New 2020 Gout management guidelines by ACR
ATLANTA – American College of Rheumatology (ACR) has released the 2020 Guideline for the Management of The guidelines have been published in the journal Arthritis Care & Research.
Gout is the most common form of inflammatory arthritis, affecting about 9.2 million adults in the United States. This condition is painful and potentially disabling, can affect anyone, and its risk factors vary. 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.
The updated guideline reflects new clinical evidence that became available since the ACR last released a treatment guideline for the condition in 2012, 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.
Key recommendations include-
"Urate Lowering Therapy (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 (<2/year).
Initiating ULT is conditionally recommended against in patients with gout experiencing their first gout flare.
However, initiating ULT is conditionally recommended for patients with experiencing their first flare when comorbid moderate‐to‐severe CKD (stage ≥3), SU concentration >9 mg/dl, or urolithiasis is present.
Initiating ULT is conditionally recommended against in patients with asymptomatic hyperuricemia.
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).
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.
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 over <3 months, with ongoing evaluation and continued prophylaxis as needed if the patient continues to experience gout flares, is strongly recommended.
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 <6 mg/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.
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 recommended against in patients of other ethnic or racial background over testing for the HLA–B*5801 allele.
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.
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 recommendations-
Using colchicine, NSAIDs, or glucocorticoids (oral, intraarticular, or intramuscular) as appropriate first‐line therapy for gout flares over IL‐1 inhibitors or adrenocorticotropic hormone (ACTH) is strongly 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.
Lifestyle Factors recommendations
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.
Recommendations about 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.
ACR guidelines are currently developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, which creates rigorous standards for judging the quality of the literature available and assigns strengths to the recommendations. The updated and expanded recommendations can be viewed at Clinical Practice Guidelines Gout.
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