EULAR EVIDENCE BASED RECOMMENDATIONS FOR THE DIAGNOSIS AND MANAGMENT OF GOUT

Background: Gout is a prevalent inflammatory joint disease affecting up to 1-2% of adults. Despite a reasonable understanding of its pathogenesis and effective treatment, gout is often misdiagnosed or diagnosed late in its course, and even when the correct diagnosis has been made treatment is often suboptimal. Therefore, evidence based recommendations on aspects relating to diagnosis and management of gout seem justified. Objectives: To develop evidence based recommendations for the diagnosis and the management of gout. Methods: The multidisciplinary guideline development group comprised 19 rheumatologists and one evidence based medicine expert representing 13 European countries. Each participant contributed up to 10 propositions relating to key clinical aspects in diagnosis, and 10 propositions relating to management of gout. Ten final recommendations for each were agreed using a Delphi consensus approach (3 rounds). MEDLINE, EMBASE, CINAHL, Cochrane Library, HTA reports were searched systematically to obtain research evidence for each proposition. Outcome data for diagnostic test, efficacy, adverse effects and cost effectiveness were abstracted. Where possible, likelihood ratio, sensitivity and specificity were calculated for diagnosis, and effect size, rate ratio, number needed to treat and incremental cost effectiveness ratio were estimated for management. The quality of evidence was categorised according to the evidence hierarchy. The strength of recommendation was assessed using EULAR visual analogue and ordinal scales. Results: Diagnostic topics included clinical manifestations (both typical and atypical) and the usefulness of urate crystal identification, serum uric acid levels and radiographs. Treatment topics included drugs (e.g., colchicine, NSAIDs, steroid, allopurinol, uricosuric agents) and non-pharmacological modalities (e.g., education, lifestyle) for the management of both acute and chronic gout. The research evidence to support each proposition and the component modalities was evaluated and the strength of recommendation was determined based on both research evidence and expert consensus. Conclusion: Ten key recommendations for diagnosis and 10 for the treatment of gout were developed using a combination of research-based evidence and expert consensus.