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American College of RheumatologyRheumatology2020advanced

Management of Gout

Published by American College of Rheumatology · GRADE

42Recommendations
118References
8Tables

Summary

AI-generated

Gout is the most common form of inflammatory arthritis, affecting approximately 9.2 million adults in the US. Despite the availability of effective and inexpensive medications, gaps in quality of care persist. The 2020 guideline was developed using GRADE methodology to update the 2012 recommendations, incorporating new clinical trial evidence regarding treat-to-target strategies, urate-lowering therapies (ULT), and patient preferences to improve gout management.

gouturic acidallopurinolcolchicineNSAIDsglucocorticoidsACRrheumatology

Key Takeaways

  • 1
    Initiation of urate-lowering therapy (ULT) is strongly recommended for patients with tophaceous gout, radiographic damage, or frequent gout flares.
  • 2
    Allopurinol is the strongly preferred first-line ULT agent, including for patients with moderate-to-severe CKD.
  • 3
    A treat-to-target strategy is strongly recommended, involving dose titration guided by serial SU measurements to achieve a target of <6 mg/dl.
  • 4
    Concomitant antiinflammatory prophylaxis (colchicine, NSAIDs, or glucocorticoids) is strongly recommended for at least 3-6 months when initiating ULT.
  • 5
    Colchicine, NSAIDs, or glucocorticoids are the strongly recommended first-line therapies for acute gout flares.

What's New in This Version

This 2020 guideline updates the 2012 ACR Guidelines. It breaks from prior ACR and EULAR guidelines by not specifying SU thresholds lower than <6 mg/dl for severe disease. It firmly establishes allopurinol as the preferred first-line ULT for all patients, including those with CKD. Indications for ULT are expanded to include evidence of radiographic damage regardless of tophi or flare frequency.

Key Recommendations

Indications for pharmacologic ULT

  • PICO_1

    For patients with 1 or more subcutaneous tophi, we strongly recommend initiating ULT over no ULT.

    StrongEvidence: HighPharmacologic
  • PICO_2

    For patients with radiographic damage (any modality) attributable to gout, we strongly recommend initiating ULT over no ULT.

    StrongEvidence: ModeratePharmacologic
  • PICO_3

    For patients with frequent gout flares (≥2/year), we strongly recommend initiating ULT over no ULT.

    StrongEvidence: HighPharmacologic
  • PICO_57

    For patients with asymptomatic hyperuricemia (SU >6.8 mg/dl with no prior gout flares or subcutaneous tophi), we conditionally recommend against initiating any pharmacologic ULT.

    ConditionalEvidence: HighPharmacologic

Recommendations for choice of initial ULT in patients with gout

  • PICO_10

    For patients starting any ULT, we strongly recommend allopurinol over all other ULT as the preferred first-line agent for all patients, including in those with CKD stage ≥3.

    StrongEvidence: ModeratePharmacologic
  • PICO_7

    For allopurinol and febuxostat, we strongly recommend starting at a low dose with subsequent dose titration to target over starting at a higher dose.

    StrongEvidence: ModeratePharmacologic
  • PICO_9

    We strongly recommend initiating concomitant antiinflammatory prophylaxis therapy (e.g., colchicine, NSAIDs, prednisone/prednisolone) over no antiinflammatory prophylaxis for 3–6 months.

    StrongEvidence: ModeratePharmacologic

Recommendations for all patients taking ULT

  • PICO_13

    For all patients taking ULT, we strongly recommend a treat-to-target strategy of ULT dose management that includes dose titration and subsequent dosing guided by serial SU values to achieve an SU target.

    StrongEvidence: ModerateDisease Management
  • PICO_14

    For all patients taking ULT, we strongly recommend continuing ULT to achieve and maintain an SU target of <6 mg/dl over no target.

    StrongEvidence: HighDisease Management

Gout flare management

  • PICO_32

    For patients experiencing a gout flare, we strongly recommend using oral colchicine, NSAIDs, or glucocorticoids as appropriate first-line therapy for gout flares over IL-1 inhibitors or ACTH.

    StrongEvidence: HighPharmacologic

Management of lifestyle factors

  • PICO_41

    For patients with gout, regardless of disease activity, we conditionally recommend limiting alcohol intake.

    ConditionalEvidence: LowLifestyle

Scope & Objectives

Clinical Topic

Management of Gout

Objectives

To provide guidance for the management of gout, including indications for and optimal use of urate-lowering therapy (ULT), treatment of gout flares, and lifestyle and other medication recommendations.

Target Patient Population

Patients with gout and individuals with asymptomatic hyperuricemia

Target Providers

RheumatologistsGeneral InternistsNephrologistsPhysician AssistantsPrimary Care Providers

Patient Criteria & Setting

Therapeutic Area

Rheumatology

Guideline Scope

Disease ManagementPharmacologic TherapyLifestyle Interventions

Special Populations

Patients with moderate-to-severe chronic kidney disease (CKD stage >3)Patients of Southeast Asian descentAfrican American patientsPatients with a history of cardiovascular disease (CVD)

Evidence Grading

System: GRADE

Evidence Distribution

42total_recommendations
16strong_recommendations
26conditional_recommendations

Evidence Levels

LowLow certainty of evidence
HighHigh certainty of evidence
ModerateModerate certainty of evidence
Very LowVery low certainty of evidence

Recommendation Strength

StrongReflect decisions supported by moderate or high certainty of evidence where the benefits consistently outweigh the risks, and, with only rare exceptions, an informed patient and his or her provider would be expected to reach the same decision.
ConditionalReflect scenarios for which the benefits and risks may be more closely balanced and/or only low certainty of evidence or no data are available.

Safety & Contraindications

Contraindications

  • Avoid febuxostat in patients with a history of CVD or a new CVD event if alternatives are available.
  • Universal HLA-B*5801 testing is recommended prior to allopurinol use in patients of Southeast Asian descent and African Americans to prevent severe hypersensitivity.
  • Uricosurics should be avoided in patients with known renal calculi or moderate-to-severe CKD.

Monitoring Guidance

Serial serum urate (SU) measurements should be checked after each dose titration to guide ULT management and ensure an SU target of <6 mg/dl is achieved and maintained.

Authors & Contributors

John D. FitzGeraldNicola DalbethTed MikulsRomina Brignardello-PetersenGordon GuyattAryeh M. AbelesAllan C. GelberLeslie R. HarroldDinesh KhannaCharles KingGerald LevyCaryn LibbeyDavid MountMichael H. PillingerAnn RosenthalJasvinder A. SinghJames Edward SimsBenjamin J. SmithNeil S. WengerSangmee Sharon BaeAbhijeet DanvePuja P. KhannaSeoyoung C. KimAleksander LenertSamuel PoonAnila QasimShiv T. SehraTarun Sudhir Kumar SharmaMichael ToproverMarat TurgunbaevLinan ZengMary Ann ZhangAmy S. Turnerand Tuhina Neogi

Guideline Features

Dosing informationBased on systematic reviewMultidisciplinaryPatient involvementDrug interactions discussed

Learning Context

Difficulty

advanced

Learning Paths

Gout ManagementUrate-Lowering TherapyRheumatologyHyperuricemiaTreat-to-TargetPharmacotherapy