Writing guidelines on gout is a difficult task. I think they made a very good effort to cover as many treatment issues as they could.
Most patients with gout in the United States are cared for by primary care physicians. The guidelines will be helpful to both primary practitioners and rheumatologists, but the subtleties may be lost on the general practitioner, whereas the rheumatologist would pick these up right away. The devil is often in the details when it comes to treating gout. If physicians use the guidelines employing a cookbook approach, they might run into some problems.
For instance, the guidelines cover the use of colchicine as a first-line agent for an acute attack: It’s a good choice, but even the randomized controlled trials that have been published on this, especially using the low-dose approach, show that a significant proportion of patients will not respond to this regimen. The guidelines recommend a dosage higher than what has been advised previously for the low-dose colchicine approach. This may actually be a better method, so I hope this will allow primary practitioners to be able identify more people using this approach. But there are definitely going to be people who do not respond to the colchicine.
Another example of where the guidelines may mislead primary care physicians is the recommendation on when to start urate-lowering therapy (ULT). Their indications for starting pharmacologic ULT include an established diagnosis of gouty arthritis and at least two attacks per year. My colleagues and I think that may exclude too many people. Theoretically, you could have a patient with one attack per year who is having gout-related joint damage and, with this criteria, wouldn’t qualify for ULT. A rheumatologist would pick that up right away, but general practitioners who adhere to these guidelines might end up undertreating some patients.
Also, they recommend using adrenocorticotropic hormone (ACTH) for people who cannot take oral medications. Not only is ACTH is extremely expensive, but the Food and Drug Administration has taken gout off the list of indications for ACTH, so I doubt it would be readily available in a real clinical situation.
When the recommendations discuss using prednisone as a prophylactic against gout attacks, they suggest using 10 mg or less. I think that the authors are trying for the best of both worlds and ending up not having either. We generally try to avoid using steroids long term, so the authors suggest using low-dose prednisone; the problem is that 10 mg would probably be ineffective. There are data suggesting that gout prophylaxis requires higher doses, maybe as much as 20 mg/day. You could try 10 mg but I anticipate that it is not going to work very well.
In their defense, were the authors to go into the subtleties and side effects, what to do with a patient with liver or coronary disease, or issues of cost effectiveness, the guidelines would have become an unmanageable length. But the devil is in the details.
That said, it’s a major effort here. It’s good work. They tried to answer a lot of questions.
Dr. Christopher M. Burns is a rheumatologist at the Geisel School of Medicine at Dartmouth, Hanover, N.H. He reported having no financial disclosures.
