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Original Nomination



Research Review - Final – Nov. 1, 2016 (Update)

Management of Gout

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Addendum – October 2016

In the manuscript summarizing the findings of this report for journal submission, we performed an update search to March 2016. We identified 11 new publications meeting inclusion criteria. Incorporating these new studies did not change any conclusion or strength of evidence for any conclusion. More information is located in the Annals of Internal Medicine manuscript.

Table of Contents

Structured Abstract

Objectives

To review the evidence base for treating patients with gout, both acute attacks and chronic disease. The review specifically focuses on the management of patients with gout in the primary care setting.

Data sources

We searched Medline, EMBASE, the Cochrane Collection, and the Web of Science using the search terms "gout," and "gouty," and terms for tophi (from January 1, 2010 to April 23, 2015, or at least one year prior to the search dates for the most recent systematic reviews). We also obtained relevant references from 28 recent systematic reviews that cover nearly all of the Key Questions. We searched Clinicaltrials.gov and the Web of Science for recently completed studies and unpublished or non-peer-reviewed study findings. Searches were not limited by language of publication.

Review methods

We used standard systematic review methods including duplicate screening and data extraction from relevant studies, and existing tools to assess the quality of previously published systematic reviews, the risk of bias of individual studies, and the strength of evidence across studies.

Results

High-strength evidence supports the use of colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs), and systemic corticosteroids to reduce pain in patients with acute gout. Moderate-strength evidence supports the use of animal-derived ACTH formulation for this condition. Moderate-strength evidence supports the finding that low-dose colchicine is as effective as higher-dose colchicine for treating acute gout attacks, and has fewer side effects. Evidence is insufficient from randomized controlled trials that assess symptomatic outcomes for specific dietary therapies. The evidence is also insufficient to support or refute the effectiveness of particular Traditional Chinese Medicine practices (e.g., herbal mixtures, acupuncture, and moxibustion) for symptomatic outcomes. High-strength evidence supports that urate lowering therapy (ULT, with allopurinol or febuxostat) reduces serum urate level. However low-strength evidence supports the finding that treating to a specific target serum urate level reduces the risk of gout attacks. High-strength evidence supports the finding that ULT does not reduce the risk of acute gout attacks within the first 6 months after initiation. However, moderate-strength evidence supports a role for ULT in reducing the risk of acute gout attacks after about 1 year of treatment. Low-strength evidence supports treating to a specific target serum urate level to reduce the risk of gout attacks. High-strength evidence supports the finding that prophylactic therapy with low-dose colchicine or low dose NSAIDs reduces the risk of acute gout attacks when beginning ULT. No criteria for when to discontinue ULT have been validated.

Conclusions

Effective treatments for acute gout include colchicine, NSAIDs, and corticosteroids/animal-derived ACTH formulation. Urate lowering therapy achieves its goal of lowering serum urate levels. Urate lowering should lead to a reduction in gout attacks, but the benefits and harms of long term urate lowering therapy have yet to be directly demonstrated. Patient preferences and other clinical circumstances are likely to be important in decisions about treating patients with gout.

Journal Publications

Newberry SJ, FitzGerald JD, Motala A, Booth M, Maglione MA, Han D, et al. Diagnosis of Gout: A Systematic Review in Support of an American College of Physicians Clinical Practice Guideline. Ann Intern Med. [Epub ahead of print 1 November 2016] doi: 10.7326/M16-0462

Shekelle PG, Newberry SJ, FitzGerald JD, Motala A, O'Hanlon CE, Tariq A, et al. Management of Gout: A Systematic Review in Support of an American College of Physicians Clinical Practice Guideline. Ann Intern Med. [Epub ahead of print 1 November 2016] doi: 10.7326/M16-0461