed. Thus, with sleep apnea there is an abrupt increase in the influx of uric acid in the blood, slowed efflux, and abruptly reduced storage capacity -- perfect storm conditions for monosodium urate precipitation. Furthermore, after awakening and normal breathing is restored, the first two effects dissipate so that a blood test taken during waking hours misses their peaks. And if monosodium urate has precipitated recently, then the measurement of serum uric acid is greatly undervalued. Gout experts should feel embarrassed for having missed this connection for so long, especially since gout has been reported to have so many of the same comorbidities already known to be consequences of long-term untreated sleep apnea (eg., cardiovascular diseases, diabetes, kidney disease, hypertension.) [7,8] One of the first steps for treating gout should be screening and diagnosis for sleep apnea, followed by treatment of the sleep apnea where indicated. I know from my own experience and the experiences of others that overcoming sleep apnea can prevent additional inflammatory gout flares immediately and completely. Effects #1 and #2 don't occur, and Effect #3 may reverse over several months of effective treatment for sleep apnea [9,10]. More importantly, gout is an early warning of sleep apnea, which when heeded can lead to the early treatment of sleep apnea, thereby greatly reducing the risk for the development of sleep apnea's later developing life-threatening consequences. Using a gout flare as a sentinel event leading to the diagnosis and treatment of sleep apnea can save lives along with saving joints.References1. Choi HK, Niu J, Neogi T, et al. Nocturnal risk of gout attacks. Arthritis Rheumatol. 2015 Feb; 67(2):555-62.2. Zhang Y, Peloquin CE, Dubreuil M, et al. Sleep apnea and the risk of incident gout: a population-based, body mass index-matched cohort study. Arthritis Rheumatol. 2015 Dec; 67(12):3298-302.3. Firestein GS, Budd RC, Gabriel SE, et al. Kelley’s Textbook of Rheumatology 9th edition. Elsevier Saunders 2013.4. Hasday JD, Grum CM. Nocturnal increase of urinary uric acid:creatinine ratio. A biochemical correlate of sleep-associated hypoxemia. Am Rev Respir Dis. 1987 Mar; 135(3):534-8.5. Grum CM. Cells in crisis. Cellular bioenergetics and inadequate oxygenation in the intensive care unit. Chest. 1992 Aug; 102(2):329-30.6. Ahmed SB, Ronksley PE, Hemmelgarn BR, et al. Nocturnal hypoxia and loss of kidney function. PLoS One. 2011 Apr; 6(4):e19029.7. Huang CF, Liu JC, Huang HC, et al. Longitudinal transition trajectory of gouty arthritis and its comorbidities: a population-based study. Rheumatol Int. 2017 Feb; 37(2):313-22.8. Chiang CL, Chen YT, Wang KL, et al. Comorbidities and Risk of Mortality in Patients with Sleep Apnea. Ann Med. 2017 Aug; 49(5): 377-83.9. Kinebuchi S, Kazama JJ, Satoh M, et al. Short-term use of continuous positive airway pressure ameliorates glomerular hyperfiltration in patients with obstructive sleep apneoa syndrome. Clin Sci (Lond). 2002 Sep; 107(3):317-22.10. Koga S, Ikeda S, Yasunaga T, et al. Effects of nasal continuous positive airway pressure on the glomerular filtration rate in patients with obstructive sleep apnea syndrome. Intern Med. 2013 Mar; 52(3):345-9.
Qaseem A, McLean RM, Starkey M, et al, for the 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. 2017;166:52–57. [Epub ahead of print 1 November 2016]. doi: https://doi.org/10.7326/M16-0569
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Published: Ann Intern Med. 2017;166(1):52-57.
Published at www.annals.org on 1 November 2016
Gout, Guidelines, High Value Care, Rheumatology.
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