SAT0532 Updated Eular Evidence-Based Recommendations for the Diagnosis of Gout

Abstract

Background Gout has become the most common inflammatory arthritis but is still frequently misdiagnosed. New data on imaging and clinical diagnosis have become available since publication of the first EULAR recommendations for the diagnosis of gout in 2006. This has prompted a systematic review and update of the 2006 recommendations. Objectives To develop updated evidence-based recommendations for the diagnosis of gout Methods The 2014 EULAR task force comprised 15 rheumatologists, 1 radiologist, 2 GPs, 2 patients and 2 experts in methodology from 12 European countries. The expert group first voted to determine whether each of the 2006 recommendations for diagnosis should be retained, modified or deleted. MEDLINE, EMBASE and Cochrane Library reports were searched systematically to obtain research evidence from 2005 to 2013 on all aspects of the diagnosis of gout. Internal and external validity of the articles was assessed. The quality of evidence was categorised according to GRADE. The task force was presented with a synopsis of this literature review and generated a first draft of key recommendations after a two-day meeting. Final recommendations were agreed using a Delphi consensus approach. The level of agreement to each recommendation was assessed using EULAR numeral rating scales. Results A search for crystals in synovial fluid (SF) or tophus aspirates was recommended in every person with suspected gout, because demonstration of monosodium urate (MSU) crystals allows a definitive diagnosis of gout. SF should also be examined for crystals in any arthritis of unknown aetiology. There was consensus that a number of suggestive clinical features supported a clinical diagnosis of gout. These are: mono articular involvement of a foot or ankle joint (especially the first MTP); previous episodes of similar acute arthritis; rapid onset of severe pain and swelling (at its worst in <24 h); erythema; male gender; and associated cardiovascular diseases and hyperuricaemia. When crystal identification is not possible, it was recommended that any atypical presentation should be investigated by imaging, in particular with ultrasound to seek features suggestive of urate deposits (double contour sign and tophi). There was consensus a that a diagnosis of gout should not be based on the presence of hyperuricaemia alone. There was also a strong recommendation that all persons with gout should be systematically assessed for the presence of associated co-morbidities and risk factors for cardiovascular disease, as well as for risk factors for chronic hyperuricaemia. Conclusions Eight updated, evidence-based, expert consensus recommendations for the diagnosis of gout are proposed. Disclosure of Interest P. Richette Speakers bureau: Ménarini, Ipsen, Savient, Novartis, Astra-ZenecaM, E. Pascual Speakers bureau: Menarini, Savient, Novartis, Astra Zaneca, M. Doherty Speakers bureau: Menarini, Ardea and Novartis, V. Barskova: None declared, F. Becce: None declared, M. Coyfish: None declared, H. Janssens: None declared, T. Jansen ...

Molecular mechanisms of pain in crystal-induced arthritis

“…The EULAR guidelines recommend 1 mg of colchicine within 12 h of flare onset followed by 0.5 mg 1 h later. A dosage of 0.5e1 mg is, instead, recommended for prophylactic treatment [62]. As opposed to gout, it is less evident in CPP-related arthritis if low doses of colchicine or nonsteroidal anti-inflammatory drugs (NSAIDs) are as effective as prophylactic treatment.…”

Why are rheumatologists still reluctant to perform joint-fluid analysis?

“…The reluctance of rheumatologists to perform joint-fluid analysis is difficult to understand, since this test is still the reference standard for diagnosing gout and calcium pyrophosphate deposition disease [3][4][5][6][7][8]. In addition, these are the most common inflammatory joint diseases in the general population and may well be the most amenable to a cure.…”

“…In addition, these are the most common inflammatory joint diseases in the general population and may well be the most amenable to a cure. The EULAR recommendations are particularly emphatic, since both the 2006 version [5] and the updated version issued in 2014 [8] indicate that joint-fluid analysis for monosodium urate crystals should be performed not only when gout is suspected, but also when the joint fluid exhibits inflammatory properties and no diagnosis has been established. The reluctance of rheumatologists to use a highly specialized tool in order to definitively confirm or infirm a diagnosis considerably damages the confidence of primary-care physicians in the ability of rheumatologists to efficiently carry out their role as specialists, most notably in the field of gout.…”

L’analyse du liquide synovial en rhumatologie. Pourquoi est-elle encore si peu pratiquée par les rhumatologues ?

“…La réticence des rhumatologues à exécuter l'examen du LS est difficile à comprendre, vu que cette analyse représente encore aujourd'hui le gold standard pour le diagnostic de la goutte et des arthropathies à cristaux de pyrophosphate de calcium (CPP) [3][4][5][6][7][8]. Si l'on tient compte qu'il s'agit des arthropathies inflammatoires les plus fréquentes dans la population et en plus, probablement, les plus facilement curables, cette réticence est bien difficile à expliquer.…”

“…Si l'on tient compte qu'il s'agit des arthropathies inflammatoires les plus fréquentes dans la population et en plus, probablement, les plus facilement curables, cette réticence est bien difficile à expliquer. Les recommandations EULAR osent même plus, en suggérant, aussi bien dans leur édition de 2006 [5] que dans celles proposées très récemment [8], qu'une recherche de routine des cristaux d'urate dans le LS est recommandée non seulement quand il y a un soupç on de goutte, mais même en présence d'un LS inflammatoire n'ayant pas encore fait l'objet d'un diagnostic. La réticence du rhumatologue à utiliser un moyen très spécialisé pour lever définitivement un doute diagnostique, diminue considérable-ment la considération des médecins de famille quant à l'efficacité de son rôle de spécialiste surtout en ce qui concerne la goutte.…”