Gout Guidelines Give Good Grades

Corticosteroids First.

The ACP made a strong recommendation that physicians use corticosteroids, NSAIDs, or colchicine to treat patients who have acute gout and suggested they consider using corticosteroids first in patients without contraindications. High-quality indirect evidence suggested that systemic corticosteroids reduce pain in patients with acute gout. Corticosteroids have a proven anti-inflammatory effect and were shown to be equivalent to NSAIDs for various outcomes.

Colchicine Considerations.

Another strong recommendation called for using colchicine in low doses when it is used for acute gout. Lower doses are as effective as higher doses at reducing pain and have fewer adverse GI effects (eg, diarrhea), the evidence showed. “Although a generic formulation of colchicine is now available, it is more expensive than NSAIDs or corticosteroids,” the ACP noted. “This is an important consideration for patients, especially as prescription drug prices continue to increase.”

No to Hasty Uric Acid-Lowering Therapy.

The ACP made a strong recommendation against initiating long-term urate-lowering therapy in most patients after a first gout attack or in patients who have infrequent attacks. The evidence does support the benefits of using uric acid-lowering therapy for shorter duration to reduce gout flares.

Treatment for Recurrent Gout.

The ACP strongly recommended that clinicians discuss benefits, harms, costs, and individual preferences with patients before initiating urate-lowering therapy, including concomitant prophylaxis, in patients with recurrent gout attacks. If and when patients do have multiple attacks, those who opt not to initiate uric acid-lowering therapy can then revisit their decision.

Triple D: Deficient Dietary Determinations.

Evidence was insufficient to determine the effectiveness of dietary changes on symptomatic outcomes. Low-quality evidence showed that gout-specific counseling about dietary changes-reducing red meat, shellfish, and yeast-rich food intake and increasing low-fat dairy, vegetables, and cherries-is not more effective than general dietary counseling-promoting weight loss and reducing alcohol intake-for reducing serum urate levels in patients who have gout.

Synovial Fluid Analysis for Diagnosis.

The ACP recommended (weak recommendation) that physicians use synovial fluid analysis when clinical judgment indicates that diagnostic testing is necessary in patients with possible acute gout. Joint aspiration with synovial fluid analysis for monosodium urate (MSU) is the reference standard for diagnosis of acute gout, but most patients are seen initially in the primary care or emergency medicine setting, where synovial fluid analysis is rarely performed.

Good Old-fashioned Clinical Judgment.

Several clinical algorithms based on clinical signs and symptoms have good specificity and sensitivity for gout diagnosis compared with assessment of synovial fluid MSU crystals, moderate-quality evidence showed. Many algorithms had a higher sensitivity in patients with a longer history of flares than in those with more recent-onset symptoms. The ACP noted, “In certain situations, physicians should use clinical judgment so patients can begin treatment if gout is suspected.”

Consequences of Misdiagnosis.

Misdiagnosis or delayed diagnosis of gout can result in unnecessary surgery, hospitalization, delays in adequate treatment (eg, antibiotics for septic joints), and unnecessary prescribing of long-term treatment. The ACP concluded that an accurate clinical algorithm that could be used in primary care would be especially valuable.