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Management of Gout: A Systematic Review in Support of an American College of Physicians Clinical Practice Guideline.
Ann Intern Med 2017; 166(1):37-51AIM

Abstract

Background

Gout is a common type of inflammatory arthritis in patients seen by primary care physicians.

Purpose

To review evidence about treatment of acute gout attacks, management of hyperuricemia to prevent attacks, and discontinuation of medications for chronic gout in adults.

Data Sources

Multiple electronic databases from January 2010 to March 2016, reference mining, and pharmaceutical manufacturers.

Study Selection

Studies of drugs approved by the U.S. Food and Drug Administration and commonly prescribed by primary care physicians, randomized trials for effectiveness, and trials and observational studies for adverse events.

Data Extraction

Data extraction was performed by one reviewer and checked by a second reviewer. Study quality was assessed by 2 independent reviewers. Strength-of-evidence assessment was done by group discussion.

Data Synthesis

High-strength evidence from 28 trials (only 3 of which were placebo-controlled) shows that colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs), and corticosteroids reduce pain in patients with acute gout. Moderate-strength evidence suggests that low-dose colchicine is as effective as high-dose colchicine and causes fewer gastrointestinal adverse events. Moderate-strength evidence suggests that urate-lowering therapy (allopurinol or febuxostat) reduces long-term risk for acute gout attacks after 1 year or more. High-strength evidence shows that prophylaxis with daily colchicine or NSAIDs reduces the risk for acute gout attacks by at least half in patients starting urate-lowering therapy, and moderate-strength evidence indicates that duration of prophylaxis should be longer than 8 weeks. Although lower urate levels reduce risk for recurrent acute attacks, treatment to a specific target level has not been tested.

Limitation

Few studies of acute gout treatments, no placebo-controlled trials of management of hyperuricemia lasting longer than 6 months, and few studies in primary care populations.

Conclusion

Colchicine, NSAIDs, and corticosteroids relieve pain in adults with acute gout. Urate-lowering therapy decreases serum urate levels and reduces risk for acute gout attacks.

Primary Funding Source

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

Authors+Show Affiliations

From RAND Corporation, Santa Monica, and Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California.From RAND Corporation, Santa Monica, and Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California.From RAND Corporation, Santa Monica, and Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California.From RAND Corporation, Santa Monica, and Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California.From RAND Corporation, Santa Monica, and Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California.From RAND Corporation, Santa Monica, and Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California.From RAND Corporation, Santa Monica, and Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California.From RAND Corporation, Santa Monica, and Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California.From RAND Corporation, Santa Monica, and Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California.

Pub Type(s)

Journal Article
Review
Systematic Review

Language

eng

PubMed ID

27802478

Citation

Shekelle, Paul G., et al. "Management of Gout: a Systematic Review in Support of an American College of Physicians Clinical Practice Guideline." Annals of Internal Medicine, vol. 166, no. 1, 2017, pp. 37-51.
Shekelle PG, Newberry SJ, FitzGerald JD, et al. Management of Gout: A Systematic Review in Support of an American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2017;166(1):37-51.
Shekelle, P. G., Newberry, S. J., FitzGerald, J. D., Motala, A., O'Hanlon, C. E., Tariq, A., ... Shanman, R. (2017). Management of Gout: A Systematic Review in Support of an American College of Physicians Clinical Practice Guideline. Annals of Internal Medicine, 166(1), pp. 37-51. doi:10.7326/M16-0461.
Shekelle PG, et al. Management of Gout: a Systematic Review in Support of an American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2017 Jan 3;166(1):37-51. PubMed PMID: 27802478.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Management of Gout: A Systematic Review in Support of an American College of Physicians Clinical Practice Guideline. AU - Shekelle,Paul G, AU - Newberry,Sydne J, AU - FitzGerald,John D, AU - Motala,Aneesa, AU - O'Hanlon,Claire E, AU - Tariq,Abdul, AU - Okunogbe,Adeyemi, AU - Han,Dan, AU - Shanman,Roberta, Y1 - 2016/11/01/ PY - 2016/11/2/pubmed PY - 2017/5/13/medline PY - 2016/11/2/entrez SP - 37 EP - 51 JF - Annals of internal medicine JO - Ann. Intern. Med. VL - 166 IS - 1 N2 - Background: Gout is a common type of inflammatory arthritis in patients seen by primary care physicians. Purpose: To review evidence about treatment of acute gout attacks, management of hyperuricemia to prevent attacks, and discontinuation of medications for chronic gout in adults. Data Sources: Multiple electronic databases from January 2010 to March 2016, reference mining, and pharmaceutical manufacturers. Study Selection: Studies of drugs approved by the U.S. Food and Drug Administration and commonly prescribed by primary care physicians, randomized trials for effectiveness, and trials and observational studies for adverse events. Data Extraction: Data extraction was performed by one reviewer and checked by a second reviewer. Study quality was assessed by 2 independent reviewers. Strength-of-evidence assessment was done by group discussion. Data Synthesis: High-strength evidence from 28 trials (only 3 of which were placebo-controlled) shows that colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs), and corticosteroids reduce pain in patients with acute gout. Moderate-strength evidence suggests that low-dose colchicine is as effective as high-dose colchicine and causes fewer gastrointestinal adverse events. Moderate-strength evidence suggests that urate-lowering therapy (allopurinol or febuxostat) reduces long-term risk for acute gout attacks after 1 year or more. High-strength evidence shows that prophylaxis with daily colchicine or NSAIDs reduces the risk for acute gout attacks by at least half in patients starting urate-lowering therapy, and moderate-strength evidence indicates that duration of prophylaxis should be longer than 8 weeks. Although lower urate levels reduce risk for recurrent acute attacks, treatment to a specific target level has not been tested. Limitation: Few studies of acute gout treatments, no placebo-controlled trials of management of hyperuricemia lasting longer than 6 months, and few studies in primary care populations. Conclusion: Colchicine, NSAIDs, and corticosteroids relieve pain in adults with acute gout. Urate-lowering therapy decreases serum urate levels and reduces risk for acute gout attacks. Primary Funding Source: Agency for Healthcare Research and Quality. (Protocol registration: http://effectivehealth-care.ahrq.gov/ehc/products/564/1992/Gout-managment-protocol-141103.pdf). SN - 1539-3704 UR - https://www.unboundmedicine.com/medline/citation/27802478/Management_of_Gout:_A_Systematic_Review_in_Support_of_an_American_College_of_Physicians_Clinical_Practice_Guideline_ L2 - https://www.annals.org/article.aspx?doi=10.7326/M16-0461 DB - PRIME DP - Unbound Medicine ER -