Multinational evidence-based recommendations for the diagnosis and management of gout: integrating systematic literature review and expert opinion of a broad panel of rheumatologists in the 3e initiative

Abstract

We aimed to develop evidence-based multinational recommendations for the diagnosis and management of gout. Using a formal voting process, a panel of 78 international rheumatologists developed 10 key clinical questions pertinent to the diagnosis and management of gout. Each question was investigated with a systematic literature review. Medline, Embase, Cochrane CENTRAL and abstracts from 2010–2011 European League Against Rheumatism and American College of Rheumatology meetings were searched in each review. Relevant studies were independently reviewed by two individuals for data extraction and synthesis and risk of bias assessment. Using this evidence, rheumatologists from 14 countries (Europe, South America and Australasia) developed national recommendations. After rounds of discussion and voting, multinational recommendations were formulated. Each recommendation was graded according to the level of evidence. Agreement and potential impact on clinical practice were assessed. Combining evidence and clinical expertise, 10 recommendations were produced. One recommendation referred to the diagnosis of gout, two referred to cardiovascular and renal comorbidities, six focused on different aspects of the management of gout (including drug treatment and monitoring), and the last recommendation referred to the management of asymptomatic hyperuricaemia. The level of agreement with the recommendations ranged from 8.1 to 9.2 (mean 8.7) on a 1–10 scale, with 10 representing full agreement. Ten recommendations on the diagnosis and management of gout were established. They are evidence-based and supported by a large panel of rheumatologists from 14 countries, enhancing their utility in clinical practice.

Patient awareness, knowledge and use of colchicine: an exploratory qualitative study in the Counties Manukau region, Auckland, New Zealand

“…While the optimal duration of prophylactic use of colchicine alongside urate-lowering agents is not conclusive, most authors recommend that adjunctive colchicine use be reviewed within 12 months, once urate levels normalise. 8,33,34 Current co-morbidities affect or limit the choice of therapeutic agents. 18 Several participants reported one or more co-morbidities such as hypertension, cardiovascular disease, diabetes and/or renal impairment, all known risk factors for exacerbating gout and increasing the risk of tophi development.…”

When to Start Urate Lowering Therapy?

“…Colchicine reduces crystal-induced inflammation 27 and is a standard agent used for both flares and prevention of further episodes. [28,29,30] A population-based study pointed out a lower prevalence of myocardial infarction in gouty patients that were on colchicine 31,32 ; this could be explained through its antiinflammatory properties. Whether urate-lowering therapy could revert the inflammation-related proatherogenic state remains to be demonstrated; however, as persistent low-grade inflammation in gout intensely relates to MSU crystal presence in synovial fluid and the joint surface, it appears logical to surmise that crystal clearance will resolve it.…”

Update on hyperuricaemia and gout with evidence based management guidelines

“…The 3e initiative noted that there is an absence of evidence to support the use of ULT in asymptomatic HU. 43 They recommended advice on lifestyle measures including diet, weight and exercise, assessment of renal function, and screening and management of cardiovascular risk factors. 43 The EULAR guidelines noted that appropriate treatment of co-morbidities could lower the serum uric acid, e.g.…”

“…43 They recommended advice on lifestyle measures including diet, weight and exercise, assessment of renal function, and screening and management of cardiovascular risk factors. 43 The EULAR guidelines noted that appropriate treatment of co-morbidities could lower the serum uric acid, e.g. the use of losartan and fenofibrate to treat hypertension and hyperlipidaemia respectively.…”

“…[4][5][6] In 2012 the American College of Rheumatology (ACR) published its first guidelines on gout 7,8 and the multinational 3e initiative (evidence, expertise, exchange) recommendations were published in 2014. 9 There have also been major recent advances in our understanding of the epidemiology, pathogenesis, co-morbidities, role of imaging and management of hyperuricaemia (HU) and gout.…”