The British Society for Rheumatology Guideline for the Management of Gout

Gout is the most common cause of inflammatory arthritis worldwide. In UK general practice, the overall prevalence has increased from 1.4% in 1999 to 2.49% in 2012 1, despite the availability of effective and potentially curative urate-lowering drugs for >50 years and evidence-based British and European management guidelines for nearly a decade 2, 3. NICE has accredited the process used by the BSR to produce its guidance for the management of gout. Accreditation is valid for 5 years from 10 June 2013. More information on accreditation can be viewed at www.nice.org.uk/accreditation. For full details on our accreditation visit: www.nice.org.uk/accreditation. Clinical manifestations of gout resulting from monosodium urate crystal deposition include tophi, chronic arthritis, urolithiasis and renal disease as well as recurrent acute arthritis, bursitis and cellulitis. Gouty arthritis and tophi are associated with chronic disability, impairment of health-related quality of life 4–7, increased use of healthcare resources and reduced productivity 8. Gout is also frequently associated with co-morbidities such as obesity, dyslipidaemia, diabetes mellitus, chronic renal insufficiency, hypertension, cardiovascular disease, hypothyroidism, anaemia, psoriasis, chronic pulmonary diseases, depression and OA 1 as well as with an increase in all-cause mortality (adjusted hazard ratio 1.13, 95% CI: 1.08, 1.18) and urogenital malignancy 1, 9. Sustained hyperuricaemia is the single most important risk factor for the development of gout. Hyperuricaemia occurs secondarily to reduced fractional clearance of uric acid in > 90% of patients with gout 10. Age, male gender, menopausal status in females, impairment of renal function, hypertension and the co-morbidities that comprise the metabolic syndrome are all risk factors for incident gout associated with decreased excretion of uric acid, as are the use of diuretic and many anti-hypertensive drugs, ciclosporin, low-dose aspirin, alcohol consumption and lead exposure. Tophi and chronic arthritis 11, alcohol consumption 12 and recent use of diuretic drugs 13 are important risk factors for recurring flares. Genome-wide association studies have identified a number of genes coding for urate anion transporters expressed in the proximal renal tubular epithelium, but these account for 50 but was of a and in the patients in and are very common in patients with gout. recent and of and studies that the overall prevalence of or in patients with gout was with in the and the prevalence of was with important in patients with and management of gout in patients with renal impairment has been the of recent and a guideline from the US For the management of acute the of be reduced in patients with but is in patients with severe renal impairment 10 be used in patients with renal impairment Although the of in with has been in clinical that can be effective and for acute gout in patients with severe renal impairment or in patients in and be for for is or are or a of to are or is for the use of and drugs in patients with renal impairment have been and for the use of urate-lowering with or in patients with gout and renal to be undertaken with as the of are increased in patients with renal impairment and can cause acute and renal in patients with with for renal function, is to be a low-dose on in patients with is that is for in or for in patients with renal but the be to in with an of and to with and 10 Although is that be in all patients with renal a recent and of studies of accelerated in patients with to severe renal impairment with low-dose 95% CI: with severe gout in hyperuricaemia be with standard or in be to a a can be effective in such patients by The is by in by with and for with and patients be with and to the risk of in to low-dose or for is be and the is as to be at increased risk for and is in patients with of the risk of and is in patients with has and in but has been by NICE or the of and a that is for the and of but for has also been used in patients with severe gout despite its in the UK be of the to for an these drugs be from patients with gout is very in and in and are are for acute can be used in the are to use in and the for the dietary are also The for are from studies of its use in are also of of can be in and is and have been was used in the of in without the prevalence of gout and the availability of effective and potentially curative for >50 its management remains with of patients with gout of information to patients has been identified as of the to effective management of gout. There is that to and of to levels can be with of information and a of care on guideline of information and of to levels clinical that secondary care of patients with on with a to primary care where is to be of with have a patients for be of recurrent and the for the for in the of Although are studies in the guideline these The guideline as the is and to be and effective in the majority of patients with gout. The of as a has been established and our guidance for its use with its NICE and The guideline include for or use of and the to use these drugs is to be rare and are to for these guideline important from the 2007 guideline 2. The of and of information gout and its are in the updated guideline for the management of acute and for the of and risk factors and and for the use of urate-lowering is now that an or are drugs of for acute gout are and that the of be by renal function, co-morbidities and for the management of acute of with or can be used for acute where to is for the management of acute and be in patients have to standard for the management of acute The revised guideline that all patients with gout be for cardiovascular risk factors and such as hypertension, diabetes mellitus, dyslipidaemia, and renal disease at and for the of and risk is now that that the of be and to all patients with gout as of the and that patients are in the as to to and for the use of urate-lowering Although the revised guideline of with to a of to the of is now years of tophi have and the remains for the use of urate-lowering is now that in patients with renal impairment the of be to the The be and increased with the of is for the use of urate-lowering can be used as an for patients in is or renal impairment to the for the use of urate-lowering For patients with severe gout in hyperuricaemia be with standard or in with can be by with and for with is on the of the British Society for for and for clinical research can be at Rheumatology and in the was from in the or to the in from Health for Health and for from