Multinational recommendations on the diagnosis and management of gout
| Recommendation | Level of evidence | Grade of recommendation | Agreement, mean (SD) | |
|---|---|---|---|---|
| 1 | Identification of MSU crystals should be performed for a definite diagnosis of gout; if not possible, a diagnosis of gout can be supported by classical clinical features* (such as podagra, tophi, rapid response to colchicine) and/or characteristic imaging findings** | *2b **2b | *D **B | 8.8 (1.6) |
| 2 | In patients with gout and/or hyperuricaemia, renal function should be measured and assessment of cardiovascular risk factors is recommended | 2c | C | 8.4 (2.1) |
| 3 | Acute gout should be treated with low-dose colchicine* (up to 2 mg daily), NSAIDs** and/or glucocorticoids (intra-articular***, oral**** or intramuscular*****) depending on comorbidities and risk of adverse effects | *1b− **1a− ***4 ****1a− *****1a− | *D **D ***D ****D *****D | 8.9 (1.7) |
| 4 | Patients should be advised a healthy lifestyle including reducing excess body weight, performing regular exercise, smoking cessation, avoiding excess alcohol and sugar sweetened drinks | 5 | D | 8.5 (1.7) |
| 5 | Allopurinol should be the first line urate-lowering therapy*; alternatives to consider next include uricosurics** (eg, benzbromarone, probenecid) or febuxostat***; uricase as monotherapy should only be considered in patients with severe gout in whom all other forms of therapy have failed or are contraindicated****. Urate-lowering therapy (except uricase) should be started in a low dose and escalated to achieve a target serum urate***** | *2b **2b ***2b ****2b *****5 | *C **C ***C ****C *****D | 9.1 (1.3) |
| 6 | When introducing urate-lowering therapy, patient education on the risk and management of flare is essential*; prophylaxis should be considered using colchicine (up to 1.2 mg daily)**, or if contraindicated or not tolerated NSAIDs*** or low dose glucocorticoids**** may be used. The duration of prophylaxis depends on individual patient factors | *5 **1b ***5 ****5 | *D **B ***D ****D | 8.1 (2.1) |
| 7 | In patients with mild-moderate renal impairment, allopurinol may be used with close monitoring for adverse events, starting at a low daily dose (50–100 mg) up-titrated to achieve usual target of serum uric acid*; febuxostat** and benzbromarone*** are alternative drugs that can be used without dose adjustment | *4 **2b ***4 | *D **B ***D | 8.5 (1.7) |
| 8 | The treatment target is serum urate below 0.36 mmol/L (6 mg/dL), and the eventual absence of gout attacks and resolution of tophi*; monitoring should include serum urate level, frequency of gout attacks and tophi size** | *2b **1b | *C **B | 9.0 (1.8) |
| 9 | Tophi should be treated medically by achieving a sustained reduction in serum uric acid, preferably below 0.30 mmol/L (5 mg/dL); surgery is only indicated in selected cases (eg, nerve compression, mechanical impingement or infection) | 2b | B | 9.2 (1.4) |
| 10 | Pharmacological treatment of asymptomatic hyperuricaemia is not recommended to prevent gouty arthritis, renal disease or CV events | 2b | D | 8.6 (2.5) |
CV, cardiovascular; MSU, monosodium urate; NSAID, non-steroidal anti-inflammatory drug.
Level of evidence and grade of recommendation were according to the Oxford Centre for Evidence-based Medicine levels of evidence.21 Agreement relates to the entire statement and was voted on a scale from 1 to 10 (fully disagree to fully agree) by the 70 rheumatologists attending the 3e multinational closing meeting (Brussels, 22–23 June 2012). These attendees were members of the national scientific committees from the 14 countries involved in 3e.