Table 2

 Propositions and strength of recommendation: order based on topic (general, acute management, and chronic management)

PropositionSOR (95% CI)
VAS 100A+B%*
*A+B%: percentage of strongly to fully recommended, based on the EULAR ordinal scale (A = fully recommended, B = strongly recommended, C = moderately recommended, D = weakly recommended, and E = not recommended).
CI, confidence interval; NSAID, non-steroidal anti-inflammatory drug; SOR, strength of recommendation; VAS, visual analogue scale (0–100 mm, 0 = not recommended at all, 100 = fully recommended).
1Optimal treatment of gout requires both non-pharmacological and pharmacological modalities and should be tailored according to:
(a) specific risk factors (levels of serum urate, previous attacks, radiographic signs)
(b) clinical phase (acute/recurrent gout, intercritical gout, and chronic tophaceous gout)
(c) general risk factors (age, sex, obesity, alcohol consumption, urate raising drugs, drug interactions, and comorbidity)96 (93 to 98)100
2Patient education and appropriate lifestyle advice regarding weight loss if obese, diet, and reduced alcohol (especially beer) are core aspects of management95 (91 to 99)100
3Associated comorbidity and risk factors such as hyperlipidaemia, hypertension, hyperglycaemia, obesity, and smoking should be addressed as an important part of the management of gout91 (86 to 97)94
4Oral colchicine and/or NSAID are first line agents for systemic treatment of acute attacks; in the absence of contraindications, an NSAID is a convenient and well accepted option94 (91 to 98)100
5High doses of colchicines lead to side effects, and low doses (for example, 0.5 mg three times daily) may be sufficient for some patients with acute gout83 (74 to 92)82
6Intra-articular aspiration and injection of long acting steroid is an effective and safe treatment for an acute attack80 (73 to 87)88
7Urate lowering therapy is indicated in patients with recurrent acute attacks, arthropathy, tophi, or radiographic changes of gout.97 (95 to 99)100
8The therapeutic goal of urate lowering therapy is to promote crystal dissolution and prevent crystal formation; this is achieved by maintaining the serum uric acid below the saturation point for monosodium urate (⩽360 μmol/l)91 (86 to 96)100
9Allopurinol is an appropriate long term urate lowering drug; it should be started at a low dose (for example, 100 mg daily) and increased by 100 mg every 2–4 weeks if required; the dose must be adjusted in patients with renal impairment; if allopurinol toxicity occurs, options include other xanthine oxidase inhibitors, a uricosuric agent, or allopurinol desensitisation (the latter only in cases of mild rash)91 (88 to 95)100
10Uricosuric agents such as probenecid and sulphinpyrazone can be used as an alternative to allopurinol in patients with normal renal function but are relatively contraindicated in patients with urolithiasis; benzbromarone can be used in patients with mild to moderate renal insufficiency on a named patient basis but carries a small risk of hepatotoxicity87 (81 to 92)94
11Prophylaxis against acute attacks during the first months of urate lowering therapy can be achieved by colchicine (0.5–1 mg daily) and/or an NSAID (with gastro-protection if indicated)90 (86 to 95)100
12When gout associates with diuretic therapy, stop the diuretic if possible; for hypertension and hyperlipidaemia consider use of losartan and fenofibrate, respectively (both have modest uricosuric effects)88 (82 to 94)100