Management of gout: American College of Rheumatology guideline

Recommendations

Indications for pharmacologic ULT

• Initiating ULT is strongly recommended for gout patients with any of the following: ≥1 subcutaneous tophi; evidence of radiographic damage (any modality) attributable to gout; OR frequent gout flares, with frequent being defined as ≥2 annually.
• Initiating ULT is conditionally recommended for patients who have previously experienced >1 flare but have infrequent flares.
• Initiating ULT is conditionally recommended against in patients with gout experiencing their first gout flare.
• Initiating ULT is conditionally recommended for patients with comorbid moderateto-severe CKD (stage ≥3), SU concentration >9 mg/ dl, or urolithiasis.
• Initiating ULT is conditionally recommended against in patients with asymptomatic hyperuricemia.

Recommendations for choice of initial ULT for patients with gout

• Treatment with allopurinol as the preferred first-line agent, over all other ULTs, is strongly recommended for all patients, including those with moderate-to-severe CKD (stage ≥3).
• The choice of either allopurinol or febuxostat over probenecid is strongly recommended for patients with moderate-to-severe CKD (stage ≥3).
• The choice of pegloticase as a first-line therapy is strongly recommended against.
• Starting treatment with low-dose allopurinol (≤100 mg/day and lower in patients with CKD [stage ≥3]) and febuxostat (≤40 mg/day) with subsequent dose titration over starting at a higher dose is strongly recommended.
• Starting treatment with low-dose probenecid (500 mg once to twice daily) with subsequent dose titration over starting at a higher dose is conditionally recommended.
• Administering concomitant antiinflammatory prophylaxis therapy (e.g., colchicine, nonsteroidal antiinflammatory drugs [NSAIDs], prednisone/ prednisolone) over no antiinflammatory prophylaxis therapy is strongly recommended.
• Continuing concomitant antiinflammatory prophylaxis therapy for 3–6 months is strongly recommended.

Timing of ULT initiation

• When the decision is made that ULT is indicated while the patient is experiencing a gout flare, starting ULT during the gout flare over starting ULT after the gout flare has resolved is conditionally recommended.
• A treat-to-target management strategy that includes ULT dose titration and subsequent dosing guided by serial SU measurements to achieve a target SU, over a fixed-dose ULT strategy, is strongly recommended for all patients receiving ULT.
• Achieving and maintaining an SU target of < 6mg/dl over the use of no target is strongly recommended for all patients receiving ULT.
• Delivery of an augmented protocol of ULT dose management by nonphysician providers to optimize the treat-to-target strategy that includes patient education, shared decision-making, and treat-to-target protocol is conditionally recommended for all patients receiving ULT.