22 recommendations, APLAR Gout Guide is here!

*Only for medical professionals to read and reference more suitable for Asians, the essence of "2021 APLAR Gout Treatment CPG" is here! Gout is the most common inflammatory arthritis in the Asia-Pacific region and even the world
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Due to differences in race, health system, resources, social values, and preferences, clinical management decisions for gout in the Asia-Pacific region may be different from those in Europe and the United States.
This indicates that it is necessary to review the data on gout among Asians and draw from these data to be suitable for the region.
Practical guide
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In this regard, the "2021 Asia Pacific Rheumatism Alliance (APLAR) Gout Treatment Clinical Practice Guidelines (CPG)" has been published in the "International Journal of Rheumatology" (Int J Rheum Dis), let us learn together
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1.
Introduction This CPG aims to provide evidence-based recommendations for the management of different stages of gout: asymptomatic hyperuricemia, acute gout, interictal and chronic tophi or complex gout
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It covers pharmacological and non-pharmacological interventions (NPI), taking into account the unique needs of gout patients in Asia, Australia and the Middle East
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The target users of the guidelines are general practitioners and specialists in these areas, including rheumatologists
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2.
Guideline Development Methods The Guideline Committee (SC) established a Guideline Development Working Group (GDG) to formulate guideline issues in a population, intervention, comparison and outcome (PICO) format and supervise the CPG process
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The Technical Working Group (TWG) evaluated and summarized the evidence, applied the Grading of Evaluation, Development, and Evaluation Recommendations (GRADE) method to determine the certainty of the evidence, and drafted recommendations
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The Consensus Group (CP) is composed of 9 major stakeholders (rheumatologists, general practitioners, academics and a patient representative) from Australia, Bangladesh, Indonesia, Iraq, the Philippines, Singapore, Sri Lanka and Taiwan
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According to CoE, patient values ​​and preferences, cost, resource use, applicability, feasibility, and fairness, the strength of each recommendation is classified as strong, weak, or none
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Strong recommendation means that the voting committee believes that the advantages of intervention outweigh the disadvantages
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Relatively speaking, weak recommendations reflect the group’s reservations, which may be due to issues such as low CoE or cost, fairness, applicability, or patient preference
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Joint decision-making discussions between patients and medical practitioners are essential for weakly recommended interventions
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No recommendation indicates that there is insufficient evidence to recommend or oppose a specific intervention
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3.
Results The final CPG for APLAR treatment of gout in 2021 includes 3 general principles and 22 recommendations (Table 1)
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Table 1 General principles for the treatment of gout and the final 22 recommendations abbreviations: HLA, human leukocyte antigen; N/A, not applicable; NSAIDs, non-steroidal anti-inflammatory drugs; ULT, uric acid-lowering treatment
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4.
Discussion (1) Similar to the recommendations of the American College of Rheumatology (ACR) and the European Union against Rheumatism (EULAR) for the treatment of gout, the APLAR guidelines cover non-pharmacological and pharmaceutical management at different stages of the disease
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In addition, it also reviewed the evidence on the effectiveness of acupuncture and herbal treatments, as well as the evidence of the HLA-B*5801 test before starting ULT, which are of concern to Asians
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In terms of drug intervention for acute gout, the clinical experience of CP members prefers low-dose colchicine
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Although the low dose defined in the randomized controlled trial (RCT) is 1.
8 mg per day, panelists use 0.
5-1.
2 mg per day for their patients
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As for the appropriate time for patients with acute gout to start ULT, group members tend to start during an acute gout attack
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This may benefit people who are unlikely to recover after an acute gout attack
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However, one disadvantage of this approach is that ULT can be mistaken for a painkiller
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In addition, the team members have different approaches in using corticosteroids as preventive agents
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In Singapore, corticosteroids are accepted as preventive drugs for allergy sufferers
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In the Philippines, these drugs are rarely used for preventive treatment due to the risk of abuse
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The team also recognized that interleukin (IL)-1 inhibitors are effective in treating acute gouty arthritis
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A survey conducted by SC found that it is not available in most countries/regions in the Asia-Pacific region, but this does not affect medical practitioners in countries where IL-1 inhibitors can be used
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As mentioned earlier, the combination of allopurinol and Resinard is the most effective for the treatment of refractory gout
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However, Resinard has been removed from the market due to adverse events and therefore cannot be used
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(2) For most non-pharmacological interventions, the evidence of benefit is insufficient
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However, CP emphasizes that weight loss due to obesity and avoiding high-purine diets are beneficial to health and should be encouraged
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It should be emphasized that recommending moderate drinking does not mean encouraging drinking
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(3) In the next update of this guideline, the evidence on IL-1 inhibitors, ULT and xanthine oxidase inhibitors combined with uric acid excretion drugs will be reviewed
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The launch of this APLAR CPG highlights several research gaps
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In APLAR countries, the prevalence of HLA-B*5801, refractory gout, ULT resistance, and gout complications and comorbidities (tophi, urate nephropathy, disability, metabolic syndrome, and cardiovascular disease) The data is not yet complete
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The long-term efficacy and safety of uric acid-lowering drugs, xanthine oxidase inhibitors and the more commonly used uric acid excretion drugs sulfopridone, benzbromarone, and probenecid, as well as the characteristics of patients that affect the response to these drugs, should be in the future To conduct research in clinical trials
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In addition, adverse events of colchicine, corticosteroids, and non-steroidal anti-inflammatory drugs in the treatment of acute gout should be reported
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The evidence for the clinical benefit of ULT in patients with AHU is insufficient and further research is needed
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Other important considerations in future recommendations are: (1) the cost-effectiveness of various ULT drugs; (2) the prevention of colchicine or NSAID; (3) HLA-B*5801 testing in different countries
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In the future, it is also necessary to study the values ​​and preferences of patients on the treatment of gout
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These gaps should be resolved to facilitate the formulation of future gout treatment recommendations, with a view to bringing better outcomes for patients
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It only takes five seconds! References: [1] Lorenzo JPP, Sollano MHMZ, Salido EO, Li-Yu J, Tankeh-Torres SA, Wulansari ManuabaI AR, Rahman MM, Paul BJ, Mok MY, De Silva M, Padhan P, Lim AL, Marcial M , Vicera JJ, Haq SA, Salman S, Liyanage CK, Keen HI, Yew Kuang C, WeiJ C, Hellmi RY, Chan CE Jr, Louthrenoo W.
2021 Asia-Pacific League of Associations for Rheumatology clinical practice guideline for treatment of gout.
Int J Rheum Dis.
2021 Dec 20.
doi: 10.
1111/1756-185X.
14266.
Online ahead of print.