Management of gout: American College of Rheumatology guideline

• Continuing ULT indefinitely over stopping ULT is conditionally recommended.

Recommendations for patients receiving ULT medications

• Testing for the HLA–B*5801 allele prior to starting allopurinol is conditionally recommended for patients of Southeast Asian descent (e.g., Han Chinese, Korean, Thai) and for African American patients, over not testing for the HLA–B*5801 allele.
• Universal testing for the HLA–B*5801 allele prior to starting allopurinol is conditionally recomm - ended against in patients of other ethnic or racial background over testing for the HLA–B*5801 allele.
• As noted above, starting allopurinol in daily doses of ≤100 mg (and lower doses in patients with CKD) is strongly recommended over starting at a higher dose.
• Allopurinol desensitization is conditionally recommended for patients with a prior allergic response to allopurinol who cannot be treated with other oral ULT agents.
• Switching to an alternative oral ULT agent, if available and consistent with other recommendations in this guideline, is conditionally recommended for patients taking febuxostat with a history of CVD or a new CVD-related event.
• Checking urinary uric acid is conditionally recommend against for patients considered for or receiving uricosuric treatment.
• Alkalinizing the urine is conditionally recommended against for patients receiving uricosuric treatment.

Changing ULT strategy

• Switching to a second XOI over adding a uricosuric agent is conditionally recommended for patients taking their first XOI, who have persistently high SU concentrations (>6 mg/dl) despite maximum-tolerated or FDA-indicated XOI dose, and who have continued frequent gout flares (>2 flares/year) OR who have nonresolving subcutaneous tophi.
• Switching to pegloticase over continuing current ULT is strongly recommended for patients with gout for whom XOI treatment, uricosurics, and other interventions have failed to achieve the SU target, and who continue to have frequent gout flares (≥2 flares/year) OR who have nonresolving subcutaneous tophi.
• Switching to pegloticase over continuing current ULT is strongly recommended against for patients with gout for whom XOI treatment, uricosurics, and other interventions have failed to achieve the SU target, but who have infrequent gout flares (<2 flares/year) AND no tophi.

Gout flare management

• Using colchicine, NSAIDs, or glucocorticoids (oral, intraarticular, or intramuscular) as appropriate firstline therapy for gout flares over IL-1 inhibitors or adrenocorticotropic hormone (ACTH) is strongly recommended for patients experiencing a gout flare.
• Given similar efficacy and a lower risk of adverse effects, low-dose colchicine over high-dose colchicine is strongly recommended when colchicine is the chosen agent.
• Using topical ice as an adjuvant treatment over no adjuvant treatment is conditionally recommended for patients experiencing a gout flare.
• Using an IL-1 inhibitor over no therapy (beyond supportive/analgesic treatment) is conditionally recommended for patients experiencing a gout flare for whom the above antiinflammatory therapies are either ineffective, poorly tolerated, or contraindicated.
• Treatment with glucocorticoids (intramuscular, intravenous, or intraarticular) over IL-1 inhibitors or ACTH is strongly recommended for patients who are unable to take oral medications.

Management of lifestyle factors

• Limiting alcohol intake is conditionally recommended for patients with gout, regardless of disease activity.
• Limiting purine intake is conditionally recommended for patients with gout, regardless of disease activity.
• Limiting high-fructose corn syrup intake is conditionally recommended for patients with gout, regardless of disease activity.
• Using a weight loss program (no specific program endorsed) is conditionally recommended for those patients with gout who are overweight/ obese, regardless of disease activity.
• Adding vitamin C supplementation is conditionally recommended against for patients with gout, regardless of disease activity.

Management of concurrent medications

• Switching hydrochlorothiazide to an alternate antihypertensive when feasible is conditionally recommended for patients with gout, regardless of disease activity.
• Choosing losartan preferentially as an antihypertensive agent when feasible is conditionally recommended for patients with gout, regardless of disease activity.
• Stopping low-dose aspirin (for patients taking this medication for appropriate indications) is conditionally recommended against for patients with gout, regardless of disease activity
• Adding or switching cholesterol-lowering agents to fenofibrate is conditionally recommended against for patients with gout, regardless of disease activity.