Clinical practice guidelines on gout management disagree on when to initiate urate-lowering therapy

An analysis of six clinical practice guidelines showed disagreement on when to initiate urate-lowering therapy for gout, length of urate-lowering therapy, and the use of pegloticase, vitamin C, losartan, and fenofibrate.

The guidelines agreed on the use of urate-lowering therapy for the management of established gout, along with prophylaxis for the prevention of future flares.

"Gout is the most common inflammatory arthritis, increasing in burden and prevalence. Of the rheumatic disease, gout is the best-understood and potentially most manageable condition," Brooke Conley, The University of Melbourne, Melbourne, VIC, Australia, and colleagues wrote in their review. "However, it frequently remains poorly managed or untreated.

The systematic review was conducted to identify Clinical Practice Guidelines (CPG) regarding gout management, assess their quality, and provide a synthesis of consistent recommendations for high-quality CPGs.

The research team included Gout management CPGs if they were (1) written in English and published between 2015 and 2022, focused on adults above 18 years of age, and met the criteria of a CPG, and (2) were rated as high-quality on the AGREE (Appraisal of Guidelines for Research and Evaluation) II instrument. They searched for online guideline repositories.

The authors reported the following findings:

· Six CPGs were appraised as high quality and included in the synthesis.

· Clinical practice guidelines consistently recommended education, commencement of non-steroidal anti-inflammatories, colchicine or corticosteroids (unless contraindicated), and assessment of cardiovascular risk factors, renal function, and co-morbid conditions for acute gout management.

· Consistent recommendations for chronic gout management were urate-lowering therapy (ULT) and continued prophylaxis recommended based on individual patient characteristics.

· Clinical practice guideline recommendations were inconsistent on when to initiate ULT and length of ULT, vitamin C intake, and use of pegloticase, losartan, and fenofibrate.

The synthesis of current high-quality CPGs guided healthcare providers, on recommended gout care. Recommendations from six CPGs were that management of acute gout flare should include education, anti-inflammatories, screening, and elevation/rest of the affected joints.

The article stated, "Established gout should be managed with urate-lowering therapy and continued prophylaxis to manage tophaceous and erosive gout and prevent further gout flare. CPGs disagreed on when to initiate ULT and ULT length, losartan, fenofibrate, pegloticase, and vitamin C intake."

"This synthesis of recommendations is pertinent to healthcare providers and can be implemented in clinical practice to optimise patient outcomes and standardise high-quality care," the investigators concluded.

Reference:

Conley, B., Bunzli, S., Bullen, J. et al. What are the core recommendations for gout management in first line and specialist care? Systematic review of clinical practice guidelines. BMC Rheumatol 7, 15 (2023). https://doi.org/10.1186/s41927-023-00335-w