2011 Recommendations for the Diagnosis and Management of Gout and Hyperuricemia

Abstract

Gout is a major health problem in the United States; it affects 8.3 million people, which is approximately 4% of the adult population. Gout is most often diagnosed and managed in primary care practices; thus, primary care physicians have a significant opportunity to improve patient outcomes. Following publication of the 2006 European League Against Rheumatism (EULAR) gout guidelines, significant new evidence has accumulated, and new treatments for patients with gout have become available. It is the objective of these 2011 recommendations to update the 2006 EULAR guidelines, paying special attention to the needs of primary care physicians. The revised 2011 recommendations are based on the Grading of Recommendations Assessment, Development, and Evaluation approach as an evidence-based strategy for rating quality of evidence and grading the strength of recommendation formulated for use in clinical practice. A total of 26 key recommendations, 10 for diagnosis and 16 for management, of patients with gout were evaluated, resulting in important updates for patient care. The presence of monosodium urate crystals and/or tophus and response to colchicine have the highest clinical diagnostic value. The key aspect of effective management of an acute gout attack is initiation of treatment within hours of symptom onset. Low-dose colchicine is better tolerated and is as effective as a high dose. When urate-lowering therapy (ULT) is indicated, the xanthine oxidase inhibitors allopurinol and febuxostat are the options of choice. Febuxostat can be prescribed at unchanged doses for patients with mild-to-moderate renal or hepatic impairment. The target of ULT should be a serum uric acid level that is ≤ 6 mg/dL. For patients with refractory and tophaceous gout, intravenous pegloticase is a new treatment option. This article is a summary of the 2011 clinical guidelines published in Postgraduate Medicine. This article provides a streamlined, accessible overview intended for quick review by primary care physicians, with the full guidelines being a resource for those seeking additional background information and expanded discussion.

Patients with Gout Treated with Conventional Urate-lowering Therapy: Association with Disease Control, Health-related Quality of Life, and Work Productivity

“…Despite the availability of multiple treatment guidelines 23,24,25 , gout in the majority of patients remains poorly controlled. Current data suggest that strategies for improving management of patients with gout are needed because very few patients are being treated effectively.…”

An Observational Study of Gout Prevalence and Quality of Care in a National Australian General Practice Population

“…Our study used as measures of gout care quality the proportion of patients prescribed urate-lowering medication, the number who had their serum urate checked, and the number who had a serum urate level below the target 0.36 mmol/l, a target widely recommended by the American College of Rheumatology, primary care guidelines, the European League Against Rheumatism, and other consensus guidelines 6,7,18,19 . The British Society for Rheumatology recommends a lower target of 0.30 mmol/l 20 .…”

Cost-effectiveness Analysis for Genotyping before Allopurinol Treatment to Prevent Severe Cutaneous Adverse Drug Reactions

“…Probenecid and sulfinpyrazone are uricosuric agents that were recommended as second-line use in those resistant to or intolerant of allopurinol 30,34,35 , but both drugs were not commonly used (< 50/100,000 persons) and not considered in the model 13 .…”