Diagnosis and treatment for hyperuricemia and gout: a systematic review of clinical practice guidelines and consensus statements

Abstract

Objectives: Despite the publication of hundreds of trials on gout and hyperuricemia, management of these conditions remains suboptimal. We aimed to assess the quality and consistency of guidance documents for gout and hyperuricemia.

Design: Systematic review and quality assessment using the appraisal of guidelines for research and evaluation (AGREE) II methodology.

Data sources: PubMed and EMBASE (27 October 2016), two Chinese academic databases, eight guideline databases, and Google and Google scholar (July 2017).

Eligibility criteria: We included the latest version of international and national/regional clinical practice guidelines and consensus statements for diagnosis and/or treatment of hyperuricemia and gout, published in English or Chinese.

Data extraction and synthesis: Two reviewers independently screened searched items and extracted data. Four reviewers independently scored documents using AGREE II. Recommendations from all documents were tabulated and visualised in a coloured grid.

Results: Twenty-four guidance documents (16 clinical practice guidelines and 8 consensus statements) published between 2003 and 2017 were included. Included documents performed well in the domains of scope and purpose (median 85.4%, range 66.7%-100.0%) and clarity of presentation (median 79.2%, range 48.6%-98.6%), but unsatisfactory in applicability (median 10.9%, range 0.0%-66.7%) and editorial independence (median 28.1%, range 0.0%-83.3%). The 2017 British Society of Rheumatology guideline received the highest scores. Recommendations were concordant on the target serum uric acid level for long-term control, on some indications for urate-lowering therapy (ULT), and on the first-line drugs for ULT and for acute attack. Substantially inconsistent recommendations were provided for many items, especially for the timing of initiation of ULT and for treatment for asymptomatic hyperuricemia.

Conclusions: Methodological quality needs improvement in guidance documents on gout and hyperuricemia. Evidence for certain clinical questions is lacking, despite numerous trials in this field. Promoting standard guidance development methods and synthesising high-quality clinical evidence are potential approaches to reduce recommendation inconsistencies.

Prospero registration number: CRD42016046104.

Keywords: clinical practice guideline; gout; hyperuricemia; systematic review.

Figure 1

Flow diagram for literature search. AGREE, appraisal of guidelines for research and evaluation; CBM, Chinese Biomedical Literature Database; GAIN, Guidelines and Audit Implementation Network; GIN, Guidelines InternationalNetwork; NGC, National Guideline Clearinghouse; NHS, National Health Service; NICE, National Institute for Health and Care Excellence; SIGN, Scottish Intercollegiate Guidelines Network; TRIP, Turning Research into Practice Database

Figure 2

Standardised domain scores for each guidance document. 3e, evidence, expertise, exchange Initiative; 3e_AU_NZ, Australian and New Zealand 3e Initiative; 3e_PT, Portuguese 3e Initiative; ACP, American College of Physicians; ACR, American College of Rheumatology; AMM, Academy of Medicine of Malaysia; ASCR, American Society of Clinical Rheumatologists; BSR, British Society for Rheumatology; CCCP, Chinese College of Cardiovascular Physicians; CRA, Chinese Rheumatology Association; CRA_multi, Chinese Multidisciplinary Expert Task Force on Hyperuricemia and Its Related Diseases; CSE, Chinese Society of Endocrinology; EULAR, European League Against Rheumatism; FMOH, Federal Ministry of Health (Nigeria); JSGNAM, Japanese Society of Gout and Nucleic Acid Metabolism; MOH, Ministry of Health Malaysia; MSR, Malaysian Society of Rheumatology; NIAMS, National Institute of Arthritis and Musculoskeletal and Skin Diseases; NIH, National Institutes of Health; PRA, Philippine Rheumatology Association; SAMA, South African Medical Association; SER, Spanish Society of Rheumatology; SIR, Italian Society of Rheumatology; T2T, treat-to-target; TRA, Taiwan Rheumatology Association; UTAustin, University of Texas at Austin.

Figure 3

Summary of key recommendations for the diagnosis and treatment of gout and hyperuricemia. 3e, evidence, expertise, exchange Initiative; 3e_AU_NZ, Australian and New Zealand 3e Initiative; 3e_PT, Portuguese 3e Initiative; ACP, American College of Physicians; ACR, American College of Rheumatology; AMM, Academy of Medicine of Malaysia; ASCR, American Society of Clinical Rheumatologists; BSR, British Society for Rheumatology; CCCP, Chinese College of Cardiovascular Physicians; CRA, Chinese Rheumatology Association; CRA_multi, Chinese Multidisciplinary Expert Task Force on Hyperuricemia and Its Related Diseases; CSE, Chinese Society of Endocrinology; EULAR, European League AgainstRheumatism; FMOH, Federal Ministry of Health (Nigeria); JSGNAM, Japanese Society of Gout and Nucleic Acid Metabolism; MOH, Ministry of Health Malaysia; MSR, Malaysian Society of Rheumatology; NIAMS, National Institute of Arthritis and Musculoskeletal and Skin Diseases; NIH, National Institutes of Health; PRA, Philippine Rheumatology Association; SAMA, South African Medical Association; SER, Spanish Society of Rheumatology; SIR, Italian Society of Rheumatology; T2T, treat-to-target; TRA, Taiwan Rheumatology Association; UTAustin, University of Texas at Austin.