Guidelines from the American College of Physicians (ACP) on the management of acute and recurring gout advocate that physicians focus on alleviating symptoms rather than managing serum urate levels, a strategy that drew immediate criticism from many in the rheumatology community.1
“Evidence was insufficient to conclude whether the benefits of escalating urate-lowering therapy to reach a serum urate target (‘treat to target’) outweigh the harms associated with repeated monitoring and medication escalation,” wrote ACP Vice President for Clinical Policy Amir Qaseem, MD, PhD, MHA and colleagues on behalf of the ACP’s Clinical Guidelines Committee.
“There is no evidence from an experimental study that examined the health outcomes of treating to one serum urate level versus another, nor is there a trial comparing a strategy of basing treatment on attaining a specific urate level versus basing treatment on reduction in symptoms (such as gout flares).”
The authors noted that comparative effectiveness studies to evaluate the incremental benefits and harms of a treat-to-target strategy over a treat-to-avoid-symptoms strategy should be a priority.
In an interview with Clinical Pain Advisor, Irene Blanco, MD, MS, attending rheumatologist in the Department of Medicine at Montefiore Health System, called recommendations by the ACP on urate lowering therapies (ULT) puzzling.
“I would agree that if a patient has normal kidneys, and only 1 to 2 attacks every year with a fairly low serum uric acid level, s/he may not really need ULT, as opposed to risk factor management for their gout treatment. However, this is only a subset of the patients with gout.”
Dr Blanco noted that dual-energy computed tomography studies have demonstrated that patients with gout typically have a higher tophaceous burden than can be perceived on physical exam.
“This will lead to joint destruction and deformity, and not to mention that without ULT we will likely not be as aggressive as we should in patients with kidney disease.”
High serum uric acid levels have been implicated in the development of chronic kidney disease, an issue not addressed in the guidelines.2
The guidelines also recommend that clinicians choose corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), or colchicine to treat patients with acute gout; that low-dose colchicine be used in preference to higher doses; and that clinicians discuss benefits, harms, costs, and individual preferences with patients, prior to initiating urate–lowering therapy.
Summary and Clinical Applicability
“I think the stance that we are taking as rheumatologists is that so long as the patient had tophi, frequent attacks, and/or kidney disease, we will be aggressive with our ULT,” commented Dr Blanco.
“For the acute setting, NSAIDS, steroids, and low dose colchicine are fine as noted in the paper. However, to prevent worsening tophi and joint destruction we do recommend a ‘treat to target’ approach.”
Dr Barry reports grants and personal fees from the Informed Medical Decisions Foundation and Healthwise outside the submitted work. Dr Boyd reports royalties fromUpToDate outside the submitted work. Dr Manaker was recused from voting on this guideline because of an active indirect financial conflict. Dr McLean was recused from voting on this guideline because of an inactive direct financial conflict.
The other authors disclosed no conflicts of interest.
- Qaseem A, Harris RP, Forciea MA, for the Clinical Guidelines Committee of the American College of Physicians. Management of Acute and Recurrent Gout: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. November 2016. doi:10.7326/M16-0570.
- Mallat SG, Al Kattar S, Tanios BY, Jurjus A. Hyperuricemia, Hypertension, and Chronic Kidney Disease: an Emerging Association. Curr Hypertens Rep. 2016;18(10):74. doi:10.1007/s11906-016-0684-z.