Allopurinol is first line therapy for Gout, declare ACR Guidelines

American College of Rheumatology has recommended Allopurinol as the first-line treatment for managing gout .According to updated guidelines from the Allopurinol is strongly recommended for all patients, including those with stage 3 and above chronic kidney disease.

In its 2012 guidelines, the ACR had also recommended febuxostat as a first-line agent.Febuxostat has not been recommended as first line therapy in Gout in new guidelines owing to treatment costs and cardiovascular concerns.

It is recommended that patients with a new cardiovascular disease (CVD) event or a history of CVD events should consider switching from febuxostat, as it has been associated with a higher risk for CVD mortality. Either febuxostat or allopurinol is still recommended over probenecid for patients with moderate-to-severe chronic kidney disease.

Gout is the most common form of inflammatory arthritis which is painful and potentially disabling.It can affect anyone and symptoms are usually intense episodes of painful swelling in single joints, most often in the feet, especially the big toe, but any joint can be involved.

"With this update, we sought to look at new and emerging clinical evidence that would be beneficial for treating patients with gout ," said John FitzGerald, MD, PhD, a rheumatologist and one of the guideline's co-principal investigators. "The guideline now includes expanded indications for starting urate lowering therapy, a greater emphasis to use allopurinol as the first line agent for all patients with gout that require urate lowering therapy including those patients with chronic kidney disease, and broadened recommendations about who needs HLA-B*5801 testing prior to starting allopurinol."

Among the 42 recommendations offered, addressing standard treat-to-target urate lowering therapy (ULT) was a key focus for the authors due to its benefit for all patients with gout that are on ULT.

The guideline suggests a management strategy of starting with a low-dose of a ULT medication and escalating the dosage to achieve and maintain a serum urate level of less than 6 mg/dL to optimize patient outcomes over a fixed-dose strategy. This strategy mitigates the risk of treatment-related adverse effects (i.e., hypersensitivity), as well as flare risk accompanying urate lowering therapy initiation.

The key recommendations arr

Indications for starting ULT have been expanded to conditionally consider patients with infrequent gout flares or after their first gout flare if they also have moderate to severe chronic kidney disease (CKD stage ≥ 3), marked hyperuricemia (serum urate > 9 mg/dl) or kidney stones.

A conditional recommendation against initiating ULT for patients experiencing their first gout flare without above comorbidities.

A strong recommendation to use allopurinol as the first-line ULT, including in patients with chronic kidney disease.

A strong recommendation to use an anti-inflammatory prophylaxis (e.g., colchicine, NSAIDs, prednisone/prednisolone) when starting ULT for at least 3-6 months rather than less than 3 months, with ongoing evaluation and continued prophylaxis as needed if the patient continues to experience flares.

A conditional recommendation for HLA-B*5801 testing prior to starting allopurinol for patients of Southeast Asian descent (e.g., Han Chinese, Korean, Thai) and African American descent who have a higher prevalence of HLA-B*5801 and against HLA-B*5801 testing in patients of other ethnic or racial backgrounds.

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https://doi.org/10.1002/art.41247