The 2012 American College of Rheumatology (ACR) Guidelines for the Management of Gout 5, 6 and other international specialty society guidelines recommend treat‐to‐target strategies with use of urate‐lowering therapy (ULT) 7-10. However, the recommendation for treat‐to‐target strategy is not absolute and not meant to be pursued at “any cost.” Even strong recommendations require sound clinical judgment to balance the potential clinical benefits and harms (including costs) of medical decisions 78. Emphasize important points on the poster with lines, frames or … Applying these more conservative rules, the summary certainty of evidence decreased (in comparison to the reported results) for some of the ULT recommendation statements, which would result in a lower strength of recommendation for 2 recommendations (PICO question 2: ULT indication for patients with erosions, and PICO question 27: switching to pegloticase for ULT failure). Notifications for late-breaking abstracts will be sent (coming soon). SU levels among patients who limited or abstained from alcohol were 1.6 mg/dl lower compared with patients who did not do so 95, 96. Explore available award and grant opportunities for fellows-in-training. As with all conditional recommendations, there may be patient factors or preferences that would reasonably support the alternative of delaying ULT initiation until the flare has resolved. We thank Janet Joyce for help in developing the literature search strategy and performing the initial literature search, and Janet Waters for performing the update searches. Click on an entry to view abstracts for that meeting. We thank N. Lawrence Edwards, MD, for his review of the manuscript. The last proposed soution is for consideration in the near future and involves investing in a point of care (POC) creatinine device, with the cheapest device costing £4,995. Dietary modifications likely yield only small changes in SU concentration, but dietary factors may serve as triggers for flares, and patients frequently seek advice on dietary management (for recommendations for management of lifestyle factors, see Table 7 and Supplementary Figure 5, available at http://onlinelibrary.wiley.com/doi/10.1002/acr.24180/abstract). For patients who are treated with uricosurics, patients should receive counseling about adequate hydration, but they need not be prescribed alkalinizing agents given the lack of evidence for efficacy. ; Search this site for a specific abstract. Since the 2012 ACR Guidelines for the Management of Gout were published, several clinical trials have been conducted that provide additional evidence regarding the management of gout, leading the ACR Guidelines Subcommittee to determine that new guidelines were warranted. In the Nurses’ Health Study, greater consumption of high‐fructose corn syrup was associated with higher risk of incident gout 102. Stand well back from your poster to see how it looks from afar. The Voting Panel made recommendations specific to hydrochlorothiazide and losartan 111 in clinical scenarios where such changes are feasible. For management of gout flares, colchicine, nonsteroidal antiinflammatory drugs, or glucocorticoids (oral, intraarticular, or intramuscular) were strongly recommended. The Voting Panel indicated that an optimal trial of oral medication would be appropriate prior to pegloticase due to cost differences and potential adverse effects of the latter medication (for recommendations for choice of initial ULT, see Table 2 and Supplementary Figure 2, available at http://onlinelibrary.wiley.com/doi/10.1002/acr.24180/abstract). This guideline is not intended to contradict or dispute prior recommendations. Posters should be in Portrait format (other size or dimensions will not be accepted). The Voting Panel aimed to provide guidance without implying any “patient‐blaming” for the manifestations of gout given its strong genetic determinants. Dr. Mount has received consulting fees from Horizon Pharma (less than $10,000). 3. As we developed these guidelines for use by providers practicing in the US, we considered pharmacologic therapies available in the US, with select exceptions. ACR … Interpretation of these results is complicated by a high dropout rate with a majority of deaths occurring after ULT discontinuation 72. This review is done by the ESR Referral Guidelines Subcommittee (RG SC) that was established at ECR 2016 (originally as a working group) as part of the … A small cohort study demonstrated that despite receiving ULT, heavy drinkers (≥30 units of alcohol/week) were more likely to continue having gout flares compared with those who do did not drink heavily 95. The place of febuxostat in the treatment of gout. Real-world patterns of pegloticase use for treatment of gout: descriptive multidatabase cohort study. Fitzgerald, Dalbeth, Mikuls, Brignardello‐Petersen, Khanna, Rosenthal, Bae, Danve, P. Khanna, Kim, Lenert, Poon, Qasim, Sehra, Sharma, Toprover, Turgunbaev, Zeng, Zhang, Neogi. Diagnosis and management of gout by clinicians in Nepal: a web-based survey. A series of cases should be used to illustrate the topic being presented. Supported by the American College of Rheumatology. ACR recommendations are not intended to dictate payment or insurance decisions, and drug formularies or other third‐party analyses that cite ACR guidelines should state this. For patients with less frequent flares and no tophi, the potential clinical benefit of ULT would be lower than the ULT benefit for patients with more burdensome gout. Although likely to render only modest urate‐lowering effects, switching from an angiotensin‐converting enzyme inhibitor to losartan carries a risk that seems to be sufficiently low in most patients to merit this change when feasible (for all recommendations for management of concurrent medications, see Table 8 and Supplementary Figure 5, available at http://onlinelibrary.wiley.com/doi/10.1002/acr.24180/abstract). Based on similar efficacy between agents demonstrated in the NMA 79-88, the Voting Panel did not further prioritize between the first‐line agents, noting that treatment selection should be driven by patient factors (e.g., comorbidity, access, past experience) as part of shared decision‐making. MAXILLOFACIAL RADIOLOGY Evidence-Based Guidelines Directorate-General for Energy Directorate D — Nuclear Energy Unit D4 — Radiation Protection 2012. Fitzgerald, Dalbeth, Mikuls, Brignardello‐Petersen, Guyatt, Abeles, Gelber, Harrold, D. Khanna, King, Levy, Libbey, Pillinger, Rosenthal, Singh, Sims, Smith, Wenger, Danve, P. Khanna, Poon, Qasim, Sehra, Sharma, Toprover, Turgunbaev, Zeng, Zhang, Neogi. An in‐person Patient Panel of 8 male patients with gout, moderated by one of the voting panel members (JAS), reviewed the evidence report (along with a summary and interpretation by the moderator) and provided patient perspectives and preferences. In the FDA‐mandated CARES trial of febuxostat versus allopurinol 72, there was no difference between the 2 arms in the primary composite CVD end point. Patients with evidence of monosodium urate monohydrate (MSU) deposition on advanced imaging may still be considered asymptomatic if they have not had a prior gout flare or subcutaneous tophi. … Where there was moderate or high certainty of evidence demonstrating improvement in any 1 of these 3 outcomes, we deemed this sufficient evidence to support a strong recommendation. Gout has differential impact on patients by sex, race, or by presence of other comorbidities. For PICO questions specific to ULT, and on the basis of input from 1) the Patient Panel; 2) prior focus group work citing the importance of SU, gout flare, and tophi to patients 19; and 3) prior guidance from the GRADE working group 20, we made the following decisions. The Core Team prespecified outcomes as critical or important for each PICO question for the systematic literature review. The Voting Panel strongly recommended allopurinol as the preferred first‐line agent given its efficacy when dosed appropriately (often required doses >300 mg/day 37 up to the maximum FDA‐approved dose of 800 mg/day 38), tolerability, safety, and lower cost. the Article by FitzGerald et al. Patients on this panel articulated that SU assessments reinforced the importance of treatment adherence. Additionally, we report results using the more conservative rating of the evidence using the lowest level of evidence for any of the critical outcomes. This guideline follows the ACR guideline development process ( https://www.rheum atolo gy.org/Pract ice-Quali ty/Clini cal-Suppo rt/Clini cal-Pract ice-Guide lines) using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to rate the certainty of evidence and develop recommendations 15-17, with an emphasis on developing actionable guidelines. From the ULT NMA (see Supplementary Appendix 6, available at http://onlinelibrary.wiley.com/doi/10.1002/acr.24180/abstract) and randomized clinical trials (RCTs) of pegloticase 21-23 and lesinurad 24, there was high certainty of evidence regarding the efficacy of ULT in reducing flare frequency 23-26, tophi 21, 23, and SU concentrations 23-26. The first NMA evaluated the impact of starting ULT versus no ULT and the relative impact of the various ULT agents (for details, see Supplementary Appendix 6, available at http://onlinelibrary.wiley.com/doi/10.1002/acr.24180/abstract). We recommend using a treat‐to‐target management strategy to optimize patient outcomes by achieving and maintaining an SU target of <6 mg/dl rather than using a fixed‐dose strategy (Table 3 and Supplementary Figure 2, available at http://onlinelibrary.wiley.com/doi/10.1002/acr.24180/abstract). Names, dates of scans, birth dates, age, zip codes, medical record numbers, and identities must not be included on slides, images, or posters that are submitted to ACR. 2011 2011 ACR/ARHP Annual Meeting November 4-9, 2011 • Chicago, Illinois PDF Only (17.8 MB) 2010 2010 ACR/ARHP Annual Meeting November 6-11, 2010 • Atlanta, Georgia PDF Only (16.7 MB) 2009 2009 ACR/ARHP Annual Meeting October 16-21, […] From observational studies, among patients with asymptomatic hyperuricemia with SU concentrations of >9 mg/dl, only 20% went on to develop gout within 5 years 32. We thank Theodore R. Fields, MD, FACP, Angelo L. Gaffo, MD, and Kenneth G. Saag, MD, for serving on the Expert Panel. Testing for this allele among Asians and African American patients was reported to be cost‐effective (incremental cost‐effectiveness ratios <$109,000 per quality‐adjusted life years) 67. For patients with a history of urolithiasis, allopurinol and febuxostat provide benefit, as both medications lower 24‐hour urinary uric acid excretion more than placebo 33. Worse renal function only had a modest negative impact on urate reduction 44. Abstracts are available for the meetings listed below. In ACR-TIRADS, the threshold size to perform a FNA are 2.5cm (TR3), 1.5cm (TR4) and 1 cm (TR5). Based on Patient Panel input, we specified that longer‐term outcomes (e.g., 24 months) would be critical, while shorter durations (e.g., <12 months) were considered important; it was recognized that very short time points (e.g., <6 months) may reflect the expected flares during ULT initiation. A large observational study (recruitment not selected for CVD) did not show an increased risk of CVD or all‐cause mortality associated with febuxostat initiation compared with allopurinol using methods to address confounding by indication 73. Learn about our remote access options, University of California, Los Angeles and VA Greater Los Angeles Health Care System, Los Angeles, California, University of Auckland, Auckland, New Zealand, University of Nebraska Medical Center and VA Nebraska–Western Iowa Health Care System, Omaha, Nebraska, McMaster University, Hamilton, Ontario, Canada, New York University School of Medicine, New York City, New York, Johns Hopkins University, Baltimore, Maryland, University of Massachusetts Medical School, Worcester Massachusetts, and Corrona, Waltham, Massachusetts, Boston University School of Medicine, Boston, Massachusetts, VA Boston Healthcare System, Boston, Massachusetts, University of Alabama at Birmingham and Birmingham Veterans Affairs Medical Center, Birmingham, Florida State University College of Medicine School of Physician Assistant Practice, Tallahassee, University of Michigan, VA Ann Arbor Healthcare System, Ann Arbor, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, US Department of Veterans Affairs, Manchester, New Hampshire, Mount Auburn Hospital, Cambridge, Massachusetts, Allegheny Health Network, Pittsburgh, Pennsylvania, American College of Rheumatology, Atlanta, Georgia. Dr. Harrold owns stock or stock options in Corrona. The Voting Panel endorsed 42 recommendations overall, including 16 strong recommendations focused on ULT management (indications [n = 3], initiation [n = 6], titration and treat‐to‐target approach [n = 2], approaches following ULT failure [n = 2]), and flare management (n = 3). sodium bicarbonate on urine alkalization in Chinese primary gout patients with benzbromarone: a prospective, randomized controlled study However, changes in body mass index (BMI) over time were associated with the risk of recurrent gout flare. The ACR graciously requests that interested parties please refrain from contacting the ACR directly to obtain information regarding abstract status, notification, distribution, and/or publication dates. Thursday, October 8 is the deadline to upload an ePoster file (required) and record a 3-minute audio accompaniment (optional). Medication costs (not part of the systematic literature review), reported as average wholesale pricing as sourced from Lexicomp on August 23, 2019, were provided to the Voting Panel, as cost of treatment was included as part of the evaluation of risks and benefits of treatment medications (see Supplementary Appendix 9, available on the Arthritis Care & Research web site at http://onlinelibrary.wiley.com/doi/10.1002/acr.24180/abstract). 7 Fig. In the National Health and Nutrition Examination Survey, artificially sweetened carbonated beverage consumption was associated with higher SU levels 101. Guidelines and recommendations developed and/or endorsed by the American College of Rheumatology (ACR) are intended to provide guidance for particular patterns of practice and not to dictate the care of a particular patient. Dr. D. Khanna has received consulting fees, speaking fees, and/or honoraria from Horizon (less than $10,000) and owns stock or stock options in Eicos Sciences. However, the development of incident gout was low for both ULT and placebo arms (<1% versus 5%) 35, 36. Breaking from prior ACR and European League Against Rheumatism (EULAR) guidelines, this guideline does not specify SU thresholds beyond <6 mg/dl for patient subsets with more severe disease (e.g., those with tophi). A group consensus process was used to compose the final recommendations and grade their strength as strong or conditional. Among patients with calcium oxalate stones and hyperuricosuria, allopurinol (300 mg/day) is superior to placebo in reducing the 3‐year incidence of stone‐related events 34. We thank Jasvinder A. Singh for leading the Patient Panel meeting, as well as the patients who participated in this meeting: Lynn Brown, Jr., Douglas P. Davis, Larry Davis, Dextral L. Ely, Adam Paul Germek, Willie Earl Henton, James Edward Sims, and James Trucks. The prevalence of HLA–B*5801 is highest among persons of Han Chinese, Korean, and Thai descent (7.4%) 66, lower among African Americans (3.8%), and even lower among whites and Hispanics (0.7% each) 66. Do patient preferences for core outcome domains for chronic gout studies support the validity of composite response criteria? Therapy and antiinflammatory prophylaxis of acute gouty arthritis, Summary of the Dutch College of General Practitioners’ “Gout” Standard, EULAR evidence based recommendations for gout. While data support an active treat‐to‐target strategy, a question remains as to what may be the optimal SU threshold for patients with more severe disease, in addition to questions about threshold values in specific populations of gout patients. In a single study (moderate certainty of evidence), patients with ≤2 previous flares (and no more than 1 gout flare in the preceding year) randomized to receive febuxostat (versus placebo) were less likely to experience a subsequent flare (30% versus 41%; P < 0.05) 27. The National Patient Safety Agency (NPSA) and Royal College of Radiologists (RCR) developed a specific checklist adapted for radiological interventions, based on the WHO Surgical Safety Checklist with emphasis first on the intervention suite but increasing attention to all invasive procedures including ‘biopsies and other invasive tissue sampling’ (1). Forty‐two recommendations (including 16 strong recommendations) were generated. Limit your poster presentation to a few main ideas. View 2018 Patient Perspectives Guidelines. This guideline is limited in commenting on specific groups of gout patients, as more studies of specific patient cohorts are needed in order to make differential recommendations. However, the panel recognized that these resources may not be available in all health care settings, and that the key is for the treating provider (who could be the treating physician) to educate the patient and implement a treat‐to‐target protocol. Medications noted above are known to have effects on SU concentrations 110. This strong recommendation recognizes the various ways in which gout may present, and that joint damage is reflective of an active biologic process. 2011 . For patients with infrequent gout flares and no tophi, we would expect a similar benefit in SU reduction. Notifications of acceptance and rejection will be sent for the general abstract submissions (coming soon). We thank Amit Aakash Shah, MD, MPH, for his assistance with the literature review. The lowest level of evidence for the outcomes deemed critical to patients determined the certainty of evidence for each PICO question 15. 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