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Editorial: Do Not Let Gout Apathy Lead to Gouty Arthropathy

During the last decade, there has been no shortage of gout guideline statements, with several publications and updates from various rheumatology specialty societies (1–5). Most recently, the American College of Physicians (ACP) published its version of guidelines for the diagnosis and management of gout (6,7). While there are modest differences between the various international rheumatology guidelines, the ACP management of gout guideline has created much debate, as several recommendations conflict with recommendations provided by the rheumatology specialty societies. Since most gout patients are cared for by primary care providers, the guidelines published by the ACP in the Annals of Internal Medicine (6) will likely reach a greater proportion of clinicians caring for patients with gout than will guidelines published in specialty journals. Therefore, it is important to understand what these new guidelines state, how they differ from rheumatology guidelines, and what this means for the field. How do different groups, reviewing essentially the same evidence, reach such different recommendations? Are the different interpretations akin to the pictorial illusion of the young lady looking away versus the old lady in profile (Figure 1)? This illusion derives its effect from the ambiguity of the image and the perception of the reader. The conceptual framework and stated purpose of the ACP-developed guidelines are different from those of the American College of Rheumatology (ACR) and other rheumatology society guidelines. The ACP seeks to provide “clinicians with recommendations based on the best available evidence; to inform clinicians of when there is no evidence; and finally, to help clinicians deliver the best health care possible” (8). “If no specific evidence exists to answer a clinical question within a topic, the ACP Clinical Guidelines Committee refrains from making a clinical recommendation” (9). By restricting themselves to statements with the highest level of evidence, the ACP authors produce guidelines with a narrower focus, whereas the ACR and other rheumatology societies have tried to present guidelines that provide broader guidance on clinically relevant issues, at times in the absence of randomized controlled trial (RCT) data. Based on differences in this conceptual framework, the ACP gout management guideline offers just 4 recommendations (Table 1) versus, for example, the recent European League Against Rheumatism 2016 update, which included 3 overarching and 11 specific recommendations (with many distinct subrecommendations) (4). In addition to including fewer recommendations, the ACP recommendations are quite conservative. The first gout management statement recommends the use of treatments for acute gout attacks that have been the standard of care for decades. The final recommendation is simply to discuss risks, benefits, costs, and harms prior to initiating urate-lowering therapy (ULT) or prophylaxis. In contrast to rheumatology society guidelines, no guidance is provided with regard to when or for whom ULT might be beneficial. Therefore, it is unlikely that these ACP recommendations will impact the often-described poor current practice of care for patients with gout.