Implementing AHRQ Effective Health Care Reviews

Helping Clinicians Make Better Treatment Choices

Gout: Diagnosis and Management

 

Am Fam Physician. 2017 Nov 15;96(10):668-670.

Author disclosure: No relevant financial affiliations.

Key Clinical Issue

What is the accuracy of clinical decision tools and imaging for the diagnosis of gout in the primary care setting, and how effective are medications used to treat and prevent gout?

Evidence-Based Answer

The Diagnostic Rule and the Clinical Gout Diagnosis are two clinical decision tools that are 88% and 97% sensitive and 75% and 96% specific, respectively, in diagnosing gout when compared with monosodium urate crystal analysis. (Strength of Recommendation [SOR]: C, based on disease-oriented evidence.) Nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, and corticosteroids all effectively treat acute gout. (SOR: A, based on consistent, good-quality patient-oriented evidence.) Urate-lowering therapy reduces serum urate levels and frequency of gout attacks at 12 months. (SOR: B, based on inconsistent or limited-quality patient-oriented evidence.) It does not lower the frequency of gout attacks during the first six months, likely because of the increased risk of gout attacks with the initiation of therapy. Prophylactic agents such as colchicine and NSAIDs should be used during the first six months of urate-lowering therapy. (SOR: A, based on consistent, good-quality patient-oriented evidence.)

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Clinical Bottom Line: Effectiveness of Treatments for Acute Gout Attack

StrategyNumber of studiesNumber of patientsFindingSOE

Colchicine

2 RCTs

229

Reduces pain compared with placebo

● ● ●

1 RCT

184

A lower dose of colchicine is as effective as a higher dose but has fewer adverse effects

● ● ○

NSAIDs*

1 RCT and observational data

30 (in RCT)

Reduce pain

● ● ●

16 RCTs

1,280

No differences among NSAIDs in effectiveness

● ● ○

Corticosteroids

4 RCTs

297

Reduce pain as much as NSAIDs

● ● ●

Animal-derived adrenocorticotropic hormone (not commonly used in clinical practice)

2 RCTs

107

Reduces pain as much as NSAIDs

● ● ○


Strength of evidence scale

High: ● ● ● There are consistent results from good-quality studies. Further research is highly unlikely to change the conclusions.

Moderate: ● ● ○ Findings are supported, but further research could change the conclusions.

Low: ● ○ ○ There are very few studies, or existing studies are flawed.

Insufficient: ○ ○ ○ Research is either unavailable or does not permit estimation of a treatment effect.


NSAIDs = nonsteroidal anti-inflammatory drugs; RCT = randomized controlled trial; SOE = strength of evidence.

*—The known anti-inflammatory action of these agents was considered when assessing SOE.

Adapted from the Agency for Healthcare Research and Quality, Effective Health Care Program. Diagnosis and management of gout: current state of the evidence. Clinician summary. Rockville, Md.: Agency for Healthcare Research and Quality; January 2017. https://www.effectivehealthcare.ahrq.gov/ehc/products/564/2323/gout-clinician-170131.pdf. Accessed July 26, 2017.

Clinical Bottom Line: Effectiveness of Treatments for Acute Gout Attack

StrategyNumber of studiesNumber of patientsFindingSOE

Colchicine

2 RCTs

229

Reduces pain compared with placebo

● ● ●

1 RCT

184

A lower dose of colchicine is as effective as a higher dose but has fewer adverse effects

● ● ○

NSAIDs*

1 RCT and observational data

30 (in RCT)

Reduce pain

● ● ●

16 RCTs

1,280

No differences among NSAIDs in effectiveness

● ● ○

Corticosteroids

4 RCTs

297

Reduce pain as much as NSAIDs

● ● ●

Animal-derived adrenocorticotropic hormone (not commonly used in clinical practice)

2 RCTs

107

Reduces pain as much as NSAIDs

● ● ○


Strength of evidence scale

High: ● ● ● There are consistent results from good-quality studies. Further research is highly unlikely to change the conclusions.

Moderate: ● ● ○ Findings are supported, but further research could change the conclusions.

Low: ● ○ ○ There are very few studies, or existing studies are flawed.

Insufficient: ○ ○ ○ Research is either unavailable or does not permit estimation of a treatment effect.


NSAIDs = nonsteroidal anti-inflammatory drugs; RCT = randomized controlled trial; SOE = strength of evidence.

*—The known anti-inflammatory action of these agents was considered when assessing SOE.

Adapted from the Agency for Healthcare Research and Quality, Effective Health Care Program. Diagnosis and management of gout: current state of the evidence. Clinician summary. Rockville, Md.: Agency for Healthcare Research and Quality; January 2017. https://www.effectivehealthcare.ahrq.gov/ehc/products/564/2323/gout-clinician-170131.pdf. Accessed July 26, 2017.

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Clinical Bottom Line: Effectiveness of Strategies for Managing Hyperuricemia in Patients with Gout

StrategyNumber of studiesNumber of patientsFindingSOE

Management of hyperuricemia

Urate-lowering therapy vs. placebo

4 RCTs

1,378

Reduces

Address correspondence to Matthew R. Noss, DO, MSEd, at matthew.r.noss.mil@mail.mil. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

show all references

1. Agency for Healthcare Research and Quality, Effective Healthcare Program. Diagnosis and management of gout: current state of the evidence. Clinical summary. Rockville, Md.: Agency for Healthcare Research and Quality; January 2017. https://www.effectivehealthcare.ahrq.gov/ehc/products/564/2323/gout-clinician-170131.pdf. Accessed July 26, 2017....

2. Qaseem A, McLean RM, Starkey M, Forciea MA. Diagnosis of acute gout: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166(1):52–57.

3. Qaseem A, Harris RP, Forciea MA. Management of acute and recurrent gout: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166(1):58–68.

4. Khanna D, Khanna PP, Fitzgerald JD, et al. 2012 American College of Rheumatology guidelines for management of gout. Part 2: therapy and antiinflammatory prophylaxis of acute gouty arthritis. Arthritis Care Res (Hoboken). 2012;64(10):1447–1461.

5. Khanna D, Fitzgerald JD, Khanna PP, et al. 2012 American College of Rheumatology guidelines for management of gout. Part 1: systematic nonpharmacologic and pharmacologic therapeutic approaches to hyperuricemia. Arthritis Care Res (Hoboken). 2012;64(10):1431–1446.

The Agency for Healthcare Research and Quality (AHRQ) conducts the Effective Health Care Program as part of its mission to produce evidence to improve health care and to make sure the evidence is understood and used. A key clinical question based on the AHRQ Effective Health Care Program systematic review of the literature is presented, followed by an evidence-based answer based on the review. AHRQ's summary is accompanied by an interpretation by an AFP author that will help guide clinicians in making treatment decisions. For the full review, clinician summary, and consumer summary, go to https://www.effectivehealthcare.ahrq.gov/ehc/index.cfm/search-for-guides-reviews-and-reports/?pageAction=displayProduct&productID=2323.

This series is coordinated by Kenny Lin, MD, MPH, Associate Deputy Editor for AFP Online.

A collection of Implementing AHRQ Effective Health Care Reviews published in AFP is available at https://www.aafp.org/afp/ahrq.

 

 

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