AAFP Endorses ACP Guideline on Managing Acute, Recurrent Gout

June 16, 2017 02:45 pm Chris Crawford

Gout is one of the most common forms of inflammatory arthritis and is caused by accumulation of excess urate crystals (monosodium urate) in synovial fluid, cartilage, bones, tendons, bursas and other sites.

[Man in pain from gout in foot]

About 4 percent of adults in the United States older than age 20 report being told by a health care professional at some point that they had gout, according to an analysis of data(onlinelibrary.wiley.com) from the National Health and Nutrition Examination Survey 2007-2008.

Gout attacks cause joint swelling and pain, known as acute gouty arthritis. For some patients, the frequency and duration of acute attacks increase over time and lead to chronic gout, which may be associated with deposits of uric acid crystals, or tophi.

Risk factors for gout include overweight and obesity; hypertension; alcohol intake; diuretic use; a diet rich in meat, seafood, and high-fructose food or drinks; and poor kidney function.

Managing gout entails both pharmacologic and nonpharmacologic approaches. Pharmacologic therapies focus on urate-lowering strategies and use of anti-inflammatory drugs. Nonpharmacologic management focuses on dietary and lifestyle changes, such as weight loss and exercise.

Story highlights
  • The AAFP has endorsed the American College of Physicians' (ACP's) guideline on managing acute and recurrent gout.
  • The evidence review for this guideline evaluated nonpharmacologic and pharmacologic interventions, as well as combinations of the two.
  • The ACP guideline offered four specific recommendations clinicians should consider when treating patients who have acute or recurrent gout.

To help clinicians sort through these management options, the American College of Physicians (ACP) published a guideline earlier this year in Annals of Internal Medicine called "Management of Acute and Recurrent Gout,"(annals.org) which the AAFP recently endorsed.

Systematic Evidence Review

The systematic evidence review for this guideline was conducted by the Agency for Healthcare Research and Quality's Southern California Evidence-based Practice Center--RAND Corporation in Santa Monica. Reviewers included relevant studies published from January 2010 to March 2016, combining data using meta-analysis when possible. The study population included all adults who were diagnosed with gout.

The review evaluated nonpharmacologic interventions, such as dietary interventions, dietary supplements and alternative treatments; pharmacologic interventions, such as anti-inflammatory drugs, colchicine, urate-lowering therapies and combination drug therapies; and combinations of drug and dietary or alternative treatments.

Evaluated outcomes included the intermediate outcome of serum urate levels; health outcomes such as recurrence, pain, joint swelling and tenderness, activities of daily living, patient global assessment, and development of tophi; and treatment harms.

Key Recommendations

The ACP offered four specific recommendations clinicians should consider when treating patients who have acute or recurrent gout.

First, the ACP guidelines group recommended clinicians choose corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs) or colchicine to treat patients with acute gout; this was a strong recommendation based on high-quality evidence.

"Corticosteroids should be considered as first-line therapy in patients without contraindications because they are generally safer and a low-cost treatment option," the guideline said. "Steroids are among the most effective anti-inflammatory medications available and have been shown to be as effective as NSAIDs for managing gout, with fewer adverse effects. Prednisolone at a dose of 35 mg for five days has been successfully used to treat acute gout."

Second, the ACP strongly recommended clinicians use low-dose colchicine when using colchicine to treat acute gout.

"Moderate-quality evidence suggests that lower doses of colchicine (1.2 mg followed by 0.6 mg one hour later) are as effective as higher doses (1.2 mg followed by 0.6 mg/h for six hours) at reducing pain and are associated with fewer gastrointestinal adverse effects," said the guideline.

The group also noted that a generic formulation of colchicine is now available for gout treatment, but it is still more expensive than NSAIDs or corticosteroids.

Third, the ACP recommended against initiating long-term urate-lowering therapy in most patients after a first gout attack or in patients who have infrequent attacks. This also was a strong recommendation backed by moderate-quality evidence.

"Although evidence supports the benefits of using urate-lowering therapy for shorter durations to reduce gout flares, the benefits of long-term use (12 months or longer) in patients with a single or infrequent gout attacks (less than two per year) have not been studied," the guideline noted. "Urate-lowering therapy is not necessary in cases where the patient would have no or infrequent recurrences."

Finally, the ACP recommended clinicians discuss benefits, harms, costs and individual preferences with patients before starting urate-lowering therapy -- including concomitant prophylaxis -- in patients with recurrent gout attacks; this was a strong recommendation based on moderate-quality evidence.

The guidelines group noted that after acute gout has resolved, some patients have recurrent episodes that may be frequent or infrequent. Whereas some have no or few attacks over a period of years, others may experience more frequent attacks.

"Although evidence is inadequate to predict which patients will have more problems, those with higher serum urate levels (especially greater than 476 µmol/L [greater than 8 mg/dL]) are at greater risk," the guideline said. "Some may prefer to initiate long-term therapy to prevent future gout attacks, whereas others may prefer to treat flares if they occur. Patients who decide not to initiate urate-lowering therapy can revisit their decision if they have multiple recurrences of acute gout."

Notes From the AAFP

Jennifer Frost, M.D., medical director for the AAFP Health of the Public and Science Division, told AAFP News that gout is a condition frequently seen in family medicine, so evidence-based guidance with a primary care focus is useful.

"The ACP's methodology for reviewing the evidence for their guidelines is very similar to the AAFP's, so we trust their interpretation of the evidence," she said.

Frost said the AAFP's guideline endorsement page shows three key recommendations (instead of the ACP's four) because it combined the ACP's second recommendation on using low-dose colchicine when using the drug with the first recommendation.

"Our summary page is meant to reflect the key points, but that doesn't mean we don't support all of the recommendations," she explained.

On the topic of dietary and lifestyle management of gout, which also is discussed in the guideline, Frost said the AAFP agreed with the ACP that there isn't sufficient evidence to determine the efficacy of dietary therapy. However, she added, this doesn't mean dietary changes shouldn't be encouraged.

"The foods that increase the risk of gout are also associated with other negative health outcomes, such as heart disease," Frost said. "I would still make dietary and lifestyle recommendations, as they affect an individual's overall health. This includes reducing alcohol intake, red meat consumption, and food and drinks with high-fructose corn syrup, and increasing vegetables and whole grains."

More From AAFP
American Family Physician: Diagnosis, Treatment, and Prevention of Gout
(12/15/2014)

Familydoctor.org: Gout(familydoctor.org)