The Impact of Gout Guidelines
Purpose of review This review discusses the impact of recent treatment guidelines for the management of gout and the barriers to treating gout patients.
Recent findings Multiple guidelines for both the treatment and prevention of gout have been put forth in the last decade including those from the British Rheumatism Society; the European League Against Rheumatism; the Multinational Evidence, Expertise, Exchange Initiative; the Japanese Society of Gout and Nucleic Acid Metabolism; the American College of Rheumatology. These guidelines are designed to facilitate the management of gout by providers with key recommendations for the management of hyperuricemia, which is the greatest risk factor for developing gout. However, despite the extant guidelines, overall adherence to recommendations and uptake have been slow and initiation of urate-lowering therapy, titration of dosing, and monitoring of serum urate is infrequent. Greater education in proper management as well as increased awareness of new treatment strategies appear to be the primary reasons for this gap and offer avenues for improvement in management as well as areas for further research.
Summary Gout remains a treatment challenge for both acute and chronic disease. Despite the availability of management guidelines, primary care providers are struggling with appropriate management of the disease. More research tools and strategies are needed to improve overall outcomes and quality of care.
Gout is currently the most common inflammatory arthritis in the United States and affects over 8 million Americans. Acute episodes of gout typically manifest as attacks of intense joint pain resulting from an inflammatory response which is precipitated by uric acid crystal deposition in the synovial tissue surrounding synovial joints. Gout causes significant morbidity and is an economic burden with annual costs exceeding 6 billion dollars annually in direct costs and lost worker productivity. Hyperuricemia is the single most identifiable parameter for the development of gout, and this risk of a gout attack increases with the degree of hyperuricemia. The management of gout focuses on the treatment of acute attacks as well as the underlying hyperuricemia to prevent future episodes. Treating hyperuricemia in gout with urate-lowering therapies (ULTs) is widely regarded as the principal strategy for preventing new attacks.
Multiple guidelines for the treatment and prevention of gout flares have been put forth, including those from the Dutch College of General Practitioners in 2002, the British Society of Rheumatology (BSR) in 2007, the European League Against Rheumatism (EULAR) in 2006, the Multinational Evidence, Expertise, Exchange Initiative (3e) in 2013, the Japanese Society of Gout and Nucleic Acid Metabolism in 2011, the American College of Rheumatology (ACR) in 2012, and the updated EULAR set in 2014. Each of these guidelines contains recommendations for pharmacologic therapy as well as lifestyle modifications for treating both acute gout attacks along with recommendations for prophylaxis against further gout attacks. The respective guidelines are comparable in that all make similar recommendations for treating acute flares and for starting ULT after a second attack (Table 1). The ACR, 3e, and EULAR guidelines all recommend a target of 6 mg/dL, whereas the BSR guidelines recommend a target of 5 mg/dL. With the exception of the 3e guidelines, all recommend starting allopurinol 100 mg daily (50 mg in the presence of kidney disease) and uptitrating the dose to achieve the target serum uric acid. The guidelines each differ in subtle ways though. The BSR guidelines, for example, date from 2007 and recommend COX-2 inhibitors as a first-line therapy for acute gout or prophylaxis, whereas the newer guidelines do not and instead recommend equal efficacy for colchicine, steroids, and NSAIDs. The ACR and BSR are both aimed at assisting primary care providers and hospital physicians. The BSR guidelines include extensive diet recommendations, and the ACR guidelines are put forth in a flowchart format to assist decision making and contain a variety of scenarios such as treatment recommendations for patients who are unable to take oral medications. The Japanese Society guidelines are the only guidelines that contain a recommendation for treating asymptomatic hyperuricemia. The ACR guidelines, which are the newest, are also unique in that febuxostat is specifically recommended as a viable first-line therapy and also recommend the use of pegloticase, an intravenous recombinant uricase, for the treatment of refractory tophaceous gout.
Abstract and Introduction
Abstract
Purpose of review This review discusses the impact of recent treatment guidelines for the management of gout and the barriers to treating gout patients.
Recent findings Multiple guidelines for both the treatment and prevention of gout have been put forth in the last decade including those from the British Rheumatism Society; the European League Against Rheumatism; the Multinational Evidence, Expertise, Exchange Initiative; the Japanese Society of Gout and Nucleic Acid Metabolism; the American College of Rheumatology. These guidelines are designed to facilitate the management of gout by providers with key recommendations for the management of hyperuricemia, which is the greatest risk factor for developing gout. However, despite the extant guidelines, overall adherence to recommendations and uptake have been slow and initiation of urate-lowering therapy, titration of dosing, and monitoring of serum urate is infrequent. Greater education in proper management as well as increased awareness of new treatment strategies appear to be the primary reasons for this gap and offer avenues for improvement in management as well as areas for further research.
Summary Gout remains a treatment challenge for both acute and chronic disease. Despite the availability of management guidelines, primary care providers are struggling with appropriate management of the disease. More research tools and strategies are needed to improve overall outcomes and quality of care.
Introduction
Gout is currently the most common inflammatory arthritis in the United States and affects over 8 million Americans. Acute episodes of gout typically manifest as attacks of intense joint pain resulting from an inflammatory response which is precipitated by uric acid crystal deposition in the synovial tissue surrounding synovial joints. Gout causes significant morbidity and is an economic burden with annual costs exceeding 6 billion dollars annually in direct costs and lost worker productivity. Hyperuricemia is the single most identifiable parameter for the development of gout, and this risk of a gout attack increases with the degree of hyperuricemia. The management of gout focuses on the treatment of acute attacks as well as the underlying hyperuricemia to prevent future episodes. Treating hyperuricemia in gout with urate-lowering therapies (ULTs) is widely regarded as the principal strategy for preventing new attacks.
Multiple guidelines for the treatment and prevention of gout flares have been put forth, including those from the Dutch College of General Practitioners in 2002, the British Society of Rheumatology (BSR) in 2007, the European League Against Rheumatism (EULAR) in 2006, the Multinational Evidence, Expertise, Exchange Initiative (3e) in 2013, the Japanese Society of Gout and Nucleic Acid Metabolism in 2011, the American College of Rheumatology (ACR) in 2012, and the updated EULAR set in 2014. Each of these guidelines contains recommendations for pharmacologic therapy as well as lifestyle modifications for treating both acute gout attacks along with recommendations for prophylaxis against further gout attacks. The respective guidelines are comparable in that all make similar recommendations for treating acute flares and for starting ULT after a second attack (Table 1). The ACR, 3e, and EULAR guidelines all recommend a target of 6 mg/dL, whereas the BSR guidelines recommend a target of 5 mg/dL. With the exception of the 3e guidelines, all recommend starting allopurinol 100 mg daily (50 mg in the presence of kidney disease) and uptitrating the dose to achieve the target serum uric acid. The guidelines each differ in subtle ways though. The BSR guidelines, for example, date from 2007 and recommend COX-2 inhibitors as a first-line therapy for acute gout or prophylaxis, whereas the newer guidelines do not and instead recommend equal efficacy for colchicine, steroids, and NSAIDs. The ACR and BSR are both aimed at assisting primary care providers and hospital physicians. The BSR guidelines include extensive diet recommendations, and the ACR guidelines are put forth in a flowchart format to assist decision making and contain a variety of scenarios such as treatment recommendations for patients who are unable to take oral medications. The Japanese Society guidelines are the only guidelines that contain a recommendation for treating asymptomatic hyperuricemia. The ACR guidelines, which are the newest, are also unique in that febuxostat is specifically recommended as a viable first-line therapy and also recommend the use of pegloticase, an intravenous recombinant uricase, for the treatment of refractory tophaceous gout.
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