Methodologic quality of guidance documents for gout and hyperuricemia needs to be improved, as the evidence for some clinical questions is lacking in these guidelines, according to results of a systematic review published in BMJ Open.
Promoting the development of standard guidance methods and synthesizing high-quality clinical evidence could potentially reduce recommendation inconsistencies.
Management of gout and hyperuricemia remains suboptimal despite several published trials on these conditions. This systematic review used the appraisal of guidelines for research and evaluation (AGREE) II methodology to assess the consistency and quality of guidance documents for gout and hyperuricemia.
Researchers located the documents, published in English or Chinese, by searching EMBASE and PubMed (October 27, 2016), 8 guideline databases, 2 Chinese academic databases, and Google and Google scholar (July 2017). They included the latest versions of international and national/regional consensus statements and clinical practice guidelines for diagnosing and/or treating hyperuricemia and gout. After screening the searched items, 2 independent reviewers extracted the data, and then 4 independent reviewers scored the documents using AGREE II. Researchers tabulated recommendations from 24 guidance documents (16 clinical practice guidelines and 8 consensus statements) published between 2003 and 2017 and depicted them in a colored grid.
Included guidance documents performed well in the domains of clarity of presentation (median, 79.2% [range, 48.6%-98.6%]) and scope and purpose (median, 85.4% [range, 66.7%-100.0%]), but unsatisfactorily in the domains of editorial independence (median 28.1% [range, 0.0%-83.3%]) and applicability (median, 10.9% [range, 0.0%-66.7%]). The item with the worst score was monitoring or auditing criteria (mean score, 1.2 [range, 1.0-4.0]), followed by implementation advice or tools (mean score, 1.7 [range, 1.0-4.8]), external review (mean, 2.1 [range 1.0-6.0]), and updating procedure (mean, 2.1 [range, 1.0-6.5]). The intra-class correlation coefficient was 0.896, and group discussion modified 16.53% (365/2208) of individual scores.
The guidance documents addressed 4 major themes: diagnosis of gout and hyperuricemia, treatment of hyperuricemia, treatment of acute gout attack, and treatment of tophi. The 2017 British Society of Rheumatology guideline received the highest scores, with concordant recommendations on target serum uric acid level for long-term control, first-line drugs for urate-lowering therapy (ULT) and acute attack, and some indications for ULT; however, the guidance documents provided significantly inconsistent recommendations for many items, particularly ULT initiation timing and asymptomatic hyperuricemia treatment.
Study limitations included using documents in only English or Chinese, a potential for unconscious bias, weaknesses in the AGREE II system, and a 12-month-old literary search.
“The [methodologic] quality needs to be improved in the current guidelines and consensuses on the diagnosis and management of gout and hyperuricemia, as assessed by the AGREE II. Inconsistent recommendations are common, even in some key aspects. Promoting standard methods for guidance documents development, and [synthesizing] high-quality clinical evidence to fill in evidence gaps, are warranted to improve the quality of guidance documents,” the researchers concluded.
Li Q, Li X, Wang J, et al. Diagnosis and treatment for hyperuricemia and gout: a systematic review of clinical practice guidelines and consensus statements. BMJ Open. 2019;9(8):e026677.