Eular evidence based recommendations for gout - Part I Diagnosis: Report of a task force of the Standing Committee for International Clinical Studies Including Therapeutics(ESCISIT)

W Zhang ^1*, M Doherty ¹, E Pascual ², T Bardin ³, V Barskova ⁴, P Conaghan ⁵, J Gerster ⁶, J Jacobs ⁷, B Leeb ⁸, F Liotè ³, G McCarthy ⁹, P Netter ¹⁰, G Nuki ¹¹, F Perez-Ruiz ¹², A Pignone ¹³, J Pimentão ¹⁴, L Punzi ¹⁵, E Roddy ¹, T Uhlig ¹⁶ and I Zimmermann-Gòrska ¹⁷

¹ Nottingham University, United Kingdom
² Hospital General Universitario de Alicante, Spain
³ Hôpital Lariboisière, France
⁴ Institute of Rheumatology, Russian Federation
⁵ University of Leeds, United Kingdom
⁶ Hôpital Nestlé, Switzerland
⁷ University Medical Center Utrecht, Netherlands
⁸ Lower Austrian Center for Rheumatology, Austria
⁹ Mater Misericordiae University Hospital, Republic of Ireland
¹⁰ Universite Henri Poincare, France
¹¹ University of Edinburgh, United Kingdom
¹² Hospital de Cruces, Spain
¹³ University of Florence, Italy
¹⁴ Hospital Egas Moniz, Portugal
¹⁵ University of Padova, Italy
¹⁶ Diakonhjemmet Hospital, Norway
¹⁷ Poznan University of Medical Sciences, Poland

^* To whom correspondence should be addressed. E-mail: weiya.zhang{at}nottingham.ac.uk.

Accepted 8 May 2006

Abstract

Objectives: To develop evidence based recommendations for the diagnosis of gout.

Methods: The multidisciplinary guideline development group comprised 19 rheumatologists and one evidence based medicine expert representing 13 European countries. Ten key propositions regarding diagnosis were generated using a Delphi consensus approach. Research evidence was searched systematically for each proposition. Wherever possible the sensitivity, specificity, likelihood ratio (LR) and incremental cost- effectiveness ratio (ICER) were calculated for diagnostic tests. Relative risk and odds ratios were estimated for risk factors and co-morbidities associated with gout. The quality of evidence was categorised according to the evidence hierarchy. The strength of recommendation was assessed using the EULAR visual analogue and ordinal scales.

Results: Ten key propositions were generated though 3 Delphi rounds including diagnostic topics in clinical manifestations, urate crystal identification, biochemical tests, radiographs and risk factors/co- morbidities. Urate crystal identification varies according to symptoms and observer skill but is very likely to be positive in symptomatic gout (LR=567, 95%CI 35.5, 9053). Classic podagra and presence of tophi have the highest clinical diagnostic value for gout (LR= 31.97, 95%CI 21.31, and 33.17, 95%CI 14.44, 76.21 respectively). Hyperuricaemia is a major risk factor for gout and may be a useful diagnostic marker when defined by the normal range of the local population (LR= 9.74, 95%CI 7.45, 12.72) although some gouty patients may have normal serum uric acid levels at the time of investigation. Radiographs have little role in diagnosis, though in late or severe gout radiographic changes of asymmetric swelling (LR=4.13, 95%CI 2.97, 5.74) and subcortical cysts without erosion (LR= 6.39, 95%CI 3.00, 13.57) may be useful to differentiate chronic gout from other joints conditions. In addition, risk factors (gender, diuretics, purine-rich foods, alcohol, lead) and co-morbidities (cardiovascular diseases, hypertension, diabetes, obesity and chronic renal failure) associate with gout. Strength of recommendation for each proposition varied according to both the research evidence and expert opinion.

Conclusion: Ten key recommendations for diagnosis of gout were developed using a combination of research- based evidence and expert consensus. The evidence for diagnostic tests, risk factors and co-morbidities were evaluated and the strength of recommendation was provided.

Keywords: EULAR, diagnosis, gout, guidelines

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EULAR evidence based recommendations for gout. Part II: Management. Report of a task force of the EULAR Standing Committee For International Clinical Studies Including Therapeutics (ESCISIT)

W Zhang, M Doherty, T Bardin, E Pascual, V Barskova, P Conaghan, J Gerster, J Jacobs, B Leeb, F Lioté, G McCarthy, P Netter, G Nuki, F Perez-Ruiz, A Pignone, J Pimentão, L Punzi, E Roddy, T Uhlig, and I Zimmermann-Gòrska
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