What are the core recommendations for gout management in first line and specialist care? Systematic review of clinical practice guidelines

Brooke Conley; Samantha Bunzli; Jonathan Bullen; Penny O'Brien; Jennifer Persaud; Tilini Gunatillake; Michelle M Dowsey; Peter F Choong; Mandana Nikpour; Rebecca Grainger; Ivan Lin

doi:10.1186/s41927-023-00335-w

What are the core recommendations for gout management in first line and specialist care? Systematic review of clinical practice guidelines

BMC Rheumatol. 2023 Jun 15;7(1):15. doi: 10.1186/s41927-023-00335-w.

Authors

Brooke Conley^{1

2}, Samantha Bunzli^{3

4

5}, Jonathan Bullen⁶, Penny O'Brien⁷, Jennifer Persaud^{8

9}, Tilini Gunatillake⁷, Michelle M Dowsey⁷, Peter F Choong⁷, Mandana Nikpour¹⁰, Rebecca Grainger^{11

12}, Ivan Lin^{13

14}

Affiliations

¹ Department of Surgery, The University of Melbourne, St Vincent's Hospital Melbourne, Level 2, Clinical Sciences Building, 29 Regent St, Fitzroy, VIC, 3065, Australia. bccon@student.unimelb.edu.au.
² Department of Physiotherapy, The University of Melbourne, Melbourne, VIC, Australia. bccon@student.unimelb.edu.au.
³ Department of Physiotherapy, The University of Melbourne, Melbourne, VIC, Australia.
⁴ School of Health Sciences and Social Work, Griffith University, Brisbane, QLD, Australia.
⁵ Physiotherapy Department, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.
⁶ EnAble Institute, Curtin University, Perth, WA, Australia.
⁷ Department of Surgery, The University of Melbourne, St Vincent's Hospital Melbourne, Level 2, Clinical Sciences Building, 29 Regent St, Fitzroy, VIC, 3065, Australia.
⁸ Arthritis and Osteoporosis Western Australia, Perth, WA, Australia.
⁹ Physiotherapy Department, Sir Charles Gairdner Hospital, Nedlands, WA, Australia.
¹⁰ Departments of Medicine and Rheumatology, The University of Melbourne at St. Vincent's Hospital, Melbourne, VIC, Australia.
¹¹ Department of Medicine, University of Otago Wellington, Wellington, New Zealand.
¹² Te Whatu Ora Health New Zealand - Capital Coast and Hutt Valley, Wellington, New Zealand.
¹³ The University of Western Australia, Western Australian Centre for Rural Health, Geraldton, WA, Australia.
¹⁴ Geraldton Regional Aboriginal Medical Service, Geraldton, WA, Australia.

Abstract

Background: Gout is the most common inflammatory arthritis, increasing in prevalence and burden. Of the rheumatic diseases, gout is the best-understood and potentially most manageable condition. However, it frequently remains untreated or poorly managed. The purpose of this systematic review is to identify Clinical Practice Guidelines (CPG) regarding gout management, evaluate their quality, and to provide a synthesis of consistent recommendations in the high-quality CPGs.

Methods: Gout management CPGs were eligible for inclusion if they were (1) written in English and published between January 2015-February 2022; focused on adults aged ≥ 18 years of age; and met the criteria of a CPG as defined by the Institute of Medicine; and (2) were rated as high quality on the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. Gout CPGs were excluded if they required additional payment to access; only addressed recommendations for the system/organisation of care and did not include interventional management recommendations; and/or included other arthritic conditions. OvidSP MEDLINE, Cochrane, CINAHL, Embase and Physiotherapy Evidence Database (PEDro) and four online guideline repositories were searched.

Results: Six CPGs were appraised as high quality and included in the synthesis. Clinical practice guidelines consistently recommended education, commencement of non-steroidal anti-inflammatories, colchicine or corticosteroids (unless contraindicated), and assessment of cardiovascular risk factors, renal function, and co-morbid conditions for acute gout management. Consistent recommendations for chronic gout management were urate lowering therapy (ULT) and continued prophylaxis recommended based on individual patient characteristics. Clinical practice guideline recommendations were inconsistent on when to initiate ULT and length of ULT, vitamin C intake, and use of pegloticase, fenofibrate and losartan.

Conclusion: Management of acute gout was consistent across CPGs. Management of chronic gout was mostly consistent although there were inconsistent recommendations regarding ULT and other pharmacological therapies. This synthesis provides clear guidance that can assist health professionals to provide standardised, evidence-based gout care.

Trial registration: The protocol for this review was registered with Open Science Framework (DOI https://doi.org/10.17605/OSF.IO/UB3Y7 ).

Keywords: Evidence-based Medicine.; Evidence-based care; Gout; Practice guidelines.