Treatment of gout: Latest Clinical practice guideline by APLAR

Gout is the most prevalent inflammatory arthritis in the Asia-Pacific region and worldwide. Lorenzo et al recognized the need to formulate and release unified Asia-Pacific guidelines for treatment of gout. This clinical practice guideline (CPG) aims to provide recommendations based on systematically obtained evidence and values and preferences tailored to the unique needs of patients with gout and hyperuricemia in Asia, Australasia, and the Middle East.

Relevant clinical questions were formulated by the Steering Committee for which systematic reviews of evidence were done, and certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation methodology.

The Consensus Panel (CP) was composed of 9 key stakeholders (rheumatologists, general practitioners, academicians, and a patient representative) from Australia, Bangladesh, Indonesia, Iraq, Philippines, Singapore, Sri Lanka, and Taiwan.

Clinical practice guideline for treatment of gout has 3 overarching principles and 22 recommendation statements.

Overarching principles

1. Recognition of gout and its complications needs collaborations among physicians and allied health professionals. Further, patient education and shared decision making between physicians and patients are essential.

2. Gout management should be holistic which includes urate-lowering medications, appropriate lifestyle choices and treatment of comorbidities such as cardiovascular diseases, hypertension, diabetes mellitus, metabolic syndrome, and renal disease.

3. Treatment of acute gout flares requires anti-inflammatory medications. Treatment should also aim to prevent organ damage by removing monosodium urate (MSU) deposits from the body by lowering serum uric acid below its saturation point.

Final set of 22 recommendations:

Treatment of asymptomatic hyperuricemia

1. Among patients with asymptomatic hyperuricemia and hypertension, they recommend against urate-lowering therapy (ULT) to reduce the risk of major cardiovascular events or mortality (cardiovascular and all-cause).

2. Among patients with asymptomatic hyperuricemia and chronic kidney disease, there is insufficient evidence to recommend for or against ULT to reduce the risk of mortality, major acute cardiovascular events, or to prevent progression to end-stage kidney disease.

Treatment of acute gout

3. Among patients with acute gouty arthritis, they recommend the use of colchicine, NSAIDs or systemic corticosteroids as first-line therapy to reduce pain.

4. Among patients with acute gouty arthritis, they recommend a low-dose regimen of colchicine (1.5-1.8 mg/d) over a high-dose regimen (4.5-4.8 mg/d) to reduce pain.

5. Among patients with acute gouty arthritis, there is insufficient evidence to recommend for or against the use of intra-articular corticosteroids to reduce pain.

6. Among ULT-naïve patients with gout, there is insufficient evidence to recommend initiating ULT during acute gout flare over initiating after the flare.

Prophylaxis against gout flare when initiating ULT

7. Among adults with gout initiating ULT, they recommend the use of low-dose colchicine prophylaxis.

8. Among adults with gout initiating ULT who are intolerant or with contraindications to colchicine, they suggest NSAIDs as second-line prophylaxis.

9. Among adults with gout initiating ULT, there is insufficient evidence to recommend for or against the use of systemic corticosteroids as prophylaxis.

Urate-lowering therapy

10. In populations with a high (≥5%) prevalence of HLA-B*5801 allele, they suggest testing for HLA-B*5801 prior to initiating allopurinol.

11. Among gout patients with high prevalence of HLA-B*5801, they neither recommend for or against febuxostat over allopurinol.

12. Among patients newly diagnosed with gout and a serum uric acid level of ≥9 mg/dL, they suggest initiating ULT to prevent recurrence of gout flare.

Treatment of chronic tophaceous gout

13. Among patients with chronic tophaceous gout, they recommend the use of a xanthine oxidase inhibitor (allopurinol or febuxostat) over no ULT to achieve resolution of tophi.

14. Among chronic tophaceous gout patients with serum uric acid >6 mg/dL, they suggest against adding lesinurad to a xanthine oxidase inhibitor for resolution of tophi.

Treatment of complicated gout and non-responders

15. Among adults with refractory gout, there is insufficient evidence to recommend uricosuric agent and xanthine oxidase inhibitor combinations other than lesinurad-allopurinol to reduce serum uric acid levels and reduce gout flares.

16. Among adults with refractory gout who have contraindications or inadequate response to xanthine oxidase inhibitor treatment, they suggest the use of pegloticase (if available) to achieve target serum uric acid level and prevent gout flare.

Treatment of gout with moderate to severe renal impairment

17. Among adult patients with gout and renal impairment, there is insufficient evidence to recommend for or against the use of ULT to prevent chronic kidney disease progression.

Non-pharmacologic interventions

18. Among patients with gout, they suggest limiting alcohol intake to moderate amounts to prevent acute gout flare.

19. Among patients with gout, there is insufficient evidence to recommend for or against limiting purine-rich food to prevent gout flares or reduce serum uric acid levels.

20. Among overweight and obese patients with gout, they suggest prescribing weight reduction interventions to prevent gout flares and lower serum uric acid levels.

21. Among patients with acute gout flare with intolerance or contraindication to standard of care anti-inflammatory medications, acupuncture may be an option for pain relief.

22. Among adults with gout, there is insufficient evidence to recommend for or against herbal medicine in the treatment of pain.

Recommendations for clinically relevant scenarios in the management of gout were formulated to guide physicians in administering individualized care.

Further reading:

2021 Asia-Pacific League of Associations for Rheumatology clinical practice guideline for treatment of gout. LORENZO et al.

International Journal of Rheumatic Dis. 2022; 25:7–20.DOI: 10.1111/1756-185X.14266