The American College of Physicians (ACP) has issued a clinical practice guideline to present the evidence and provide clinical recommendations on the management of gout. Clinical outcomes evaluated included pain, joint swelling and tenderness, activities of daily living, patient global assessment, recurrence, intermediate outcomes of serum urate levels, and harms. Recommendations include:

• ACP recommends that clinicians choose corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), or colchicine to treat patients with acute gout.

• ACP recommends that clinicians use low-dose colchicine when using colchicine to treat acute gout.

• ACP recommends against initiating long-term urate–lowering therapy in most patients after a first gout attack or in patients with infrequent attacks.

Citation: Qaseem A, Harris RP, Forciea MA, et al. Management of acute and recurrent gout: A clinical practice guideline from the American College of Physicians. [Published online ahead of print November 1, 2016]. Ann Intern Med. doi:10.7326/M16-0570.

Commentary: Gout is the most common inflammatory arthritis and occurs when monosodium urate crystals deposit within a joint when the serum uric acid level is above its saturation point of 6.8 mg/dl in the blood. Due to the high-frequency of GI side effects, most physicians have moved away from treating acute attacks of gout with colchicine, and prefer to use anti-inflammatory therapy. The guideline clarifies that NSAIDs and steroids have equal efficacy. For long-term uric acid lowering treatment, the primary agents available and discussed in this review are allopurinol and febuxostat. While the guideline states that there is little evidence to suggest that treating to a target uric acid level of below 6.8 mg/dl is more effective than just treating to minimize the frequency of attacks, an editorial in this issue of Annals of Internal Medicine convincingly points out that based on the pathophysiology of gout, it may just make sense to test uric acid levels when doses can be adjusted to achieve target uric acid levels. —Neil Skolnik, MD