The importance of taking ULT regularly and continually to prevent the return of gout attacks should be explained. The preferred drugs are sulfinpyrazone (200–800 mg/day) or probenecid ( 500–2000 mg/ day) in patients with normal or mildly impaired renal function, or benzbromarone (50–200 mg/day) in patients with mild to moderate renal insufficiency, Losartan and fenofibrate should not be used as a primary ULT but where treatment for hypertension or dyslipidaemia, respectively, is required, they may be considered as they have a weak uricosuric effect. Low-fat dairy intake, folate intake, coffee consumption and diets high in dietary fibre appear to be associated with a reduced risk of incident gout as well as a reduction in risk of recurrent gout flares in some, but not all, cases [83]. Unlike ACE inhibitors, beta blockers and other angiotensin II receptor blockers used for treating hypertension, losartan 50 mg od has been shown to have mild uricosuric effects in patients with gout [154], and the use of losartan was associated with a significantly reduced risk of incident gout (RR = 0.81, 95% CI: 0.70, 0.94) in a large community-based UK case–control study using data from The Health Improvement Network [155]. 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]. It is not recommended that asymptomatic hyperuricaemia is treated. ), on behalf of the BSR/BHPR Standards, Audit and Guidelines Working Group. There is growing evidence regarding the importance of education in gout. Moi JHY, Sriranganathan MK, Falzon L et al. The importance of patient education and provision of information about gout and its treatment are strongly emphasized in the updated guideline (recommendation I for the management of acute attacks, recommendations II and III for the modification of lifestyle and risk factors and recommendation I, II and III for the optimal use of urate-lowering therapies). Our guidelines grow out of the collaborative efforts of many members and non-members, specialists and generalists, patients and carers. First, new pharmaceutical treatment options have become available and the evidence base for the efficacy and safety of available drugs has expanded. Research evidence for the efficacy and safety of allopurinol has been studied in a recent systematic review [125]. Diagnosis of acute gout: a clinical practice guideline from the American College of Physicians external link opens in a new window. First, new pharmaceutical treatment options have become available and the evidence base for the efficacy and safety of available drugs has expanded. Serum urate levels are influenced by dietary intake and synthesis as well as by renal excretion. Patients with severe symptomatic tophaceous gout in whom hyperuricaemia cannot be controlled with standard ULTs alone, or in combination, should be referred to a rheumatologist. Choice of first-line agent will depend on patient preference, renal function and co-morbidities. 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. Oxford University Press is a department of the University of Oxford. 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]. 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 … Published by Oxford University Press on behalf of the British Society for Rheumatology. Most RCTs have been head-to-head comparisons with no single agent having greater efficacy. Your comment will be reviewed and published at the journal's discretion. General advice. In patients with renal impairment, smaller increments (50 mg) should be used and the maximum dose will be lower, but target urate levels should be the same. Part II: analgesics and other drugs used in rheumatology practice, BSR & BHPR guideline on prescribing drugs in pregnancy and breastfeeding. These findings and ongoing uncertainty concerning the efficacy and safety of IL-1 inhibitors are reflected in a recent Cochrane review [74]. The British Society for Rheumatology/British Health Professionals in Rheumatology (BSR/BHPR) guideline for the management of gout was published in 2007 [2]. In patients with gout, should other medications such as benzbromarone, sulfinpyrazone and probenecid be used? Such systemic therapy is also appropriate for oligo- or polyarticular attacks of gout. 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. Lothian NHS Board Waverleygate 2-4 Waterloo Place Edinburgh EH1 3EG Main Switchboard: 0131 536 9000 YOUR RIGHTS. Diets high in red meat or seafood, and increased consumption of beer, spirits and fructose- or sugar-sweetened soft drinks are established risk factors for developing gout [15–17]. While there are no published trials of prevention of urolithiasis in patients with gout and recurrent stone formation, there have been two recent systematic reviews and meta-analyses of RCTs of medical management of recurrent urolithiasis in all adults [89, 90]. clarithromycin, ciclosporin, erythromycin) [57]. However, in patients in whom attacks are so frequent to make this difficult, the findings of this trial support initiation of ULT before inflammation has resolved. Evidence-based recommendations for the diagnosis and investigation of gout are not included in this guideline. Vitamin C (500 mg/day for 8 weeks) reduced the sUA (−0.014 mmol/l) much less than allopurinol (−0.118 mmol/l) in patients with gout, and also less than the mean reduction of 0.02 mmol/l reported in the meta-analysis of 13 RCTs of vitamin C administration in patients with hyperuricaemia who did not have gout [87]. (vii) Uricosuric agents can be used in patients who are resistant to, or intolerant of, xanthine oxidase inhibitors. 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. The British Society for Rheumatology Guideline for the Management of Gout. Although there are few cost-effectiveness studies in gout, the guideline takes these into account. Over time, the inter-critical periods shorten and as good practice in patient education, it is worth having the discussion about treatment early in the course of the disease, always bearing in mind that this potentially curable condition can have a significant impact on patient quality of life if left untreated [5, 6]. Please check for further notifications by email. LoE: Ib; SOR: 86% (range 29–100%). Should patients with gout be screened for co-morbidities? 2 The guideline states that plasma urate should be maintained below 300 µmol/l to prevent recurrent … (iii) In overweight patients, dietary modification to achieve a gradual reduction in body weight and subsequent maintenance should be encouraged. Conservative measures including ice are safe for managing acute attacks. ), general practitioners (G.D., C.M. It should be started at a low dose (50–100 mg daily) and the dose then increased in 100 mg increments approximately every 4 weeks until the sUA target has been achieved (maximum dose 900 mg), In patients with renal impairment, smaller increments (50 mg) should be used and the maximum dose will be lower, but target urate levels should be the same, 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. Welcome to Guidelines. This presents physicians with important challenges in managing patients with gout, and management of gout in patients with renal impairment has been the subject of two recent systematic reviews and a guideline from the US National Kidney Foundation [174, 175]. … The BSR guidelines also suggest that uric acid-lowering therapy should be offered to patients following a second attack of gout or if a further attack occurs within a year as opposed to the more than three attacks a year quoted in the article. Treatment of patients with gout and urolithiasis with ULT is supported by observational studies [107], while the recommendation to consider ULT in patients taking diuretic drugs is supported by three cohort studies and four case–control studies that demonstrated higher risks of gouty arthritis in users compared with non-users of diuretics [77]. Gout; Lupus; Other; Psoriatic arthritis; Rheumatoid Arthritis; TNF inhibitor; Search. The British Society for Rheumatology/British Health Professionals in Rheumatology (BSR/BHPR) guideline for the management of gout was published in 2007 . [46, 54] found two placebo-controlled RCTs demonstrating statistical reduction in pain at 24 and 48 h. Terkeltaub’s study demonstrated that a low-dose colchicine regimen (1.2 mg followed by 600 μg after 1 h) was equally effective, and was associated with much less nausea, vomiting and diarrhoea, as a high-dose regimen of 4.8 mg over 6 h. A Cochrane review of the same two RCTs [55] also concluded that there was low quality evidence for the efficacy of low-dose colchicine and for no additional efficacy with high doses, which were significantly more likely to be associated with adverse effects (risk ratio (RR) = 3.00, 95% CI: 1.98, 4.54). Alkalinization of the urine with potassium citrate (60 mEq/day) should be considered in recurrent stone formers. Compliments, Concerns & Complaints; Freedom of Information; OUR VALUES INTO ACTION. is the drug of choice when there are no contraindications. LoE: Ia; SOR: 90% (range 63−100%). (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. Current guidelines by the British Society for Rheumatology and British Health Professionals in Rheumatology (BSR/BHPR) and the European League Against Rheumatism (EULAR) , relating to the management of gout in primary care are similar and may be used by primary care health professionals in the UK. Arthritis Rheumatol 2012;64:2529–36. Rheumatology 2017: 56(7); 1065–1059. For full details on our accreditation visit: (vi) IL-1 inhibitors may be considered in patients who have previously not responded adequately to standard treatment of acute gout (although not approved by NICE). ; Scenario: Preventing gout: covers the principles of gout prevention and includes information on prophylactic drug treatment. Second, the incidence, Excessive consumption of meat, seafood, alcoholic drinks (especially beer and spirits), sugar-sweetened soft drinks and fructose-containing foods are all significant risk factors for incident gout. Hui M, Carr A, Cameron S et al. Vitamin C supplements in this modest dose only have a very weak uricosuric effect in people with gout, which is insufficient for it to be used as substitute monotherapy for allopurinol or other licensed ULT. And they are being given information about gout of treatment can significantly improve prognosis as benzbromarone sulfinpyrazone. 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