Open access Research Diagnosis and treatment for ...

1 Open access Research Diagnosis and treatment for BMJ Open: first published as on 24 August 2019. Downloaded from on October 7, 2019 by guest. Protected by copyright. hyperuricemia and gout: a systematic review of clinical practice guidelines and consensus statements Qianrui Li,1,2 Xiaodan Li,3 Jing Wang,4 Hongdie Liu,1 Joey Sum-Wing Kwong,5. Hao Chen,6 Ling Li,7 Sheng-Chia Chung,2 Anoop Shah,2,8,9,10 Yaolong Chen,11. Zhenmei An,1 Xin Sun,7 Harry Hemingway, 2,9,10 Haoming Tian,1 Sheyu Li 1,12. To cite: Li Q, Li X, Wang J, Abstract et al. Diagnosis and Strengths and limitations of this study Objectives Despite the publication of hundreds of treatment for hyperuricemia trials on gout and hyperuricemia, management of these and gout: a systematic The first systematic review to assess the quality of conditions remains suboptimal.

2 We aimed to assess the review of clinical practice clinical practice guidelines and consensus state- quality and consistency of guidance documents for gout guidelines and consensus ments on the Diagnosis and treatment for both hy- statements. BMJ Open and hyperuricemia. peruricemia and gout. 2019;9:e026677. Design Systematic review and quality assessment using The first systematic review to summarise recom- bmjopen-2018-026677 the appraisal of guidelines for Research and evaluation mendations for best practice in hyperuricemia and (AGREE) II methodology. Prepublication history and gout. additional material for this Data sources PubMed and EMBASE (27 October The appraisal of guidelines for Research and eval- paper are available online.)

3 To 2016), two Chinese academic databases, eight guideline uation II instrument is an international, structured, view these files, please visit databases, and Google and Google scholar (July 2017). validated and rigorously developed tool. the journal online (http:// dx. doi. Eligibility criteria We included the latest version of Only guidance documents in English and Chinese org/ 10. 1136/ bmjopen- 2018- international and national/regional clinical practice 026677). were included. guidelines and consensus statements for Diagnosis and/or Literature search was >1 year old at the time of treatment of hyperuricemia and gout, published in English publication. QL and XL contributed equally. or Chinese. Data extraction and synthesis Two reviewers QL and XL are joint first authors.

4 Independently screened searched items and extracted data. Four reviewers independently scored documents PROSPERO registration number CRD42016046104. Received 13 September 2018 using AGREE II. Recommendations from all documents Revised 19 July 2019 were tabulated and visualised in a coloured grid. Accepted 23 July 2019. Results Twenty-four guidance documents (16 clinical practice guidelines and 8 consensus statements) published Background between 2003 and 2017 were included. Included documents Gout is an inflammatory arthritis occurring performed well in the domains of scope and purpose (median in response to monosodium urate (MSU). , range ) and clarity of presentation crystals formation, a common and necessary (median , range ), but unsatisfactory pathogenic factor of which is hyperuricemia.

5 In applicability (median , range ) and The prevalence of gout and hyperuricemia,1 4. editorial independence (median , range ). as well as their disease burden,5 6 are rising The 2017 British Society of Rheumatology guideline received the highest scores. Recommendations were concordant on globally. However, although >600 related clin- the target serum uric acid level for long-term control, on ical studies7 have been published to date, the some indications for urate-lowering therapy (ULT), and on quality of care for gout and hyperuricemia the first-line drugs for ULT and for acute attack. Substantially remains suboptimal. The goal of treatment is Author(s) (or their inconsistent recommendations were provided for many to reduce the body's total uric acid pool8 9 and employer(s)) 2019.

6 Re-use items, especially for the timing of initiation of ULT and for consequently to minimise the risk of acute permitted under CC BY-NC. No treatment for asymptomatic hyperuricemia. commercial re-use. See rights flares, arthropathy, nephrolithiasis and other Conclusions Methodological quality needs improvement 10 11 A study in the USA found and permissions. Published by BMJ. in guidance documents on gout and hyperuricemia. that only 22% of patients with gout received Evidence for certain clinical questions is lacking, despite For numbered affiliations see numerous trials in this field. Promoting standard guidance therapy adhering to all quality end of article. development methods and synthesising high-quality A nationwide population study in the UK.

7 Correspondence to clinical evidence are potential approaches to reduce reported that only 48% of prevalent patients Dr Sheyu Li; lisheyu@ gmail. com recommendation inconsistencies. received proper consultation and only 27%. Li Q, et al. BMJ Open 2019;9:e026677. 1. Open access . BMJ Open: first published as on 24 August 2019. Downloaded from on October 7, 2019 by guest. Protected by copyright. of incident patients were provided with urate-lowering We included the latest versions of all international therapy (ULT) within 1 year of and national/regional clinical practice guidelines and High-quality guidance documents are important for consensus statements for the Diagnosis and/or treat- improving the quality of care for gout and hyperuricemia ment of gout and hyperuricemia, published in English at individual, community and national Current or Chinese.

8 Two reviewers (QL, XL) independently guidance documents for gout and hyperuricemia have screened all searched documents. Reasons for exclusion been developed by rheumatology, endocrinology and cardi- were provided for documents excluded during the full- ology groups, at regional, national or international levels. text review (online supplementary table 4). Disagree- Among these documents, the American College of Rheu- ments were resolved through discussion with a third matology (ACR) guidelines,14 15 updated in 2012, and the reviewer (SL). European League Against Rheumatism (EULAR) guide- lines,16 18 updated in 2016, have the most substantial global Data extraction influence. Besides, the most recent documents (released We extracted the following data from each included docu- in 2017) are two national guidelines, from the American ment: document characteristics (eg, year of publication, College of Physicians (ACP)19 20 and the British Society for funding body and evidence base), recommendations for Rheumatology (BSR),21 respectively, and one consensus Diagnosis and monitoring of gout and hyperuricemia, and statement, from the Chinese Multidisciplinary Expert Task recommendations for management.

9 Data were extracted Force on Hyperuricemia and Its Related by one investigator (QL) and checked by another (XL). Despite the variety of documents, current guidelines and consensuses on gout and hyperuricemia provide incon- Appraisal of guidance documents sistent recommendations, even those released by highly All included documents were assessed by four reviewers respected professional organisations, such as the ACP and (QL, XL, JW and HL) independently using the appraisal the Some distinct differences lie in key aspects for of guidelines for Research and evaluation (AGREE) II. patient care, such as the pharmacological treatment for AGREE II is an internationally developed asymptomatic hyperuricemic patients, the timing of initi- and validated tool to evaluate the quality of clinical prac- ation of ULT in patients with gout flare24 and indications tice guidelines29 31 and consensus 33.

10 For These discrepancies may result from ethnic and All reviewers completed an online training tutorial34. social differences, but can be a consequence of inconsis- before the commencement of appraisal to ensure stan- tent guideline Low-quality guidance docu- dardisation. We adapted detailed instructions for scoring ments put individual patients and communities at risk, and from the AGREE II User's Manual28 and provided objec- impede the application of guideline recommendations tive scoring criteria for each item (online supplementary in clinical Hence, we conducted this study to file 1). We selected four guidance documents for pilot systematically evaluate the quality of clinical practice guide- scoring, during which we discussed and clarified our lines and consensus statements on gout and hyperuricemia objective scoring criteria.