British Society for Rheumatology and British Health Professionals in Rheumatology Guideline for the Management of Gout

Abstract

Gout is a common disease both in primary care and hospital practice [1]. Although drug therapy for gout has become a paradigm for the effective management and prevention of an acute and potentially chronic rheumatic disease, many of the recommendations for treatment are based on expert consensus rather than research evidence and audits of practice suggest that treatment is very variable. Evidence-based guidelines are needed at the present time: The aim has been to develop concise, patient-focussed, evidence-based recommendations for the management of gout for doctors and allied heath professionals in primary care and hospital practice in the UK, which will also provide a useful resource for patients. to provide a framework for improving standards of care. to assess the potential of new therapies such as Coxibs [2], urate oxidases [3] and novel xanthine oxidase inhibitors [4] currently in clinical development; to provide recommendations for alcohol consumption, diet and lifestyle modification in response to frequently asked questions by patients (www.ukgoutsociety.org) in the light of recent epidemiological studies linking gout with alcohol consumption [5], dietary protein intake [6] and features of the metabolic syndrome, which are assuming epidemic proportions [7]; to define recommendations for treating secondary atypical gout, and small subgroups of patients with severe recurrent gout associated with renal insufficiency, organ transplantation, allopurinol hypersensitivity or primary purine overproduction. Recommendations for the diagnosis and investigation of gout [8] are not addressed. This is a short summary of the guideline. The full guideline can be accessed at Rheumatology Online (www.rheumatology.oxfordjournals.org). The management pathways proposed are summarized in the accompanying flowchart. The strength recommendations, based on levels of evidence, are graded A–C [9], and the recommendations are divided into three sections: Affected joints should be rested (C) and analgesic, anti-inflammatory drug therapy commenced immediately, and continued for 1–2 weeks (A). Fast-acting oral NSAIDs at maximum doses are the drugs of choice when there are no contraindications (A). In patients with increased risk of peptic ulcers, bleeds or perforations, co-prescription of gastro-protective agents should follow standard guidelines for the use of NSAIDs and Coxibs (A). Colchicine can be an effective alternative but is slower to work than NSAIDs (A). In order to diminish the risks of adverse effects (especially diarrhoea) it should be used in doses of 500 μg bd–qds (C). Allopurinol should not be commenced during an acute attack (B) but in patients already established on allopurinol, it should be continued and the acute attack should be treated conventionally (A). Opiate analgesics can be used as adjuncts (C). Intra-articular corticosteroids are highly effective in acute gouty monoarthritis (B) and i.a, oral, i.m or i.v corticosteroids can be effective in patients unable to tolerate NSAIDs, and in patients refractory to other treatments (A). If diuretc drugs are being used to treat hypertension, an alternative antihypertensive agent should be considered, but in patients with heart failure, diuretic therapy should not be discontinued (C). In overweight patients dietary modification to achieve ideal body weight should be attempted (B), but ‘crash dieting’ (B) and high protein/low carbohydrate (Atkins-type) diets (C) should be avoided. Inclusion of skimmed milk and/or low fat yoghurt, soy beans and vegetable sources of protein and cherries, in the diet should be encouraged (B). Intake of high purine foods and red meat should be restricted (B). Liver, kidneys, shellfish and yeast extracts should be avoided (B), and overall protein intake should be restricted (C). Patients with gout and a history of urolithiasis should be encouraged to drink >2 l of water daily (B) and avoid dehydration (C). Alkalinization of the urine with potassium citrate (60 mEq/day) should be considered in recurrent stone formers (B). Alcohol consumption should be restricted to <21 units/week (men) and 14 units/week (women) (B), and patients should be encouraged to have at least 3 alcohol-free days per week (C). Beer, stout, port and similar fortified wines are best avoided (C). Patients should be discouraged from undertaking trials of herbal remedies without medical consultation (C). Affected joints should be elevated and exposed in a cool environment (C). ‘Bed cages’ (C) and ice packs (B) can be effective adjuncts to therapy. Trauma to joints (B) and intense physical exercise (B) should be avoided but moderate physical exercise encouraged (B). The full guideline also contains recommendations for the use of uricolytic agents and combined therapy with allopurinol and uricosuric drugs; as well as for the management of special groups of patients with chronic gout. The plasma urate should be maintained below, 300 μmol/l (C). In uncomplicated gout uric