Management of Gout: A Systematic Review in Support of an American College of Physicians Clinical Practice Guideline

Shekelle, Paul G; Newberry, Sydne J; Fitzgerald, John; Motala, Aneesa; O’Hanlon, Claire E; Tariq, Abdul; Okunogbe, Adeyemi; Han, Dawei; Shanman, Roberta

doi:10.7326/m16-0461

Cited by 92 publications

(55 citation statements)

References 128 publications

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“…In addition, those patients with a durable response to pegloticase (with serum urate level <6 mg/dl) have an enduring improvement in all relevant clinical outcomes 29,30 . The ACP Clinical Guidelines Committee decided not to consider the pegloticase clinical trial data because pegloticase was considered an agent unlikely to be prescribed by primary care physicians 44 . Nevertheless, the high level of evidence showing a clear clinical benefit of this highly potent urate-lowering agent should help confirm the therapeutic principle of the treat-to-target ULT approach, already universally adopted by rheumatology guidelines.…”

Section: Clinical Benefits Of Successful Ultmentioning

confidence: 99%

Discordant American College of Physicians and international rheumatology guidelines for gout management: consensus statement of the Gout, Hyperuricemia and Crystal-Associated Disease Network (G-CAN)

et al. 2017

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Gout is a common form of inflammatory arthritis for which highly effective treatments are available, yet the management of this disease is frequently suboptimal. Gout often presents as an acute 'flare' of painful inflammation that typically resolves within a week or two, but can be difficult to control in some instances, can negatively affect quality of life, can be costly to experience and treat, and can warrant hospital admission. If gout-associated hyperuricaemia is inadequately treated, gout flares often progress in frequency and severity, and a state of chronic, inflammatory arthritis can supervene, leading to continuous pain, decreased joint function, and permanent joint damage.Guidelines for the management of gout are intended to help physicians select the most effective course of treatment and to educate patients in order to ensure adherence. In November 2016, the American College of Physicians (ACP) published a clinical practice guideline for the management of acute and recurrent gout 1 . Despite evaluating similar evidence, the ACP clinical practice guideline differs substantially from all other gout management guidelines issued by major international rheumatology groups in the past 5 years, including the 2012 Abstract | In November 2016, the American College of Physicians (ACP) published a clinical practice guideline on the management of acute and recurrent gout. This guideline differs substantially from the latest guidelines generated by the American College of Rheumatology (ACR), European League Against Rheumatism (EULAR) and 3e (Evidence, Expertise, Exchange) Initiative, despite reviewing largely the same body of evidence. The Gout, Hyperuricemia and Crystal-Associated Disease Network (G-CAN) convened an expert panel to review the methodology and conclusions of these four sets of guidelines and examine possible reasons for discordance between them. The G-CAN position, presented here, is that the fundamental pathophysiological knowledge underlying gout care, and evidence from clinical experience and clinical trials, supports a treat-to-target approach for gout aimed at lowering serum urate levels to below the saturation threshold at which monosodium urate crystals form. This practice, which is truly evidence-based and promotes the steady reduction in tissue urate crystal deposits, is promoted by the ACR, EULAR and 3e Initiative recommendations. By contrast, the ACP does not provide a clear recommendation for urate-lowering therapy (ULT) for patients with frequent, recurrent flares or those with tophi, nor does it recommend monitoring serum urate levels of patients prescribed ULT. Results from emerging clinical trials that have gout symptoms as the primary end point are expected to resolve this debate for all clinicians in the near term future. NATURE REVIEWS | RHEUMATOLOGY VOLUME 13 | SEPTEMBER 2017 | 561 CONSENSUS STATEMENT © 2 0 1 7 M a c m i l l a n P u b l i s h e r s L i m i t e d , p a r t o f S p r i n g e r N a t u r e . A l l r i g h t s r e s e r v e d . UricaseAn enzyme that degrades ur...

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Section: Clinical Benefits Of Successful Ultmentioning

confidence: 99%

Discordant American College of Physicians and international rheumatology guidelines for gout management: consensus statement of the Gout, Hyperuricemia and Crystal-Associated Disease Network (G-CAN)

et al. 2017

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“…Those who survive SJS/TEN are often left with substantial sequelae of involved organs (e.g., corneal damage and renal insufficiency) [1,7]. The 2016 Agency for Healthcare Research and Quality review of the evidence on gout care has identified an important research gap about how to further minimize the rare but serious adverse events from ULT (e.g., by HLA typing for predisposition) in order to improve the benefit/risk profile of therapy and make more patients eligible for treatment [8]. As such, there is an unmet need to improve risk management and perception of allopurinol safety.…”

Section: Introductionmentioning

confidence: 99%

The cost-effectiveness of HLA-B*5801 screening to guide initial urate-lowering therapy for gout in the United States

Jutkowitz

Dubreuil

et al. 2017

Seminars in Arthritis and Rheumatism

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Objective Positive HLA-B*5801 carriers are at greater risk of experiencing rare but severe allopurinol hypersensitivity syndrome (AHS) (i.e., Stevens-Johnson Syndrome [SJS] and Toxic Epidermal Necrolysis [TEN]); however, HLA-B*5801 prevalence and AHS risk vary by race/ethnicity. We evaluated the cost-effectiveness of HLA-B*5801 testing according to race/ethnicity in the US. Methods We determined the cost-effectiveness of universal testing for HLA-B*5801 compared to no testing prior to the initiation of allopurinol per US major race/ethnicity groups. Using US specific data, SJS/TEN risks and HLA-B*5801 prevalences were modeled per race/ethnicity (i.e., 1/3846 and 0.7% among Caucasians and Hispanics; 1/735 and 3.8% among African Americans; 1/336 and 7.4% among Asians, respectively). Those who tested positive for HLA-B*5801 received febuxostat. Costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) were estimated over a lifetime. Results Compared to no testing, universal testing for HLA-B*5801 cost more and was more effective for all races/ethnicities. The ICERs varied substantially across racial/ethnic groups, following their HLA-B*5801 prevalences. HLA-B*5801 testing was cost-effective for African Americans (ICER $83,450) and Asians (ICER $64,190), but not for Caucasians or Hispanics (ICER $183,720), using accepted US willingness-to-pay threshold ($109,000/QALY). Results were robust in sensitivity analyses, except that reducing the risk of SJS/TEN by a half made testing not cost-effective for all races/ethnicities. Conclusion Testing for HLA-B*5801 prior to allopurinol initiation is cost-effective for Asians and African Americans, but not for Caucasians or Hispanics in the US. Reducing AHS risk by other predictive measures could make HLA-B*5801 testing not cost-effective even among Asians and Blacks.

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“…(2–5) We agree with the authors’ conclusions and support for the use of colchicine, NSAIDs, and glucocorticoids for gout flare management as having a high strength of evidence despite there being few placebo-controlled trials (none for glucocorticoids) because of “the known physiology of gout,” and “that symptoms arise from an inflammatory reaction to the deposition of urate crystals, which occurs when serum uric acid rises above its saturation point in blood”. (4) The authors also acknowledge evidence that urate-lowering therapy (ULT) reduces serum urate, which is a strong predictor of flares, and data from open-label extension studies of ULT trials support an association between lower serum urate levels and lower risk of gout flares. It is therefore puzzling that the strength of evidence for monitoring serum urate, a prerequisite to ensuring adequate ULT dosing, is judged to be low.…”

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confidence: 95%

To Treat or Not to Treat (to Target) in Gout

Neogi

Mikuls

2016

Ann Intern Med

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Management of Gout: A Systematic Review in Support of an American College of Physicians Clinical Practice Guideline

Abstract: Agency for Healthcare Research and Quality. (Protocol registration: http://effectivehealth-care.ahrq.gov/ehc/products/564/1992/Gout-managment-protocol-141103.pdf).

Cited by 92 publications

References 128 publications

Discordant American College of Physicians and international rheumatology guidelines for gout management: consensus statement of the Gout, Hyperuricemia and Crystal-Associated Disease Network (G-CAN)

Discordant American College of Physicians and international rheumatology guidelines for gout management: consensus statement of the Gout, Hyperuricemia and Crystal-Associated Disease Network (G-CAN)

The cost-effectiveness of HLA-B*5801 screening to guide initial urate-lowering therapy for gout in the United States

To Treat or Not to Treat (to Target) in Gout

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