2014 ACR/ARHP Annual Meeting: New Directions for Gout

The ACR is in the process of updating all of its disease management guidelines. The organization is investing more money to allow developers to thoroughly vet data and distribute more detailed surveys to the membership to validate questions used in the guideline process, said Dr. Saag. The current gout panel is using the GRADE method, which they believe will improve the process of qualifying the strength and relevance of scientific evidence. Dr. Saag urged members in the audience to respond to the ACR’s survey invitations and provide much-needed feedback to make future recommendations more practical.

Although gout is growing in prevalence, affecting as many as 6.1 million Americans according to the Centers for Disease Control and Prevention, disease management is still poor in many patients, said Dr. Saag. “Unfortunately, some people start off on no treatment, and stay on no treatment for their gout until they die,” he said.

Urate-lowering therapies have been available for more than 50 years, and febuxostat became available in the last decade. Rheumatologists must weigh various factors, including dosage and cost, to help patients reach urate targets. “However, a fixed-dose strategy is not cost effective” for either allopurinol or febuxostat, Dr. Saag said. As ACR gout management guidelines are updated, new evidence on cost-effectiveness, and more diverse input from allied health professionals and gout patients will make them more useful in clinical practice, he added.

Perceptions Must Change

Dr. Keenan

Current gout management recommendations are simply not being followed because rheumatologists and other providers find them unclear or contradictory, said Robert T. Keenan, MD, MPH, assistant professor of medicine at Duke University in Durham, N.C. As the ACR guidelines are updated, practicality should be taken into account along with high-quality data to support recommendations, he said.

“Even if you had Level A evidence for every recommendation, it doesn’t do anybody any good if you can’t implement them,” said Dr. Keenan. Gout patients are not meeting urate targets and disease management is suboptimal in too many cases, he said. “The bottom line is that the gout guidelines ought to be applied clinically to improve patient care and outcomes.”

Only about half of the existing recommendations reach gout patients, Dr. Keenan estimated. “That’s not the best track record.” Guideline recommendations may not reflect practical clinical challenges, he said. “The complexity of guidelines impedes implementation across the board.” More input from different stakeholders in gout management may identify and mitigate real-world barriers to application of recommendations, he said.