Multinational evidence-based recommendations for the diagnosis and management of gout: integrating systematic literature review and expert opinion of a broad panel of rheumatologists in the 3e initiative

The Association between Serum Uric Acid Levels and the Prevalence of Vulnerable Atherosclerotic Carotid Plaque: A Cross-sectional Study

Little is known about the associations between serum uric acid (SUA) levels and atherosclerotic carotid plaque vulnerability. The aim of this study was to assess the associations of SUA levels with the prevalence of vulnerable atherosclerotic carotid plaque in a community-based cohort. In the Asymptomatic Polyvascular Abnormalities Community (APAC) study, cross-sectional data from 2860 Chinese residents who underwent SUA measurement and ultrasonographic assessment of carotid plaque were analyzed. Multivariable logistic regression models were used to assess the associations of SUA levels with presence of vulnerable carotid plaque. After adjustment for potential confounders, SUA levels were significantly associated with the prevalence of vulnerable plaque amongst the middle-aged adults (odds ratio [OR] = 1.19, 95% confidence interval [CI]: 1.11-1.28). Compared to the lowest quartile, quartiles 2, 3 and 4 had a prevalence OR of 1.33 (1.02-1.74), 1.70 (1.27-2.27) and 2.05 (1.53-2.75), respectively, for the presence of vulnerable carotid plaque (p for trend across quartiles < 0.001). In the APAC study, elevated SUA levels were independently associated with the prevalence of vulnerable carotid plaque in middle-aged adults.

Australian and New Zealand recommendations for the diagnosis and management of gout: integrating systematic literature review and expert opinion in the 3e Initiative

AIM

To develop evidence-based recommendations for the diagnosis and management of gout in Australia and New Zealand as part of the multi-national 3e Initiative.

METHOD

Using a formal voting process, a panel of 78 international rheumatologists selected 10 key clinical questions pertinent to the diagnosis and management of gout. An additional question was also developed by participating Australian and New Zealand rheumatologists. Each question was investigated with a systematic literature review. MEDLINE, EMBASE, Cochrane CENTRAL and abstracts from 2010 to 2011 European League Against Rheumatism and American College of Rheumatology meetings were searched in each review. Relevant studies were independently reviewed by two individuals for data extraction and synthesis and risk of bias assessment. Using this evidence, 47 Australian and New Zealand rheumatologists developed national recommendations. For each recommendation the level of agreement was assessed and the level of evidence graded.

RESULT

Eleven recommendations were produced relating to the diagnosis of gout, different aspects of the management of gout, cardiovascular and renal comorbidities and the management of asymptomatic hyperuricemia. The mean level of agreement with the recommendations was 9.1 on a 1-10 scale, with 10 representing full agreement.

CONCLUSION

Eleven Australian and New Zealand recommendations on the diagnosis and management of gout were developed combining systematically reviewed evidence with local expertise, enhancing their utility in clinical practice.

An appraisal of the 2012 American College of Rheumatology Guidelines for the Management of Gout

PURPOSE OF REVIEW

Appraisal of the 2012 American College of Rheumatology (ACR) Guidelines for the Management of Gout.

RECENT FINDINGS

The ACRs first clinical practice guidelines for the management of gout focus on recommendations for nonpharmacologic and pharmacologic approaches to hyperuricaemia and the treatment and prophylaxis of acute gouty arthritis. The RAND/UCLA appropriateness methodology employed assessed risks and benefits of alternative treatments for efficacy, safety and quality but not for cost-effectiveness. Novel recommendations include the use of either allopurinol or febuxostat for first-line urate-lowering drug therapy (ULT), screening for HLA-B*5801 prior to initiation of allopurinol in Asians at relatively high risk for allopurinol hypersensitivity, and the use of pegloticase for patients with severe, symptomatic, tophaceous gout refractory to, or intolerant of, appropriately dosed ULTs. Appraisal and comparison with other guidelines using Guidelines International Network and Appraisal of Guidelines, Research and Evaluation (AGREE II) criteria showed good scores for scope and purpose, stakeholder involvement, rigour of development, clarity of presentation, editorial independence and, overall quality, but not for applicability.

SUMMARY

The ACR guidelines provide comprehensive, up-to-date, good-quality, evidence-based, expert consensus recommendations for the management of gout in clinical practice but score poorly for applicability. To improve the management of gout in the community a summary of key recommendations, criteria for audit and standards of care are now required.

Pharmacokinetics considerations for gout treatments

INTRODUCTION

Patients with gout often have comorbid conditions such as renal failure, cardiovascular disease and metabolic syndrome. The presence and required treatment of these conditions can make the treatment of gout challenging. Knowledge of the pharmacokinetics of the available drugs for the management of gout is mandatory.

AREAS COVERED

A MEDLINE PubMed search for articles published in English from January 1990 to January 2014 was completed using the terms: pharmacokinetics, colchicine, canakinumab, allopurinol, febuxostat, pegloticase, gout, toxicity, drug interaction.

EXPERT OPINION

Colchicine is a drug with a narrow therapeutic-toxicity window. Co-prescription with strong CYP3A4 or P-glycoprotein inhibitors can greatly modify its pharmacokinetics and is to be avoided. Elimination of canakinumab mainly occurs via intracellular catabolism, following receptor mediator endocytosis. Canakinumab appears to be a good alternative for patients with contraindications to colchicine, NSAIDs and corticosteroids. For patients with renal impairment, some authors recommend that the allopurinol maximum dosage should be adjusted to creatinine clearance. If the urate target cannot be achieved, the therapy should be switched to febuxostat, which is appropriate with mild-to-moderate renal failure. Anti-pegloticase antibodies affect the pharmacokinetics of the drug because they increase its clearance, with loss of pegloticase activity.

Prevention of comorbidity and acute attack of gout by uric acid lowering therapy

The object of this study was to evaluate the effect of uric acid lowering therapy in reducing the new development of comorbidities and the frequency of acute attacks in gout patients. We retrospectively reviewed patients who were diagnosed to have gout with at least 3 yr of follow up. They were divided into 2 groups; 53 patients with mean serum uric acid level (sUA)<6 mg/dL and 147 patients with mean sUA≥6 mg/dL. Comorbidities of gout such as hypertension (HTN), type II diabetes mellitus (DM), chronic kidney disease, cardiovascular disease (CVD) and urolithiasis were compared in each group at baseline and at last follow-up visit. Frequency of acute gout attacks were also compared between the groups. During the mean follow up period of 7.6 yr, the yearly rate of acute attack and the new development of HTN, DM, CVD and urolithiasis was lower in the adequately treated group compared to the inadequately treated group. Tight control of uric acid decreases the incidence of acute gout attacks and comorbidities of gout such as HTN, DM, CVD and urolithiasis.

[Diagnosis and management of gout in Austria. Survey of current practice considering the EULAR recommendations]

BACKGROUND AND OBJECTIVES

Gout shows an increasing incidence and has become a major health problem in the Western world. Despite effective treatment options, neither diagnosis nor therapeutic efforts can be regarded sufficient to date. It was of interest to investigate current handling of gout among Austrian rheumatologists.

MATERIAL AND METHODS

In 2012, a survey of Austrian rheumatologists concerning diagnosis and management of hyperuricemia and gout was performed. With the consent of the Austrian Society of Rheumatology, 574 society members (343 via electronic mail, 23 via mail) were sent a questionnaire consisting of 17 questions. This is the first survey assessing the management of gout among Austrian rheumatologists.

RESULTS

The overall response rate was 22.1 %. Of all the contacted members (email and mail), 19.9 % answered the questionnaire electronically and only 5.6 % by mail. The adherence to the EULAR recommendations for gout ranged between 69 and 95 % (median 84 %).

CONCLUSION

Among Austrian rheumatologists, the knowledge about gout, its diagnostic and imaging procedures, management and therapeutic goals is good and mainly in line with current international recommendations. To improve the management of patients with gout and hyperuricemia, a more frequent referral to rheumatologists could be beneficial.

Conflicts of interest in biomedical publications: considerations for authors, peer reviewers, and editors

This article overviews evidence on common instances of conflict of interest (COI) in research publications from general and specialized fields of biomedicine. Financial COIs are viewed as the most powerful source of bias, which may even distort citation outcomes of sponsored publications. The urge to boost journal citation indicators by stakeholders of science communication is viewed as a new secondary interest, which may compromize the interaction between authors, peer reviewers and editors. Comprehensive policies on disclosure of financial and non-financial COIs in scholarly journals are presented as proxies of their indexing in evidence-based databases, and examples of successful medical journals are discussed in detail. Reports on clinical trials, systematic reviews, meta-analyses and clinical practice guidelines may be unduly influenced by author-pharmaceutical industry relations, but these publications do not always contain explicit disclosures to allow the readers to judge the reliability of the published conclusions and practice-changing recommendations. The article emphasizes the importance of adhering to the guidance on COI from learned associations such as the International Committee of Medical Journal Editors (ICMJE). It also considers joint efforts of authors, peer reviewers and editors as a foundation for appropriately defining and disclosing potential COIs.