using MEDLINE 1946 to present, EMBASE 1974 to present, PubMed from inception to present, the Cochrane Controlled Trials Register from inception to present and the ISI Web of Science and AMED databases 1985 to present. The British Society for Rheumatology/British Health Professionals in Rheumatology (BSR/BHPR) guideline for the management of gout was published in 2007 . 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. There is growing evidence regarding the importance of education in gout. They have just updated and published their new guideline, largely because of new therapies, an increasing incidence of gout, … CKD and nephrolithiasis are very common in patients with gout. Colchicine should also only be used with caution and at low doses in patients taking drugs that are potent inhibitors of cytochrome P450 3A4 (e.g. The importance of taking ULT regularly and continually to prevent the return of gout attacks should be explained. 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. Wallace SL, Singer JZ, Duncan GJ, Wigley FM, Kuncl RW. 8. There is no research evidence to support the use of corticosteroids for flare prophylaxis. Features a holistic assessment algorithm and treatment options, This updated summary of the NICE rheumatoid arthritis guideline includes recommendations on referral, diagnosis, and investigations. However, small observational studies, expert opinion and clinical experience suggest that intra-articular and intramuscular steroid injections can be very effective treatments for acute gouty arthritis [62–64]. Thank you for submitting a comment on this article. Co-morbidities associated with gout are well recognized [81, 91, 92]. Jennings CG, Mackenzie IS, Flynn R et al. The revised guideline emphasizes that all patients with gout should be screened for cardiovascular risk factors and co-morbid conditions such as cigarette smoking, hypertension, diabetes mellitus, dyslipidaemia, obesity and renal disease at least annually and treated appropriately (recommendation V for the modification of lifestyle and risk factors). More recently, studies by Stamp et al. A retrospective study of patients seen by rheumatologists in Taiwan suggested that the age at which gout presents was falling [112] and heritability accounts for 35% of gout risk in men and 17% in women in Taiwan [1]. In patients with frequent flare and contraindications to colchicine, NSAIDs and corticosteroids, an … (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). 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. In patients with acute gout, what medication should be used to manage acute attacks? Gout is the most common cause of inflammatory arthritis worldwide, with 1–2 in every 100 people estimated to be affected by gout. Ghosh P, Cho M, Rawat G, Simkin PA, Gardner GC. An electronic search of the practice records was performed to identify adults with a di agnosis of gout. Algorithm reproduced with kind permission from Hui, Carr, and Cameron et al and the British Society for Rheumatology. Copyright © 2012 by John Wiley & Sons, Inc. Reprinted by permission of John Wiley & Sons, Inc. GFR: glomerular filtration rate. 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 OA [1] as well as with an increase in all-cause mortality (adjusted hazard ratio 1.13, 95% CI: 1.08, 1.18) and urogenital malignancy [1, 9]. Williams SE, Reed AAC, Galvanovskis J et al. 10. Clinical Insights into Gout Management Rheumatology Drugs. 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. Becker MA, Schumacher HR, Espinoza LR et al. Prior gout recommendations and guidelines, at the in-dependent (i.e., non–pharmaceutical industry sponsored) ... (BSR) (12). Acute attacks of gout usually completely subside in 1-2 weeks without treatment. PDF | On Apr 1, 2014, Nirupam Purkayastha and others published Audit on Gout Management: Adhering to the BSR Guidelines | Find, read and cite all the research you need on ResearchGate NICE has accredited the process used by the BSR to produce its guidance for the management of gout. The target sUA of <300 μmol/l recommended in the previous BSR/BHPR guideline [2] remains the recommended target to prevent crystal formation and recurrent flares [117]. Methods: Audit criteria were derived from the EULAR and BSR/BHPR guidelines; standards were set arbitrarily, but with consideration of patient comorbidity and other factors which may influence concordance. This site is intended for UK healthcare professionals, Guidelines Live 2020—now available on demand, academic.oup.com/rheumatology/article/56/7/1056/3855178, Non-alcoholic steatohepatitis: identification, management, and referral pathways, New COVID guidelines focus on long-term effects and vitamin D, 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 urate-lowering therapy (ULT) during an attack, Affected joints should be rested, elevated and exposed in a cool environment. 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. First, new pharmaceutical treatment options have become available and the evidence base for the efficacy and safety of available drugs has expanded. Part II: Management. reports grants from Arthritis Research UK, Health Technology Assessment, National Institute for Health Research and honoraria for consultations from AstraZenica, Daiichi Sankyo, Biobarica, Hisun and Grunenthal outside the submitted work. Schlesinger N, Moore DF, Sun JD, Schumacher HRJ. 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. Perez-Ruiz F, Calabozo M, Fernandez-Lopez MJ et al. 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. guidelines for gout are rheumatologist-generated and disseminated in rheumatology journals. Measure blood pressure and arrange additional blood … Part 1 of the guidelines focused on systematic nonpharmacologic measures (patient education, diet and lifestyle choices, identification and management of comorbidities) that impact hyperuricemia, and made recommendations on pharmacologic ULT in a range of case scenarios of patients with disease activity manifested by acute and chronic forms of gouty arthritis, including chronic tophaceous gouty arthropathy … However, anecdotal reports suggest that some secondary care organizations prohibit follow-up of patients with gout, insisting on discharge with a treatment plan to primary care where treatment is known to be suboptimal. COVID-19 guidance. Richette P, Brière C, Hoenen-Clavert V, Loeuille D, Bardin T. Simmonds HA, Cameron JS, Goldsmith DJ, Fairbanks LD, Raman GV. Karimzadeh H, Nazari J, Mottaghi P, Kabiri P. Schumacher HRJr, Evans RR, Saag KG et al. A meta-analysis of 13 RCTs found that sUA can be lowered by vitamin C supplementation in patients without gout and that sUA reductions were greater in trials administering vitamin C >500 mg/day [87]. Evidence-based information on gout management pathway from hundreds of trustworthy sources for health and social care. Intra-articular triamcinolone hexacetonide (40 mg for large joints, 10–20 mg for smaller joints) is often recommended if only one or two joints are inflamed, or a 7–14-day course of oral prednisolone (30–40 mg tapering to nothing), if multiple joints are involved or if arthrocentesis is not possible. Janssens HJEM, Fransen J, van de Lisdonk EH et al. BSR & BHPR, BOA, RCGP and BSAC guidelines for management of the hot swollen joint in adults external link opens in a new window. Such factors, as well as co-morbid disease, have been found to be associated with poorer health-related quality of life [6]. It is also frequently associated with co-morbidities such as diabetes mellitus, depression, cardiovascular disease, and chronic pulmonary diseases. Introduction Gout and hyperuricaemia are major health issues and relevant guidance documents have been released by a variety of national and international organisations. The draft recommendations were presented for discussion and feedback at the annual scientific meeting of the BSR in 2014. The importance of educating patients about the disease and its treatment has been highlighted by the BSR and EULAR guidelines. The guideline recommends as the first-line ULT allopurinol, which is inexpensive and likely to be tolerated and effective in the vast majority of patients with gout. Editorials, commentaries, conference abstracts and non-evidence-based narrative/personal reviews were excluded. Their efficacy and safety for ULT is supported by a recent systematic review and meta-analysis [148] of two RCTs comparing benzbromarone with allopurinol, two RCTs comparing benzbromarone with probenecid and one non-randomized case–control trial comparing probenecid with allopurinol, and a cohort study examining probenecid [149], but there have been no placebo-controlled RCTs of the three drugs that are currently approved for use as ULT in patients with gout in Europe (sulfinpyrazone 200–800 mg od, probenecid 250–500 mg qds, benzbromarone 50–200 mg od). Andres M, Sivera F, Falzon L, Buchbinder R, Carmona L. Stamp LK, O'Donnell JL, Frampton C et al. Part 1: systematic nonpharmacologic and pharmacologic therapeutic approaches to hyperuricemia, Multinational evidence-based recommendations for the diagnosis and management of gout: integrating systematic literature review and expert opinion of a broad panel of rheumatologists in the 3e initiative, Agency for Healthcare Research and Quality, Australian and New Zealand recommendations for the diagnosis and management of gout: integrating systematic literature review and expert opinion in the 3e Initiative, Portuguese recommendations for the diagnosis and management of gout, Updated EULAR Evidence-based recommendations for the diagnosis of gout, Clinical guidelines: developing guidelines, Evidence-based clinical guidelines: a new system to better determine true strength of recommendation, A comparative double-blind parallel study with tenoxicam vs placebo in acute gouty arthritis, High versus low dosing of oral colchicine for early acute gout flare: Twenty-four-hour outcome of the first multicenter, randomized, double-blind, placebo-controlled, parallel-group, dose-comparison colchicine study, Effect of exercise on urate crystal-induced inflammation in canine joints, Lifestyle interventions for the treatment of gout: a summary of 2 Cochrane systematic reviews, Treatment of acute gout: a systematic review, Randomised double blind trial of etoricoxib and indometacin in treatment of acute gouty arthritis, Risk of myocardial infarction associated with selective COX-2 inhibitors: meta-analysis of randomised controlled trials, National Institute for Health and Care Excellence, Does colchicine work? No studies have been undertaken to assess whether vitamin C supplementation is effective in reducing the incidence of recurrent gout attacks. Questions for audit and recommendations for future clinical research can be found Supplementary Table S2, available at Rheumatology online and in the audit tool. Moi JHY, Sriranganathan MK, Falzon L et al. Second, the incidence, 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. The content on this page is intended for UK healthcare professionals only. All uricosurics are contraindicated or need to be used with great caution in patients with urolithiasis or severe renal impairment. 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. The consensus recommendations were developed without any input from, or consultation with, any pharmaceutical company and potential conflicts of interest of all members of the working group have been fully declared. 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. ; Scenario: Preventing gout: covers the principles of gout prevention and includes information on prophylactic drug treatment. Your comment will be reviewed and published at the journal's discretion. A brief summary of SIGN's guideline on management of osteoporosis and prevention of fragility fractures, including risk factors and a treatment algorithm. 17. [50] recently published a systematic review that included 30 papers examining the management of acute gout. The efficacy of NSAIDs is supported by a single placebo-controlled RCT of tenoxicam 40 mg daily [45]. 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]. However, the wisdom of the recommendation that commencement of ULT should at least be considered after the first attack of gout is supported by observational data from the UK Clinical Practice Research Datalink that showed that less than half the patients with gout eligible for ULT were offered treatment [23]. First, new pharmaceutical treatment options have become available and the evidence base for the efficacy and safety of available drugs has expanded. Pegloticase is contraindicated in patients with glucose-6-phosphate dehydrogenase deficiency because of the risk of haemolysis, and extra caution is required in patients with congestive heart failure. Patients who do not, or cannot, adhere to prescribed ULT are more likely to experience more gout attacks more frequently and in more joints. 3. Enhancement of uric acid excretion and reduction of sUA in patients with tophaceous gout by combined treatment with sulfinpyrazone and allopurinol was first demonstrated nearly 50 years ago [160]. 5. Uric acid levels are generally elevated for 20 years before onset of symptoms. The British Society for Rheumatology is the UK's leading specialist medical society for rheumatology and musculoskeletal professionals. Conclusion: Clinical records indicate that the management of gout by UK General Practitioners in Primary Care is suboptimal in concordance with the BSR guidelines. The lipid-lowering agent fenofibrate has been shown to be uricosuric [156] and to have a modest additional urate-lowering effect in gout patients being treated with allopurinol [157, 158]. COVID-19 in rheumatoid arthritis cases: an Iranian referral center experience. Patients should be fully involved in the decision as to when to commence ULT. LoE: IV; SOR: 80% (28–100%). Adverse events did not differ between the three groups. Lindsay K, Gow P, Vanderpyl J, Logo P, Dalbeth N. Khanna D, Khanna PP, FitzGerald JD et al. Patients should be supported during the process of lowering their serum uric acid levels as it can cause an increase in gout flares during this time, ULT should be discussed and offered to all patients who have a diagnosis of gout. The updated EULAR and BSR guidelines advise that ULT should be considered and discussed with every patient from the first presentation. 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]. 5 EULAR guidelines suggest initiating urate-lowering therapy close to the time of diagnosis, 8 and the BSR specifies initiating 1–2 weeks after an acute attack. Tophi are often clinically detectable 10 years after the first gout attack. The recommendation to rest acutely affected joints is based on widespread patient experience and expert opinion. Perez-Ruiz F, Calabozo M, Erauskin GG, Ruibal A, Herrero-Beites AM. 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