First, new pharmaceutical treatment options have become available and the evidence base for the efficacy and safety of available drugs has expanded. Start with a dose of 80 mg daily and, if necessary, increase after 4 weeks to 120 mg daily, to achieve therapeutic target, Uricosuric agents can be used in patients who are resistant to, or intolerant of, xanthine oxidase inhibitors. Canakinumab is licensed for use in Europe by the European Medicines Agency (EMA) but not in the USA by the Food and Drug Administration (FDA) because of uncertainty about its risk/benefit ratio. A Cochrane review of systemic corticosteroids [65] for acute gout included one randomized double-blind equivalence trial that showed that 5-day courses of naproxen 500 mg twice daily and prednisolone 35 mg daily had equal efficacy [66]. The SOR for educating patients to understand the importance of treating acute attacks of gout as early as possible is largely based on common sense, patient experience and expert opinion because of the severity of pain experienced by patients with acute gout. Treatment with febuxostat in patients with ischaemic heart disease or congestive cardiac failure is currently not recommended [143, 144] but large scale RCTs are currently in progress in Europe [128] and North America [145] to establish and compare the cardiovascular safety of febuxostat and allopurinol in patients with gout, high cardiovascular risk and co-morbidities. Gout is the most common cause of inflammatory arthritis worldwide. LoE: III; SOR: 89% (range 63–100%). Hui M, Carr A, Cameron S, et al. Long-term prophylaxis with colchicine or NSAIDs in patients with gout always demands a careful consideration of the overall benefit to risk balance in individual patients, and especially in those with co-morbidities and potential for drug interactions. Prescribers in the UK should be aware of the potential need to obtain approval for an individual funding request before these drugs should be used. (iii) In overweight patients, dietary modification to achieve a gradual reduction in body weight and subsequent maintenance should be encouraged. G.J.D. Steroids are generally safe to use in pregnancy [188] and the recommendations for lifestyle modifications including the dietary changes discussed previously are also safe. Although a small RCT has shown that commencement of allopurinol during an acute attack was not associated with a significant increase in daily pain, recurrent flares or inflammatory markers [116], the working group thought that postponing detailed discussion of long term ULT until a time when the patient was no longer in pain would allow the information to be better absorbed. Ungprasert P, Cheungpasitporn W, Crowson CS, Matteson EL. Management should be individualized and take into account co-morbidities and concurrent medications. Starting dose is a risk factor for allopurinol hypersensitivity syndrome: a proposed safe starting dose of allopurinol. Evidence-based information on gout management pathway from hundreds of trustworthy sources for health and social care. Caution is also required when using colchicine in patients receiving statins, particularly in those with renal impairment, as there are case reports of myopathy and rhabdomyolysis following combined use of colchicine and statins [58–60]. Probenecid and benzbromarone are only available for the treatment of patients with gout in the UK on a named patient basis, and patients requiring these unlicensed drugs should be under the care of a rheumatologist. Febuxostat can be used as an alternative second-line xanthine oxidase inhibitor for patients in whom allopurinol is not tolerated or whose renal impairment prevents allopurinol dose escalation sufficient to achieve the therapeutic target (recommendation VI for the optimal use of urate-lowering therapies). If diuretic drugs are being used to treat hypertension rather than heart failure, an alternative anti-hypertensive agent can be considered as long as blood pressure is controlled. Prescribers in the UK should be aware of the potential need to obtain approval for an individual funding request before these drugs are used. Uric acid levels are generally elevated for 20 years before onset of symptoms. Severe cutaneous hypersensitivity reactions to febuxostat [141–144] are very unusual but the risk of SCAR or DRESS with febuxostat in patients with previous allopurinol hypersensitivity has still to be established. A short course of oral corticosteroid or a single injection of an intramuscular corticosteroid is an alternative in patients who are unable to tolerate NSAIDs/colchicine and in whom intra-articular injection is not feasible. The British Society for Rheumatology has updated its guideline for the management of gout and has recommended that urate-lowering drugs be offered to patients who are early in … Am J Med 2012; 125:1126. 14. Lothian NHS Board Waverleygate 2-4 Waterloo Place Edinburgh EH1 3EG Main Switchboard: 0131 536 9000 YOUR RIGHTS. Early diagnosis and definitive treatment can significantly improve prognosis. A systematic review published in 2012 [77] attempted to assess the risk, but as the number of studies was small, it concluded that there was insufficient evidence to recommend the discontinuation of diuretics across all indications in patients with gout. There are currently insufficient data available on its use in patients with more severe CKD. Choice of first-line agent will depend on patient preference, renal function and co-morbidities. Research evidence for the efficacy and safety of allopurinol has been studied in a recent systematic review [125]. 4. Features a holistic assessment algorithm and treatment options, This updated summary of the NICE rheumatoid arthritis guideline includes recommendations on referral, diagnosis, and investigations. Terkeltaub RA, Schumacher HR, Carter JD et al. 2018 updated European League Against Rheumatism evidence-based recommendations for the diagnosis of gout Annals of the Rheumatic Diseases Published Online First: 05 June 2019. doi: 10.1136/annrheumdis-2019-215315 Read recommendation See slide deck See Lay Summary . Second, the incidence, ), general practitioners (G.D., C.M. Rheumatology 2007; 46 (8): 1372 Dasgupta B, Borg F, Hassan N et al on behalf of the BSR and BHPR Standards, Guidelines and Audit Working Group. A simplified algorithm (Fig. However, these documents contain inconsistent recommendations with unclear quality profiles. Comparable gout guidelines independently (i.e., not developed with pharmaceutical company support) assembled at the level of national and multinational rheumatology societies in the last decade by EULAR and the BSR did not comprehensively evaluate newer evidence and therapies, including febuxostat and pegloticase (21, 24). recurrent attacks of gout may occur and this is also observed in clinical practice. ), and nephrology (S.C.), allied health professionals (A.C., W.J. Although the efficacy of corticosteroids in those with CKD has not been evaluated in RCTs [174], clinical experience suggests that they can be effective and safe for managing acute gout in patients with severe renal impairment or in other patients in whom colchicine and NSAIDs cannot be used. All uricosurics are contraindicated or need to be used with great caution in patients with urolithiasis or severe renal impairment. A Cochrane systematic review of the efficacy and safety of dietary supplements in patients with gout found only two RCTs, one for skimmed milk powder (SMP) enriched with glycomacropeptides (n = 120) and the other for vitamin C (n = 40) [86]. ), and an epidemiologist with expertise in evidence-based medicine (W.Z. The use of benzbromarone was restricted in Europe following rare reports of severe hepatotoxicity, mainly from Asian countries. Tophi are often clinically detectable 10 years after the first gout attack. Is dietary advice effective in the management of patients with gout? Welcome to Guidelines. Gout is definitively diagnosed by demonstrating uric acid crystals in synovial fluid. Following elimination of closely similar and overlapping recommendations, a preliminary list of 51 proposed recommendations included 13 for the management of acute gout, 15 relating to education, diet and lifestyle modification, and 23 for the management of recurrent, inter-critical and chronic gout. Although <6 mg/dL (360 mmol/L = 0.36 mmol/L) is the most common target serum uric acid, levels differ in value and unit measurement. cimetidine, clarithromycin, erythromycin, fluoxetine, ketoconazole, protease inhibitors, tolbutamide) or p-glycoprotein (e.g. A Cochrane review in 2013 [61] found no RCTs of intra-articular steroid use for the management of acute gout. While there is evidence that urate crystal-induced experimental arthritis in dogs is aggravated by movement and ameliorated by rest [48], there have been no RCTs of rest undertaken in patients with gout. Background Gout is one of the most common inflammatory joint diseases in the UK managed by GPs. Systematic literature searches were undertaken by M.H. Accreditation is valid for 5 years from 10 June 2013. Read the most up-to-date coronavirus advice Find out more. Search for other works by this author on: for the British Society for Rheumatology Standards, Audit and Guidelines Working Group, Rising burden of gout in the UK but continuing suboptimal management: a nationwide population study, British Society for Rheumatology and British Health Professionals in Rheumatology guideline for the management of gout, EULAR evidence based recommendations for gout. An update to the British Society for Rheumatology (BSR) Guideline for the management of gout has been published. BSR Guidelines on Gout (rheumatology.org.uk) CONTACT NHS LOTHIAN. 9. For the management of acute gout, the dose of oral colchicine should be reduced in patients with eGFR 10–50 ml/min/1.73 m2 but is contraindicated in patients with more severe renal impairment (GFR < 10 ml/min/1.73 m2). The length of time between the first and subsequent episode of gout can vary considerably between individuals, but typically is < 2 years. The importance of educating patients about the disease and its treatment has been highlighted by the BSR and EULAR guidelines. Sustained hyperuricaemia is the single most important risk factor for the development of gout. Schlesinger N, Moore DF, Sun JD, Schumacher HRJ. It was estimated that 2 patients could have had admissions/flares prevented if they had received allopurinol or other uric acid lowering drug prior to gout admission/flare according to BSR guidelines. In patients with acute gout, does the use of ice packs reduce pain? Pegloticase has FDA approval and EMA marketing authorization in Europe but has not been approved by NICE or the SMC because of concerns about toxicity and cost. (ii) Affected joints should be rested, elevated and exposed in a cool environment. This study, however, does not take into account the ongoing silent deposition of crystals and the significant pain experienced by patients with each attack. Janssens HJ, Lucassen-Peter LBJ, Van-de-Laar FA, Janssen M, Van-de-Lisdonk EH. It is now recommended that that the option of ULT should be explained and offered to all patients with gout as part of their education about the condition and that patients are fully involved in the decision as to when to commence ULT (recommendations I and II for the optimal use of urate-lowering therapies). (v) Cardiovascular risk factors and co-morbid conditions such as cigarette smoking, hypertension, diabetes mellitus, dyslipidaemia, obesity and renal disease should be screened for in all patients with gout, reviewed at least annually and managed appropriately. Gout: why is this curable disease so seldom cured? infusion (8 mg in 250 ml normal saline over 2 h) every 2 weeks by physicians with experience and facilities for dealing with infusion reactions, and patients should be pre-treated with antihistamines and steroids to reduce the risk of infusion reactions, in addition to low-dose colchicine or NSAIDs for flare prophylaxis. 15. Diet and exercise should be discussed with all patients with gout, and a well-balanced diet low in fat and added sugars, and high in vegetables and fibre should be encouraged: sugar-sweetened soft drinks containing fructose should be avoided; excessive intake of alcoholic drinks and high-purine foods should be avoided; inclusion of skimmed milk and/or low fat yoghurt, soy beans and vegetable sources of protein, and cherries in the diet should be encouraged. In patients with gout, should febuxostat be used as an alternative urate-lowering therapy to allopurinol and, if so, in what situations? (v) In patients with acute gout where response to monotherapy is insufficient, combinations of treatment can be used. (BSR/BHPR) guideline for the management of gout was published in 20072. Selective cyclooxygenase-2 inhibitors such as etoricoxib have equal efficacy and better gastrointestinal tolerability than non-selective NSAIDs [51], but there are ongoing uncertainties about their relative cardiovascular and renal toxicity with chronic administration [52]. Pegloticase, a polyethylene glycol modified mammalian uricase, can be effective in such patients [182, 183], although not approved by NICE. Vitamin C supplements (500–1500 mg daily) also have a weak uricosuric effect. The British Society for Rheumatology is the UK's leading specialist medical society for rheumatology and musculoskeletal professionals. For patients on diuretic therapy presenting with acute gout, should diuretic therapy be discontinued? The guideline should also provide a helpful resource for patients and those responsible for commissioning care for patients with gout in the National Health Service (NHS). Metabolic and Crystal Arthropathies [70–72]: 70. is the drug of choice when there are no contraindications. Conclusion: Clinical records indicate that the management of gout by UK General Practitioners in Primary Care is suboptimal in concordance with the BSR guidelines. For diagnosis in clinical practice, clinical scores, without imaging or synovial fluid analysis, have been proposed [21] that include consideration of the patient’s history and co-morbidities. Probenecid was used extensively in the past during antibiotic treatment of infections in pregnant women without any reported fetal toxicity. Taylor TH, Mecchella JN, Larson RJ, et al. LoE: III; SOR: 88% (range 71−100%). Gout is an independent risk factor for chronic kidney disease, myocardial infarction and cardiovascular disease mortality. This guideline has been reviewed and endorsed by the Royal College of General Practitioners. Gout is a common form of inflammatory arthritis characterised by raised uric acid concentration in the blood (hyperuricaemia) and the deposition of urate crystals in joints and other tissues. LoE: IV; SOR: 91% (range 85–100%). 1. A number of rare monogenic disorders associated with inborn errors of purine metabolism [108, 109], glycogen storage diseases [110] or uromodulin mutations associated with decreased fractional urate excretion [111] can result in the development of gout at an early age. A placebo-controlled study of probenecid-treated patients, Colchicine for prophylaxis of acute flares when initiating allopurinol for chronic gouty arthritis, Effect of prophylaxis on gout flares after the initiation of urate-lowering therapy: analysis of data from three phase III trials, Different duration of colchicine for preventing recurrence of gouty arthritis, Rilonacept for gout flare prevention during initiation of uric acid-lowering therapy: results from the PRESURGE-2 international, phase 3, randomized, placebo-controlled trial, Rilonacept (interleukin-1 trap) for prevention of gout flares during initiation of uric acid-lowering therapy: results from a phase III randomized, double-blind, placebo-controlled, confirmatory efficacy study, Rilonacept for gout flare prevention in patients receiving uric acid-lowering therapy: results of RESURGE, a phase III, international safety study, Gout and risk of chronic kidney disease and nephrolithiasis: meta-analysis of observational studies, Challenges associated with the management of gouty arthritis in patients with chronic kidney disease: a systematic review, Management of gouty arthritis in patients with chronic kidney disease, Non-steroidal anti-inflammatory drugs and chronic kidney disease progression: a systematic review, Renal function predicts colchicine toxicity: guidelines for the prophylactic use of colchicine in gout, Individual non-steroidal anti-inflammatory drugs and risk of acute kidney injury: A systematic review and meta-analysis of observational studies, Colchicine dosing guideline for gout patients with varying degrees of renal impairment based on pharmacokinetic data, Efficacy and tolerability of pegloticase for the treatment of chronic gout in patients refractory to conventional treatment: two randomized controlled trials, Rasburicase for tophaceous gout not treatable with allopurinol: an exploratory study, Familial juvenile hyperuricaemic nephropathy is not such a rare genetic metabolic purine disease in Britain, Gout in pregnancy: a case report and review of the literature, BSR & BHPR guideline on prescribing drugs in pregnancy and breastfeeding. (iv) Joint aspiration and injection of a corticosteroid are highly effective in acute monoarticular gout and may be the treatment of choice in patients with acute illness and co-morbidity. Observational studies by Perez-Ruiz and colleagues have shown that the velocity of tophus volume reduction in patients with chronic tophaceous gout could be accelerated with more profound reduction of sUA by combined treatment with allopurinol and benzbromarone [118]. They subsequently demonstrated that even gout patients that are primary overproducers of urate, with apparently increased urine uric acid excretion, also have evidence of defective fractional urate clearance [161] and may therefore respond to addition of a uricosuric drug if their sUA is not reduced to target levels with a xanthine oxidase inhibitor alone. Genome-wide association studies have identified a number of genes coding for urate anion transporters expressed in the proximal renal tubular epithelium, but these account for <5% of the variation in serum urate [14]. There was heterogeneity in the dosages of febuxostat and allopurinol used, the length of time patients had had gout, the length of follow-up, and whether prophylaxis was used. They have just updated and published their new guideline, largely because of new therapies, an increasing incidence of gout, … Part 2: therapy and antiinflammatory prophylaxis of acute gouty arthritis, 2012 American College of Rheumatology guidelines for management of gout. 12. Educate patients to understand that attacks should be treated as soon as an attack occurs and ensure that patients are aware of the importance of continuing any established ULT during an attack. Patients on NSAIDs or cyclooxygenase-2 inhibitors (coxibs) should be co-prescribed a gastro-protective agent, Joint aspiration and injection of a corticosteroid are highly effective in acute monoarticular gout and may be the treatment of choice in patients with acute illness and co-morbidity. Vazquez-Mellado J, Morales EM, Pacheco-Tena C, Burgos-Vargas R. Becker MA, Schumacher HR, Wortmann RL et al. On the 26 th May 2017, the British Society for Rheumatology released an important update to their most ‘in demand’ clinical guideline, on the Management of Gout.Gout is the most searched for term on the BSR website and it’s is a particularly painful form of arthritis which is becoming more common, yet continues to be poorly managed. Frequency of attacks varies from more than two per year to recurrent flares. A recent systematic review and meta-analysis of epidemiological and observational studies suggested that the overall prevalence of CKD (stage 3 or greater; GFR < 60 ml/min/1.73 m2) in patients with gout was 24% compared with 8.5% in the non-gouty population, and the prevalence of self-reported nephrolithiasis was 14% [173]. has received educational sponsorship and funding for UK Gout Society in capacity as Trustee. Second, the incidence, prevalence and severity of gout have increased [1] despite the availability of safe, effective and potentially curative therapy. 2018 updated European League Against Rheumatism evidence-based recommendations for the diagnosis of gout Annals of the Rheumatic Diseases Published Online First: 05 June 2019. doi: 10.1136/annrheumdis-2019-215315 Read recommendation See slide deck See Lay Summary General advice. T.M.M. Disclosure statement: W.Z. Initiation of allopurinol at first medical contact for acute attacks of gout: a randomized clinical trial. NICE has accredited the process used by the BSR to produce its guidance for the management of gout. The recommendation that allopurinol should be the first-line ULT to consider is further supported by health economic studies [129, 130]. Whilst diuretics have been found to be associated with an increased risk of gout with a rate ratio of 11.8 (95% CI: 5.2, 27.0) [75], blood pressure control may require a number of agents and often includes a diuretic [76]. In patients with gout and renal failure, should the dose of allopurinol be adjusted? After some years of successful treatment, when tophi have resolved and the patient remains free of symptoms, the dose of ULT can be adjusted to maintain the sUA at or below a less stringent target of 360 µmol/l to avoid further crystal deposition and the possibility of adverse effects that may be associated with a very low sUA, Allopurinol is the recommended first-line ULT to consider. Patients treated with benzbromarone should have liver function tests monitored but the risk of serious hepatotoxicity in patients receiving the benzbromarone in Europe is estimated as approximately 1 in 17 000 [153]. Compliments, Concerns & Complaints; Freedom of Information; OUR VALUES INTO ACTION. Recommendations for identifying and managing ‘long-COVID’ in primary care, Commissioned by Intercept Pharma UK and Ireland Ltd. Perez-Ruiz F, Calabozo M, Fernandez-Lopez MJ et al. ULT should particularly be advised in patients with the following: recurring attacks (⩾2 attacks in 12 months); tophi; chronic gouty arthritis; joint damage; renal impairment (eGFR < 60 ml/min); a history of urolithiasis; diuretic therapy use; primary gout starting at a young age. By 12 months, recurrent acute gout was reported by 54%, 28% and 23%, respectively. The starting dose should, however, be low and then carefully increased with smaller increments (50 mg) until the target sUA of 300 µmol/l is reached (recommendation V for the optimal use of urate-lowering therapies). 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SOR: 95% (range 82−100%). Jutkowitz E, Choi HK, Pizzi LT, Kuntz KM. The importance of taking ULT regularly and continually to prevent the return of gout attacks should be explained. BSR & BHPR, BOA, RCGP and BSAC guidelines for management of the hot swollen joint in adults external link opens in a new window Published by: British Society for Rheumatology Last published: 2006 (re … Kydd ASR, Seth R, Buchbinder R, Edwards CJ, Bombardier C. Reinders MK, van-Roon EN, Jansen TL et al. It is now recommended that an NSAID or colchicine are both drugs of choice for acute gout when there are no contraindications and that the choice of first-line agent should be determined by renal function, co-morbidities and patient preference (recommendation III for the management of acute attacks). Medical record review with a descriptive analysis was undertaken to assess the … Final consensus on the most appropriate wording for 21 recommendations was agreed at a second face-to-face meeting of the guideline working group after further minor amalgamations and discussion of the draft recommendations and the feedback from members of the BSR. Thank you for submitting a comment on this article. Although well tolerated by the majority of patients, allopurinol is rarely (∼0.1−0.4%) associated with potentially life-threatening severe, cutaneous adverse reactions (SCAR) including toxic epidermal necrolysis, hypersensitivity drug reactions with rash, eosinophilia and systemic symptoms (DRESS) or Stevens–Johnson syndrome with vasculitis, liver and renal toxicity [131]. The updated EULAR and BSR guidelines advise that ULT should be considered and discussed with every patient from the first presentation. Iii ; SOR: 57 % ( range 82−100 % ) early diagnosis and investigation gout... 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