ACP gout guidelines perpetuate clinical inertia: panel

An expert panel has lashed out at gout guidelines from the American College of Physicians, saying a lack of clear recommendations on ULT and serum urate monitoring have the potential to perpetuate clinical and therapeutic inertia.

The Gout, Hyperuricemia and Crystal-Associated Disease Network (G-CAN) are also concerned the guidelines could promote excessive use of NSAIDs, colchicine and prednisolone for long term ‘symptom suppression’.

Late last year the American College of Physicians (ACP) published a clinical practice guideline on the management of acute and recurrent gout that differed substantially from the latest guidelines from the ACR, EULAR and 3e.

According to the G-CAN panel, whose members are from the US and New Zealand, the discordance between the sets of guidelines “extend from differences in the interpretation of the literature with respect to ULT”.

This was despite the literature overwhelmingly supporting the concept that ULT lowering to below sub-saturation concentrations can achieve clinical benefits.

“The fundamental pathophysiological knowledge underlying gout care, and evidence from clinical experience and clinical trials, supports a treat-to-target approach for gout aimed at lowering serum urate lowering to below the saturation threshold at which monosodium urate crystals form,” the 10 member panel wrote in a position paper in Nature Reviews Rheumatology.

They say the ACP guidelines reflect an apparent chasm within the medical community regarding the perception of the disease, where primary care physicians see gout as an “intermittent disease” and rheumatologists see the disease as chronic and progressive.

“Widespread adoption of the ACP clinical practice guideline, with its focus on episodic acute gout therapy and lack of clear recommendations regarding indications regarding indications for ULT or serum urate monitoring has the potential to perpetuate clinical (therapeutic) inertia, leading to a  greater burden of poorly managed gout and rising costs to affected patients and society,” the panel concluded.

They added that results from emerging clinical trials that have gout symptoms as their primary end point were expected to resolve the debate for all clinicians in the “near future”.

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