Gout

Jordan KM, Cameron JS, Snaith M, Zhang W, Doherty M, Seckl J, Hingorani A, Jaques R, Nuki G, Anonymous00227. · Rheumatology Department, Princess Royal Hospital, Brighton and Sussex University Hospitals Trust, UK. · Rheumatology (Oxford). · Pubmed #17522099 No free full text.

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Zhang W, Doherty M, Pascual E, Bardin T, Barskova V, Conaghan P, Gerster J, Jacobs J, Leeb B, Lioté F, McCarthy G, Netter P, Nuki G, Perez-Ruiz F, Pignone A, Pimentão J, Punzi L, Roddy E, Uhlig T, Zimmermann-Gòrska I, Anonymous00035. · Academic Rheumatology, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham NG5 1PB, UK. · Ann Rheum Dis. · Pubmed #16707533 No free full text.

Abstract: OBJECTIVE: To develop evidence based recommendations for the diagnosis of gout. METHODS: The multidisciplinary guideline development group comprised 19 rheumatologists and one evidence based medicine expert, representing 13 European countries. Ten key propositions regarding diagnosis were generated using a Delphi consensus approach. Research evidence was searched systematically for each proposition. Wherever possible the sensitivity, specificity, likelihood ratio (LR), and incremental cost-effectiveness ratio were calculated for diagnostic tests. Relative risk and odds ratios were estimated for risk factors and co-morbidities associated with gout. The quality of evidence was categorised according to the evidence hierarchy. The strength of recommendation (SOR) was assessed using the EULAR visual analogue and ordinal scales. RESULTS: 10 key propositions were generated though three Delphi rounds including diagnostic topics in clinical manifestations, urate crystal identification, biochemical tests, radiographs, and risk factors/co-morbidities. Urate crystal identification varies according to symptoms and observer skill but is very likely to be positive in symptomatic gout (LR = 567 (95% confidence interval (CI), 35.5 to 9053)). Classic podagra and presence of tophi have the highest clinical diagnostic value for gout (LR = 30.64 (95% CI, 20.51 to 45.77), and LR = 39.95 (21.06 to 75.79), respectively). Hyperuricaemia is a major risk factor for gout and may be a useful diagnostic marker when defined by the normal range of the local population (LR = 9.74 (7.45 to 12.72)), although some gouty patients may have normal serum uric acid concentrations at the time of investigation. Radiographs have little role in diagnosis, though in late or severe gout radiographic changes of asymmetrical swelling (LR = 4.13 (2.97 to 5.74)) and subcortical cysts without erosion (LR = 6.39 (3.00 to 13.57)) may be useful to differentiate chronic gout from other joint conditions. In addition, risk factors (sex, diuretics, purine-rich foods, alcohol, lead) and co-morbidities (cardiovascular diseases, hypertension, diabetes, obesity, and chronic renal failure) are associated with gout. SOR for each proposition varied according to both the research evidence and expert opinion. CONCLUSIONS: 10 key recommendations for diagnosis of gout were developed using a combination of research based evidence and expert consensus. The evidence for diagnostic tests, risk factors, and co-morbidities was evaluated and the strength of recommendation was provided.

Zhang W, Doherty M, Bardin T, Pascual E, Barskova V, Conaghan P, Gerster J, Jacobs J, Leeb B, Lioté F, McCarthy G, Netter P, Nuki G, Perez-Ruiz F, Pignone A, Pimentão J, Punzi L, Roddy E, Uhlig T, Zimmermann-Gòrska I, Anonymous00034. · Academic Rheumatology, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham NG5 1PB, UK. · Ann Rheum Dis. · Pubmed #16707532 No free full text.

Abstract: OBJECTIVE: To develop evidence based recommendations for the management of gout. METHODS: The multidisciplinary guideline development group comprised 19 rheumatologists and one evidence based medicine expert representing 13 European countries. Key propositions on management were generated using a Delphi consensus approach. Research evidence was searched systematically for each proposition. Where possible, effect size (ES), number needed to treat, relative risk, odds ratio, and incremental cost-effectiveness ratio were calculated. The quality of evidence was categorised according to the level of evidence. The strength of recommendation (SOR) was assessed using the EULAR visual analogue and ordinal scales. RESULTS: 12 key propositions were generated after three Delphi rounds. Propositions included both non-pharmacological and pharmacological treatments and addressed symptomatic control of acute gout, urate lowering therapy (ULT), and prophylaxis of acute attacks. The importance of patient education, modification of adverse lifestyle (weight loss if obese; reduced alcohol consumption; low animal purine diet) and treatment of associated comorbidity and risk factors were emphasised. Recommended drugs for acute attacks were oral non-steroidal anti-inflammatory drugs (NSAIDs), oral colchicine (ES = 0.87 (95% confidence interval, 0.25 to 1.50)), or joint aspiration and injection of corticosteroid. ULT is indicated in patients with recurrent acute attacks, arthropathy, tophi, or radiographic changes of gout. Allopurinol was confirmed as effective long term ULT (ES = 1.39 (0.78 to 2.01)). If allopurinol toxicity occurs, options include other xanthine oxidase inhibitors, allopurinol desensitisation, or a uricosuric. The uricosuric benzbromarone is more effective than allopurinol (ES = 1.50 (0.76 to 2.24)) and can be used in patients with mild to moderate renal insufficiency but may be hepatotoxic. When gout is associated with the use of diuretics, the diuretic should be stopped if possible. For prophylaxis against acute attacks, either colchicine 0.5-1 mg daily or an NSAID (with gastroprotection if indicated) are recommended. CONCLUSIONS: 12 key recommendations for management of gout were developed, using a combination of research based evidence and expert consensus. The evidence was evaluated and the SOR provided for each proposition.

Thomsen HS, Morcos SK, Anonymous00029. · Department of Diagnostic Radiology 54E2, Copenhagen University Hospital at Herlev, Herlev Ringvej 75, 2730 Herlev, Denmark. · Eur Radiol. · Pubmed #15627181 No free full text.

Abstract: Routine measurement of serum creatinine before injection of intravascular iodinated contrast material in all patients would be cumbersome and have an associated cost. There is doubt about whether serum creatinine should be measured routinely in all patients or selectively. The Contrast Media Safety Committee of the European Society of Urogenital Radiology decided to review the literature and draw up guidelines on this important practical issue. A literature search was carried out and summarized in a report. Based on the available information and discussions amongst the members of the Committee, guidelines were produced. The report and guidelines were discussed at the 11th European Symposium on Urogenital Radiology in Santiago de Compostela, Spain. The practice for identifying patients at risk of contrast medium induced nephropathy varies considerably from one institution to another. Patients at risk constitute only a small percentage of all cases referred for contrast enhanced imaging examination. However, it is important to identify them and take the necessary precautions. Recent serum creatinine level should be available in patients with an increased probability of a raised serum creatinine level (renal disease, renal surgery, proteinuria, diabetes mellitus, hypertension, gout, current intake of nephrotoxic drugs). A simple guideline has been produced.

Kim SY, Choi HK. · No affiliation provided · J Rheumatol. · Pubmed #19435969 No free full text.

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Singh JA. · No affiliation provided · J Clin Rheumatol. · Pubmed #19131762 No free full text.

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Hope S. · No affiliation provided · Menopause Int. · Pubmed #19037061 No free full text.

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Ben-Chetrit E, Ozdogan H. · No affiliation provided · Clin Exp Rheumatol. · Pubmed #19026114 No free full text.

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Gaffo AL, Saag KG. · No affiliation provided · Arthritis Res Ther. · Pubmed #18983690 links to  free full text

Abstract: The relationship between serum urate, menopause, and aging has not been clearly defined by scientific evidence. In the present issue of Arthritis Research and Therapy, Hak and Choi present a cross-sectional analysis to clarify the effect of menopause and hormone replacement therapy on serum urate in women within the Third National Health and Nutritional Examination Survey. Menopause increased serum urate and hormone replacement therapy significantly decreased serum urate, although the overall level of change was small. The implications of these urate changes on gout and cardiovascular disease outcomes require further study.

Sundy JS. · No affiliation provided · Arthritis Rheum. · Pubmed #18975368 No free full text.

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Mandell BF. · No affiliation provided · Cleve Clin J Med. · Pubmed #18819328 links to  free full text

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Gelber AC. · No affiliation provided · J Rheumatol. · Pubmed #18785294 links to  free full text

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Roddy E. · No affiliation provided · J Rheumatol. · Pubmed #18785293 links to  free full text

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So A. · No affiliation provided · Arthritis Res Ther. · Pubmed #18564404 links to  free full text

Abstract: Understanding how uric acid crystals provoke inflammation is crucial to improving our management of acute gout. It is well known that urate crystals stimulate monocytes and macrophages to elaborate inflammatory cytokines, but the tissue response of the synovium is less well understood. Microarray analysis of mRNA expression by these lining cells may help to delineate the genes that are modulated. Employing a murine air-pouch model, a number of genes expressed by innate immune cells were found to be rapidly upregulated by monosodium urate crystals. These findings provide new research avenues to investigate the physiopathology of gouty inflammation, and may eventually lead to new therapeutic targets in acute gout.

Pritzker KP. · No affiliation provided · J Rheumatol. · Pubmed #18528950 links to  free full text

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Neogi T. · No affiliation provided · J Rheumatol. · Pubmed #18464314 links to  free full text

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Felson DT. · No affiliation provided · Arthritis Res Ther. · Pubmed #18341701 links to  free full text

Abstract: Geographic or ethnic differences in the occurrence of disease often provide insights into causes of disease and possible opportunities for disease prevention. Persons in China appear to have a consistently lower prevalence of rheumatoid arthritis and fibromyalgia than persons in the United States and Europe; reasons for these prevalence differences might include genetic differences, differences in environmental exposures or a combination of both. With increasing obesity, gout is becoming endemic in China. Finally, symptomatic knee osteoarthritis is extremely common in China and constitutes a major public health problem there.

Underwood M. · No affiliation provided · BMJ. · Pubmed #18258933 No free full text.

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Rush RM. · No affiliation provided · Surg Obes Relat Dis. · Pubmed #18065287 No free full text.

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Grahame R. · No affiliation provided · Int J Clin Pract. · Pubmed #17997801 No free full text.

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Meyer MF, Rüther W. · Medizinische Klinik I, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Ruhr-Universität Bochum, Bürkle-de-la-Camp-Platz 1, 44789 Bochum, Deutschland. · Z Rheumatol. · Pubmed #17934741 No free full text.

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Terkeltaub R. · No affiliation provided · J Rheumatol. · Pubmed #17924606 links to  free full text

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Dalbeth N, Stamp L. · Department of Medicine, University of Auckland, Auckland, New Zealand. · Semin Dial. · Pubmed #17897242 No free full text.

Abstract: Allopurinol is the mainstay of urate-lowering therapy for patients with gout and impaired renal function. Although rare, a life-threatening hypersensitivity syndrome may occur with this drug. The risk of this allopurinol hypersensitivity syndrome (AHS) is increased in renal impairment. The recognition that AHS may be because of delayed-type hypersensitivity to oxypurinol, the main metabolite of allopurinol, and that oxypurinol concentrations are frequently elevated in patients with renal impairment prescribed standard doses of allopurinol has led to the widespread adoption of allopurinol-dosing guidelines. These guidelines advocate allopurinol dose reduction according to creatinine clearance in patients with renal impairment. However, recent studies have challenged the role of these guidelines, suggesting that AHS may occur even at low doses of allopurinol, and that these guidelines lead to under-treatment of hyperuricemia, a key therapeutic target in gout. Based on current data, we advocate gradual introduction of allopurinol according to current treatment guidelines, with close monitoring of serum uric acid concentrations. In patients with severe disease and persistent hyperuricemia, allopurinol dose escalation above those recommended by the guidelines should be considered, with careful evaluation of the benefits and risks of therapy. Further work is needed to clarify the safety and efficacy of allopurinol dose escalation, particularly in patients with renal impairment.

Pascual E, Sivera F. · No affiliation provided · Ann Rheum Dis. · Pubmed #17881662 No free full text.

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Alderman MH. · No affiliation provided · Circulation. · Pubmed #17709648 links to  free full text

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