Gout is a common problem in older people, affecting up to 5% of men aged 65 to 74 years in the UK; with an ageing population and increasing obesity, it is set to become more common. While there are established treatment patterns for gout, it is important to appreciate the quality of the evidence that underpins these and how this informs judgements about the balance of risks and benefits.
Focus of the review
The focus of this review is on the principal drug groups used for the treatment and prevention of acute gout. We have not considered the evidence for the treatment of hyperuricaemia in this review as it is symptomatic gout that has direct patient relevance. Whilst other drugs, including uricosurics, may reduce serum urate, they are not all easily available in different jurisdictions.
Comments on evidence
There are few robust data from RCTs to inform our management of gout. There are few placebo controlled trials of treatments for acute gout, mainly of poor quality; although, there are some good studies comparing active treatments. Notwithstanding evidence for reduction in serum urate, the therapeutic target, the evidence for reduction of recurrent gout over 1 year using xanthine oxidase inhibitors is weak.
Search and appraisal summary
The update literature search for this review was carried out from the date of the last search, September 2010, to September 2013. For more information on the electronic databases searched and criteria applied during assessment of studies for potential relevance to the review, please see the Methods section. Searching of electronic databases retrieved 179 studies. After deduplication and removal of conference abstracts, 92 records were screened for inclusion in the review. Appraisal of titles and abstracts led to the exclusion of 61 studies and the further review of 31 full publications. Of the 31 full articles evaluated, two systematic reviews and two RCTs were added at this update.
There is international consensus that reducing serum urate to less than 0.36 mmol/L should be the therapeutic target for prevention of gout using urate-lowering drugs, as this will allow crystals to be mobilised. This urate mobilisation may itself trigger gout. This is a possible explanation for the apparent paradox that effective urate reduction over 1 year does not reduce incidence of recurrent gout over the same period.
Substantive changes at this update
Corticosteroids One systematic review added. Categorisation unchanged (unknown effectiveness), as there remains insufficient evidence to judge the effects of this intervention.
Non-steroidal anti-inflammatory drugs (NSAIDs) Two subsequent RCTs added. Categorisation unchanged (unknown effectiveness), as there remains insufficient evidence to judge the effects of this intervention.
Xanthine oxidase inhibitors One systematic review added. Categorisation updated (unknown effectiveness [insufficient evidence compared to placebo]), as there remains insufficient evidence to judge the effects of this intervention.
INTRODUCTION: Gout affects about 5% of men and 1% of women, with up to 80% of people experiencing a recurrent attack within 3 years. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments for acute gout? What are the effects of xanthine oxidase inhibitors to prevent gout in people with prior acute episodes? We searched: Medline, Embase, The Cochrane Library, and other important databases up to September 2013 (BMJ Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 21 studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review, we present information relating to the effectiveness and safety of the following interventions: colchicine, corticosteroids, non-steroidal anti-inflammatory drugs (NSAIDs), and xanthine oxidase inhibitors.
Rated by doctors in Relevance Newsworthiness General Practice(GP)/Family Practice(FP) ****** **** General Internal Medicine-Primary Care(US) ****** **** Internal Medicine ****** **** Rheumatology ****** ***
Rated by doctors in Relevance Newsworthiness General Practice(GP)/Family Practice(FP) ****** ***** General Internal Medicine-Primary Care(US) ****** ***** Internal Medicine ****** **** Rheumatology ****** *****