New Gout Guidelines Geared to Both Patients and Physicians

Gout guidelines recently approved by the American College of Rheumatology (ACR) have a 2-part focus. They offer patients information on effective methods for preventing gout attacks, and they provide physicians with recommended therapies for long-term disease management.

In this ACR-funded collaborative effort, US researchers reviewed medical literature from the 1950s to the present. Then, a task force panel that included 7 rheumatologists, 2 primary care physicians, a nephrologist, and a patient representative ranked and voted on the recommendations.

Part I of the guidelines focus on systematic nonpharmacological and pharmacological therapeutic approaches to hyperuricemia. They include the following:

• Providing patients with information on diet, lifestyle choices, treatment objectives, and management of concomitant diseases.
• Treating patients with an xanthine oxidase inhibitor, such as allopurinol, as the first-line approach to pharmacological urate-lowering therapy.
• Recommending that patients’ urate levels be reduced to lower than 6 mg/dL, at a minimum, to improve gout symptoms.
• Suggesting that the initial dose of allopurinol be no greater than 100 mg/d for most patients and less for those who chronic kidney disease (CKD), followed by a gradual increase of the maintenance dose, which can exceed 300 mg/d even in patients with CKD.
• Considering HLA-B*5801 prescreening of patients who are at particularly high risk for a severe adverse reaction to allopurinol (eg, Koreans with stage 3 or worse kidney disease).
• Prescribing combination therapy, with 1 xanthine oxidase inhibitor and 1 uriocosuric agent, when target urate levels are not achieved; prescribing pegloticase for patients with severe gout who do not respond to standard, appropriately dosed urate-lowering therapy.

The part II guidelines for physicians cover therapy and prophylactic anti-inflammatory treatment for patients with acute gouty arthritis. The recommendations include the following:

• Initiating pharmacological therapy within 24 hours of the onset of an acute gouty arthritis attack.
• Continuing urate-lowering therapy, without interruption, during acute gout flares.
• Using NSAIDs, corticosteroids, or oral colchicine as first-line treatment for patients with acute gout and combinations of these medications for severe or unresponsive cases.
• Using oral colchicine or low-dose NSAIDs as first-line treatment options to prevent gout attacks when initiating urate-lowering therapy, as long as there is no medical contraindication or a lack of tolerance.

The gout guidelines are designed to emphasize safety and the quality of therapy and to reflect best practices on the basis of current medical evidence, the researchers noted. The are published in Arthritis Care & Research, an ACR publication.