LAUSR

TO THE EDITOR: We read Qaseem and colleagues' guideline on management of gout (1) with interest. We agree with Neogi and Mikuls' accompanying editorial recommending thatsimilar to diabetes mellitustreatment of gout must not rely solely on symptom relief, because preventing joint destruction and disability is important. However, we are concerned that the guideline takes a step back in the treatment of high serum urate levels, the underlying defect in gout. Qaseem and colleagues cite a lack of knowledge of cost and harms versus benefits of a treat-to-target strategyone that is widely accepted in clinical practiceand offer an alternate, unproven, new strategy: treat to avoid symptoms. Qaseem and colleagues do not cite any literature showing more harms with a higher final dose of allopurinol or febuxostat in gout management. Achieving a target serum urate level less than 357 mol/L (equivalent to<6 mg/dL) is associated with reduction of gout flares, tophi, and costs of medical care. One randomized trial of febuxostat (2) and 2 randomized trials of pegloticase (3) that the Agency for Healthcare and Research Quality evidence report for this guideline regrettably did not include showed that achieving this serum urate target reduced tophi. Tophi are strongly associated with bony erosions and reduced hand function and have a negative physical and psychological effect. No evidence is provided to support the treat-to-avoid-symptoms strategy proposed. Allopurinol use is actually cost-saving in patients with gout who have 2 or more attacks per year (4), a rare finding in the cost-effectiveness literature related primarily to the low cost of generic allopurinol ($10 for a 90-day supply at discount pharmacies). Measurement of serum urate is similarly inexpensive, costing less than $20. Thus, we believe that the benefitharmscost equation based on an evidence-based medicine approach greatly favors a treat-to-target strategy. A 2004 American College of Physicians guideline addressed the similar dilemma of whether to treat lipid levels to target in patients with diabetes. The authors recommended that the decision be shared between the physician and the patient (5), which would have been the preferred approach for gout as well. Documentation of joint pain, gout flares and their severity, and functional limitations in routine clinical care, which would be necessary in the treat-to-avoid-symptoms strategy proposed, is rare and has low feasibility for widespread implementation. Although we laud the College's interest in gout management, we believe that this guideline will have adverse public health consequences and move us in the wrong direction at a time when the prevalence of gout is increasing and a more aggressive approach is needed. We suggest that Qaseem and colleagues critically reevaluate these recommendations to avoid doing more harm than good.