Conservative measures including ice are safe for managing acute attacks. A recent population-based case–control study using the General Practice Research Database demonstrated that while the use of thiazide and loop diuretics was associated with the development of incident gout, the use of potassium-sparing diuretics was not [78]. Canakinumab is licensed for use in Europe by the European Medicines Agency (EMA) but not in the USA by the Food and Drug Administration (FDA) because of uncertainty about its risk/benefit ratio. Screening patients of Korean, Han Chinese and Thai descent for HLA-B*5801 before considering ULT with allopurinol has been recommended [35] because of the high frequency (6–12%) of this allele in these ethnic groups compared with <2% in Caucasian populations. Single gene disorders associated with urate overproduction, hyperuricaemia and accelerated purine synthesis de novo (such as glycogen storage diseases and Lesch–Nyhan syndrome) are very rare causes of primary gout. Gout Other Crystal Arthropathies, Ed. Sriranganathan MK, Vinik O, Falzon L et al. Published by: British Society for Rheumatology. Objectives: To audit and evaluate the management of gout in patients in a primary care setting against the current guidelines treat to target guidelines set by the British Society of Rheumatology (BSR)2. Diet and exercise should be discussed with all patients with gout, and a well-balanced diet low in fat and added sugars, and high in vegetables and fibre should be encouraged: sugar-sweetened soft drinks containing fructose should be avoided; excessive intake of alcoholic drinks and high purine foods should be avoided; and inclusion of skimmed milk and/or low fat yoghurt, soy beans and vegetable sources of protein, and cherries in the diet … Patients with gout are typically managed longitudinally by general practitioners (GPs),14 who are often underexposed to this literature. Part 1 of the guidelines focused on systematic nonpharmacologic measures (patient education, diet and lifestyle choices, identification and management of comorbidities) that impact hyperuricemia, and made recommendations on pharmacologic ULT in a range of case scenarios of patients with disease activity manifested by acute and chronic forms of gouty arthritis, including chronic tophaceous gouty arthropathy … Clinical experience indicates that sulfinpyrazone and probenecid have limited efficacy in patients with mild or moderate renal insufficiency (GFR < 60 ml/min) but benzbromarone has been shown to maintain uricosuric efficacy when the GFR is as low as 20 ml/min [152]. There is preliminary evidence that patient adherence to ULT and lowering of sUA to target levels can be achieved with better provision of information and a package of care based on guideline recommendations [33]. Vitamin C supplements (500–1500 mg daily) also have a weak uricosuric effect, A uricosuric agent can be used in combination with a xanthine oxidase inhibitor in patients who do not achieve a therapeutic serum urate target with optimal doses of monotherapy, Colchicine 500 mcg b.d. In this trial, greater pain reduction (−3.3 cm, 95% CI: −5.84 to −0.82 on 10 visual analogue scale) was observed with adjunctive use of ice packs without additional adverse events. 11. Pain from self-reported flares was marginally less in those receiving enriched, compared with unenriched, SMP (mean difference −1.03, 95% CI: −1.96 to −0.10), but enriched SMP was no better in reducing the mean number of acute attacks or the sUA. Vazquez-Mellado J, Morales EM, Pacheco-Tena C, Burgos-Vargas R. Becker MA, Schumacher HR, Wortmann RL et al. guideline on gout STEVE CHAPLIN The British Society for Rheumatology published a revised and updated guideline on the management of gout in July 2017, the first in a decade. Schumacher HR, Becker MA, Wortmann RL et al. Moi JHY, Sriranganathan MK, Falzon L et al. Second, the incidence, ; Scenario: Preventing gout: covers the principles of gout prevention and includes information on prophylactic drug treatment. LoE: IIb; SOR: 96% (range 83–100%). SOR: 95% (range 82−100%). First, new pharmaceutical treatment options have become available and the evidence base for the efficacy and safety of available drugs has expanded. ), secondary care physicians with specialist experience in general internal medicine, clinical pharmacology (T.M. It is now recommended that in patients with renal impairment the maintenance dose of allopurinol need not be strictly limited according to the creatinine clearance. Based on pharmacokinetic data in patients with CKD [180], it is suggested that there is no need for reduction in colchicine dosage (500 μg od or bd) for flare prophylaxis in patients with mild renal insufficiency (eGFR >60 ml/min/1.73 m2) but the dose should be limited to 500 μg od in those with an eGFR of 30–60 ml/min/1.73 m2 and to 500 μg every 2–3 days with eGFR 10–30 ml/min/1.73 m2 [181] and avoided altogether if eGFR < 10 ml/min/1.73 m2. Reasons for full patient involvement have been discussed earlier in this guideline and are supported by preliminary evidence from a proof of concept study [33]. Hyperuricaemia occurs secondarily to reduced fractional clearance of uric acid in > 90% of patients with gout [10]. Enhancement of uric acid excretion and reduction of sUA in patients with tophaceous gout by combined treatment with sulfinpyrazone and allopurinol was first demonstrated nearly 50 years ago [160]. In an RCT, the mAb anti-human IL-1β antibody canakinumab (150 mg by subcutaneous injection) showed good efficacy in reducing pain and swelling when compared with 40 mg intramuscular triamcinolone acetonide [69, 70]. If diuretic drugs are being used to treat hypertension rather than heart failure, an alternative anti-hypertensive agent can be considered as long as blood pressure is controlled. No studies have been undertaken to assess whether vitamin C supplementation is effective in reducing the incidence of recurrent gout attacks. This article summarises the main recommendations of the new guideline. Prophylaxis with low-dosage colchicine, adjusted for renal function, is believed to be a safer option than low-dose NSAIDs [174, 175]. The use of flare prophylaxis is particularly important when ULT is initiated with febuxostat, as the lowest available starting dose in the UK (80 mg) lowers the serum acid level to a greater degree than the starting dose of allopurinol (100 mg), and the risk of precipitating a gout flare is consequently greater [97]. Clinical manifestations of gout resulting from monosodium urate crystal deposition include tophi, chronic arthritis, urolithiasis and renal disease as well as recurrent acute arthritis, bursitis and cellulitis. cimetidine, clarithromycin, erythromycin, fluoxetine, ketoconazole, protease inhibitors, tolbutamide) or p-glycoprotein (e.g. BSR Guidelines on Gout; www.rheumatology.oxfordjournals.org Diet advice and patient information leaflets on Gout; www.ukgoutsociety.org Dr KJ Donaldson Gout Guideline March 2019 Review date March 2022 . We would like to draw attention to the British Society for Rheumatology (BSR) and British Health Professionals in Rheumatology (BHPR) guideline for the management of gout published in 2007. Meeting Coverage > BSR Gout Admissions Escalate in the U.K. — A 59% increase since 2006, while rheumatoid arthritis hospitalizations halved. Objectives of the guideline The aim of this guideline was to produce recommendations for the management of adult lupus patients in the UK that cover the diagnosis, assessment and monitoring of lupus and the treatment of mild, moderate and severe active lupus disease, but which do not imply a … The British Society for Rheumatology/British Health Professionals in Rheumatology (BSR/BHPR) guideline for the management of gout was published in 2007 [2]. One study showed an increased risk of incident Parkinson’s disease in men with sUA <300 µmol/l compared with those with sUA 300−500 µmol/l [124]. It should be started at a low dose (50−100 mg daily) and the dose then increased in 100 mg increments approximately every 4 weeks until the sUA target has been achieved (maximum dose 900 mg). SOR: 97% (range 88−100%). However, these documents contain inconsistent recommendations with unclear quality profiles. For Permissions, please email: journals.permissions@oup.com. The recommendation for ULT dose reduction to the less stringent target of sUA below 360 µmol/l once the patient is stable to avoid further crystal deposition and the possibility of adverse effects that may be associated with a very low sUA is based on expert opinion, a reasoned proposal for such a two-stage approach [119] and caution in the light of studies that have shown a possible association between low sUA levels and progression of neurodegenerative disorders such as Parkinson’s disease [120], dementia [121], Huntingdon’s disease [122] and amyotrophic lateral sclerosis [123]. 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