November 04, 2016
2 min read

ACP omits treat-to-target approach in latest gout guidelines

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The American College of Physicians released recommendations for the diagnosis and management of gout which omitted the 6-mg/dL treat-to-target approach that was recommended by the American College of Rheumatology in 2012, according to recently published reports. Instead, the physician group recommend practitioners wait for repeated attacks before the initiation of urate-lowering therapy.

Robert McLean
Robert M. McLean

This change occurred because the treat-to-target approach was recommended before the National Guideline Clearinghouse criteria were established in 2013, Robert M. McLean, MD, member of both the American College of Physicians (ACP) Clinical Guidelines Committee (CGC) and the American College of Rheumatology (ACR) Quality of Care Committee, wrote in a related editorial.

“Many professional organizations, including the ACR in its development of its gout recommendations, still develop ‘guidelines’ that are actually consensus expert panel opinions that do not clearly meet the current 2013 [Institute of Medicine] IOM and National Guideline Clearinghouse definitions and standards,” McLean wrote. “Although consensus panel opinions clearly have a role, we must be careful about inappropriately labeling them as guidelines.”

For acute gout diagnosis, the ACP recommended the use of synovial fluid analysis in light of clinical judgement for diagnostic testing.  This recommendation was graded as “weak” and based on “low-quality evidence” based on 21 studies.

For management, the ACP made the following four recommendations:

  • use corticosteroids, NSAIDs or colchicine for acute gout;
  • when administering colchicine, use low doses for acute gout;
  • do not use long-term urate-lowering therapy after a first gout attack or in patients with infrequent attacks; and
  • prior to the initiation of urate-lowering therapy, discuss treatment aspects with patients who have recurrent gout attacks.

All management recommendations — which were graded as “strong” and based on at least “moderate-quality” evidence — were based on 28 studies, three of which were placebo-controlled.

“The ACP CGC finds it difficult when it cannot endorse a widely disseminated recommendation from a fellow professional society because of a lack of adequate supporting evidence,” McLean wrote. “Yet, it believes that evidence must direct guideline recommendations.” – by Will Offit


McLean RM, et al. Ann Intern Med. 2016;doi:10.7326/M16-2426.

Newberry SJ, et al. Ann Intern Med. 2016;doi:10.7326/M16-0462.

Qaseem A, et al. Ann Intern Med. 2016;doi:10.7326/M16-0569.

Qaseem A, et al. Ann Intern Med. 2016;doi:10.7326/M16-0570.

Shekelle PG, et al. Ann Intern Med. 2016;doi:10.7326/M16-0461.

Disclosures: McLean reports personal fees from Takeda Pharmaceuticals speakers bureau before 2015 and outside the submitted work, and is a member of the ACP CGC and ACR Quality of Care Committee. Please see the full studies for a list of all other relevant financial disclosures.