Guidelines. Love ‘em or hate ‘em, we know they are an important tool to help us manage the massive range of problems we see in General Practice. As GPs we can’t know the ins and outs of the evidence base for every single condition we see, so are reliant on guideline groups to review the evidence for us, and present us with (we hope) a sensible and clear set of recommendations to help guide us and our patients. But we all know that the quality of the guidelines we are given can vary widely, whether it be due to the underlying evidence base, the way they are presented or whether the recommendations are achievable based on current service provision. We will all have seen recommendations in guidelines over the years where we take one look at them and go ‘crikey, that’s a bit strong…’ - our GP ‘sixth sense’ bleeping and highlighting a disconnect and gap between what we are being told to do and what we are actually able to do at the coal face. Ultimately guidelines need to have ‘buy in’ from both us and our patients.
One guideline that I suspect didn’t quite pass the GP and patient ‘buy in’ test for many of us was the British Society of Rheumatology (BSR) guideline on gout from 2017. The recommendation that all patients with even a single episode of gout should be commenced on urate lowering therapy (ULT), and that the target should be a stringent <300 µmol/l certainly raised a few eyebrows, including from the Drugs and Therapeutics Bulletin in 2018, and probably left many of us thinking ‘well, that’s probably not realistic’.
And indeed that has turned out to been the case. A recent study in The Lancet July 2022 used the Clinical Practice Research Datalink to assess how well the BSR guidelines were being followed in UK General Practice. None of us will be surprised to see that only about a third of people with a new diagnosis of gout were started on ULT within 12 months of diagnosis, with only 17.1% achieving the strict urate target of <300 µmol/l. The authors concluded that ‘Initiation of ULT and attainment of urate targets remain poor for people diagnosed with gout in the UK’ and that ‘implementation strategies to encourage the uptake of guideline-recommended treatments are urgently needed’. Really? These are just the sort of conclusions that make my hackles go up, and thankfully a timely article from the Drugs and Therapeutics Bulletin (DTB September 2022) came wading in….
The DTB is a brilliant publication and is celebrating it’s 60th anniversary this year. It remains truly independent, a voice of reason, and (if needed) is willing to do a good hatchet job on any recommendations that don’t have a good evidence base. As the DTB pointed out this study didn’t address any important patient outcomes such as disease burden, the number of flares or the impact of ULT on those who were initiated on it. Essentially it just looked at various surrogate markers.
At about the time the Lancet study came out NICE was publishing its new guidance on gout (NG 219, June 2022), which the DTB also looked into. NICE have recommended more relaxed urate targets, with more of a focus on giving ULT to those at higher risk of gouty flares, which all seems eminently sensible. But even then, as the DTB point out, the quality of the evidence for ULT is low and very little of it is long term, which makes ULT a difficult ‘sell’ to patients who will be recommended to have it lifelong. On top of that there is no evidence identifying what urate levels should be aimed for, and that ultimately the target was chosen based on expert consensus. Finally, some of the recommendations were supported by cost-effectiveness analyses which did not include clinical time in the management of ULT (nice to know our time is valued…). It’s worth noting that the American College of Physicians do not recommend a ‘treat to target’ urate level for ULT, but rather a ‘treat to avoid symptoms’ strategy for when to use ULT and recommend against lifelong ULT for those with infrequent attacks. When you get international guidelines that can’t even agree on the outcome measure for a condition, you know the evidence base is pretty murky.
The Lancet study finished its interpretation with ‘If the evidence-practice gap in gout management is to be bridged, strategies to implement best practice care are needed.’ I would argue this is not an ‘evidence-practice’ gap, but simply an ‘evidence gap’ and that we are still a way off knowing what ‘best practice’ is.
For what it’s worth I think NICE have made a pretty good stab with the gout guideline - it seems reasonably sensible with pragmatic recommendations given the uncertain underlying evidence. We discuss the details of the new NICE gout guideline and the key differences from previous BSR recommendations in our new Hot Topics course, so why not sign up and join us on one of the upcoming live webinars to find out more!