The British Society for Rheumatology Guideline for the Management of Gout

Abstract

Background to the diseaseGout is the most common cause of inflammatory arthritis worldwide. In UK general practice, the overall prevalence has increased from 1.4% in 1999 to 2.49% in 2012 1 , despite the availability of effective and potentially 'curative' urate-lowering drugs for more than 50 years and evidence-based British and European management guidelines for nearly a decade 2;3 . Clinical manifestations of gout resulting from monosodium urate (MSU) crystal deposition, include tophi, chronic arthritis, urolithiasis and renal disease as well as recurrent acute arthritis, bursitis and cellulitis. Gouty arthritis and tophi are associated with chronic disability, impairment of health-related quality of life (HRQOL) [4][5][6][7] , increased use of healthcare resources, and reduced productivity 8 . Gout is also frequently associated with co-morbidities such as obesity, dyslipidaemia, diabetes mellitus, chronic renal insufficiency, hypertension, cardiovascular disease, hypothyroidism, anaemia, psoriasis, chronic pulmonary diseases, depression and osteoarthritis 1 as well as with an increase in all-cause mortality (adjusted hazard ratio 1.13, 95% CI 1.08 to 1.18) and urogenital malignancy 1;9 . Sustained hyperuricaemia is the single most important risk factor for the development of gout. Hyperuricaemia occurs secondary to reduced fractional clearance of uric acid in more than 90% of patients with gout 10 . Age, male gender, menopausal status in females, impairment of renal function, hypertension and the co-morbidities that comprise the metabolic syndrome are all risk factors for incident Recently published guidelines include the 2012 American College of Rheumatology Guidelines for the Management of Gout 34,35 and the 2013 evidence-based recommendations for the diagnosis and management of gout by a multinational panel of rheumatologists participating in the 3e initiative 36 . Other National and Regional guidelines include the US Government 2014 Agency for Healthcare Research and Quality (AHRQ) Guidelines for the Diagnosis and Management of Gout 37,38 , and the Australian and New Zealand 39 and Portuguese 40 recommendations for the diagnosis and management of gout which arose from the 3e initiative. 36 Updated EULAR recommendations for the management of gout will be published in 2016. ObjectiveThis guideline aims to offer revised and updated, concise, patient-focussed, evidence-based, expert recommendations for the management of gout in the UK.

New Perspectives in Rheumatology: Implications of the Cardiovascular Safety of Febuxostat and Allopurinol in Patients With Gout and Cardiovascular Morbidities Trial and the Associated Food and Drug Administration Public Safety Alert

“…Fifth, allopurinol dose-escalation was effective in the majority of patients with gout in a recent RCT (34). Last, uricosuric monotherapy, and combinations of allopurinol with certain uricosurics (eg, probenecid, lesinurad), also are effective in many patients (3–6,39,40). …”

“…Urate lowering therapy (ULT) is central to long-term management of gout (3–6). Use of an inhibitor of the dual enzyme xanthine oxidoreductase (commonly known as xanthine oxidase) is the consensus first line therapeutic strategy for ULT (3–6).…”

“…Use of an inhibitor of the dual enzyme xanthine oxidoreductase (commonly known as xanthine oxidase) is the consensus first line therapeutic strategy for ULT (3–6). In clinical practice, allopurinol is generally employed as the first line XOI in gout.…”

Management of patients with gout and achievement of target serum urate levels at a tertiary rheumatology service in Australia

“…International guidelines suggest the use of allopurinol as first line ULT; probenecid, benzbromarone and febuxostat can be used as second line agents. [3][4][5][6] In theory, gout should be relatively easily treatable, and should be curable in the majority of patients, yet in clinical settings in Australia and around the world success of treatment has been suboptimal. [7][8][9] Studies suggest lack of patient adherence, lack of education by health professionals and poor tolerance of medication side effects as possible explanations for poor success rates.…”

Management of gout in older people

“…Attention to lifestyle, including diet and exercise, and attending to comorbidities and risk factors for accelerated cardiovascular disorders is a critical component of the management and education of people with gout, although most of the benefit from these measures derives from reduction of cardiovascular risk. [30][31][32][33] The focus upon pharmacotherapy in this paper should not be construed as undervaluing the contribution of nonpharmacological interventions to the long-term health of people with gout.…”