Gout - Chronic Management and Prevention of Recurrent Flare

The references listed below are used in this DynaMed topic primarily to support background information and for guidance where evidence summaries are not felt to be necessary. Most references are incorporated within the text along with the evidence summaries.

1. Dalbeth N, Merriman TR, Stamp LK. Gout. Lancet. 2016 Oct 22;388(10055):2039-2052.
2. Richette P, Doherty M, Pascual E, et al. 2016 updated EULAR evidence-based recommendations for the management of gout. Ann Rheum Dis. 2017 Jan;76(1):29-42.
3. FitzGerald JD, Dalbeth N, Mikuls T, et al. 2020 American College of Rheumatology Guideline for the Management of Gout. Arthritis Rheumatol. 2020 Jun;72(6):879-895, commentary can be found in Arthritis Rheumatol 2021 Mar;73(3):413.

• British Society for Rheumatology (BSR) grading system for recommendations
  • strength of recommendation (SOR)
    • strength of recommendation for each treatment recommendation by members of the guideline development group was graded anonymously on a 0-100 mm visual analog scale and expressed as percentages
  • levels of evidence
    • Level Ia - meta-analysis of randomized controlled trials
    • Level Ib - ≥ 1 randomized controlled trial
    • Level IIa - ≥ 1 well-designed controlled study without randomization
    • Level IIb - ≥ 1 well-designed quasi-experimental study
    • Level III - ≥ 1 nonexperimental descriptive study (comparative, correlation, or case-control)
    • Level IV - expert committee reports, opinions, and/or experience of respected authorities
  • Reference - BSR guideline on management of gout (Rheumatology (Oxford) 2017 Jul 1;56(7):e1), correction can be found in Rheumatology (Oxford) 2017 Jul 1;56(7):1246
• American College of Physicians (ACP) guideline grading system
  • strength of recommendation
    • Strong - benefits clearly outweigh risks and burden, or risks and burden clearly outweigh benefits
    • Weak - benefits closely balanced with risks and burden or uncertainty in estimates of benefits, risks, and burdens
    • Insufficient - balance of benefits and risks cannot be determined
  • quality of evidence
    • High - randomized trials without important limitations, or overwhelming evidence from observational studies
    • Moderate - randomized trials with important limitations (inconsistent results, methodologic flaws, indirect, or imprecise), or exceptionally strong evidence from observational studies
    • Low - observational studies or case series
    • Insufficient - evidence is conflicting, poor quality, or lacking
  • Reference - ACP guideline on management of acute and recurrent gout (Ann Intern Med 2017 Jan 3;166(1):58), supporting systematic review can be found in Ann Intern Med 2017 Jan 3;166(1):37
• European League Against Rheumatism (EULAR) grading system for recommendations
  • European League Against Rheumatism (EULAR) levels of evidence
    • strength of recommendations
      • Grade A - directly based on category 1 evidence
      • Grade B - directly based on category 2 evidence or extrapolated recommendations from category 1 evidence
      • Grade C - directly based on category 3 evidence or extrapolated recommendations from category 1 or 2 evidence
      • Grade D - directly based on category 4 evidence or extrapolated recommendations from category 2 or 3 evidence
    • levels of evidence
      • Category 1A - meta-analysis of randomized controlled trials
      • Category 1B - ≥ 1 randomized controlled trial
      • Category 2A - ≥ 1 controlled study without randomization
      • Category 2B - ≥ 1 type of quasi-experimental study
      • Category 3 - descriptive studies, such as comparative studies, correlation studies, or case-control studies
      • Category 4 - expert committee reports or opinions and/or clinical experience of respected authorities
    • Reference - EULAR evidence-based recommendations on management of gout (Ann Rheum Dis 2017 Jan;76(1):29)
• American College of Rheumatology (ACR) uses Grading of Recommendations Assessment, Development and Evaluation (GRADE) system
  • strength of recommendation
    • Strong recommendation - high certainty that benefits do or do not outweigh risks and burdens
    • Conditional recommendation - benefits and risks/burdens are balanced, and/or considerable uncertainty exists about magnitude of benefits and risks
  • quality of evidence
    • High-quality evidence - further research is very unlikely to change confidence in estimate of effect
    • Moderate-quality evidence - further research is likely to have an important impact on confidence in estimate of effect and may change estimate
    • Low-quality evidence - further research is very likely to have an important impact on confidence in estimate of effect and is likely to change estimate
    • Very low-quality evidence - any estimate of effect is very uncertain
  • ACR guideline on management of goutPubMed32390306Arthritis & rheumatology (Hoboken, N.J.)Arthritis Rheumatol20200601726879-895879 (Arthritis Rheumatol 2020 Jun;72(6):879), commentary can be found in Arthritis Rheumatol 2021 Mar;73(3):413

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