title: Lifestyle interventions for chronic gout.
abstract: BACKGROUND
  Although lifestyle interventions are commonly recommended in the management of patients with chronic gout, the evidence from trial data for their benefits and safety has not been previously examined in a systematic review.
  
  
  OBJECTIVE
  The objective of this systematic review was to evaluate the benefits and safety of lifestyle interventions for the treatment of people with chronic gout.
  
  
  METHODS
  We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE for studies on 5 April 2013. We also searched the 2010 to 2011 American College of Rheumatology (ACR) and European League against Rheumatism (EULAR) abstracts and performed a handsearch of the reference lists of included articles.
  
  
  METHODS
  Studies were included if they were randomised or quasi-randomised controlled trials (RCTs or CCTs) which compared lifestyle interventions to another therapy (active or placebo) in patients with chronic gout. Outcomes of interest were changes in gout attack frequency, joint pain, serum urate levels, tophus size, function, quality of life and adverse effects.
  
  
  METHODS
  Two review authors independently applied methods recommended by The Cochrane Collaboration for the selection, appraisal, data collection and synthesis of studies. We assessed the quality of the body of evidence for each outcome using the GRADE approach.
  
  
  RESULTS
  Only one study (120 participants), at moderate risk of bias, was included in the review. Patients were randomised to one of three interventions: either skim milk powder (SMP) enriched with glycomacropeptide (GMP) and G600, non-enriched SMP or lactose powder, over a three-month period. The frequency of acute gout attacks, measured as the number of flares per month, decreased in all three groups over the three-month study period. Low quality evidence indicated that there was no difference between the SMP/GMP/G600 group and combined control groups (SMP and lactose powder) at three months (mean difference (MD) -0.21, 95% confidence interval (CI) -0.76 to 0.34). There were no significant between-group differences in terms of withdrawals due to adverse effects (risk ratio (RR) 1.27, 95% CI 0.53 to 3.03), and serious adverse events resulting in hospitalisation (2/40 SMP/GMP/G600 group versus 3/80 controls; RR 1.33, 95% CI 0.23 to 7.66). Gastrointestinal adverse effects were the most commonly reported. Pain from self reported gout flares, measured on a 10-point Likert scale, improved more in the SMP/GMP/G600 group compared to controls (MD -1.03, 95% CI -1.96 to -0.10), an absolute difference of 10% (absolute risk difference -0.10, 95% CI -0.20 to -0.01). This is unlikely to be of clinical significance. Physical function, tophus regression and serum urate normalisation were not reported in this study.
  
  
  CONCLUSIONS
  While there is good evidence from observational studies of an association between various lifestyle risk factors and gout development, there is a paucity of high-quality evidence from randomised controlled trials to either support or refute the use of lifestyle modifications for improving outcomes in people with chronic gout.
authors.affiliation: Department of Rheumatology, The Royal Melbourne Hospital, Parkville, Australia. john.moi@mh.org.au.
authors.forename: John H Y
authors.initials: JH
authors.lastname: Moi
authors.forename: Melonie K
authors.initials: MK
authors.lastname: Sriranganathan
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Edwards
authors.forename: Rachelle
authors.initials: R
authors.lastname: Buchbinder
mesh_terms: D000818:Animals; D002364:Caseins / Q000627:therapeutic use*; D002908:Chronic Disease; D006073:Gout / Q000178:diet therapy*; D006801:Humans; D007785:Lactose / Q000627:therapeutic use*; D008019:Life Style; D008875:Middle Aged; D008892:Milk; D010446:Peptide Fragments / Q000627:therapeutic use*; D011208:Powders; D016032:Randomized Controlled Trials as Topic
chemical_list: D002364:Caseins; D010446:Peptide Fragments; D011208:Powders; C065989:caseinomacropeptide; D007785:Lactose