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American College of Rheumatology guideline for managing patients with gout
Clinical Question
How should clinicians manage patients with gout?
Bottom line
The following are some of the strong recommendations from the American College of Rheumatology (ACR) for managing patients with gout: start urate-lowering therapy (ULT) for all patients with tophi, frequent gout flares (2 or more per year), or those with radiographic evidence of joint damage attributable to gout; use allopurinol as the preferred first-line medication, including for patients with stage 3 or worse chronic kidney disease; and treat patients to a serum urate target of less than 6 mg/dL. When initiating ULT, the ACR strongly recommends concomitant anti-inflammatory prophylactic therapy for at least 3 months to 6 months. Finally, the ACR strongly recommends using colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs), or glucocorticoids (oral, intra-articular, or intramuscular) to manage gout flares. 5
Reference
Study design: Practice guideline
Funding: Self-funded or unfunded
Setting: Outpatient (any)
Synopsis
The ACR assembled a guideline development team consisting of the usual suspects plus a general internist, a physician assistant, and a patient representative. This team used modern guideline development methods consisting of 57 (57!) framing-focused questions, systematic reviews (including network meta-analyses) of the literature, and an explicit process to synthesize all their findings into actionable recommendations. They made strong recommendations when there was moderate- or high-certainty evidence that the benefits consistently outweigh the harms, and they made conditional recommendations when the harms and benefits were too close to call or when the evidence was shaky. The following is a brief summary of some of their 42 recommendations. They made strong recommendations for ULT in patients with tophi, frequent gout flares (2 or more per year), or those with radiographic evidence of joint damage attributable to gout. They made a conditional recommendation for ULT in patients with infrequent flares, those with stage 3 or worse chronic kidney disease, with urolithiasis, or those with urate levels exceeding 9 mg/dL. They made conditional recommendations against starting ULT after a first flare and for those with asymptomatic hyperuricemia. The ACR also strongly recommends allopurinol as the drug of first choice, including for those with chronic kidney disease. They recommend switching febuxostat to another agent in patients with cardiovascular disease The panel also strongly recommends adding an anti-inflammatory (colchicine, NSAIDs, or prednisone/prednisolone at the discretion of the clinician) for 3 to 6 months when initialing ULT. They made a strong recommendation to treat to a target urate levels of less than 6 mg/dL. During acute flares, the ACR strongly recommends using low-dose colchicine, NSAIDs, or corticosteroids (oral, intra-articular, or intramuscular) and conditionally recommends ice application to the affected joint. They made conditional recommendations to limit the intake of alcohol, purines, high-fructose corn syrup and a conditional recommendation against the addition of vitamin C. The panel also conditionally recommends switching hydrochlorothiazide to a different antihypertensive in patients who take it. There are many more recommendations, including medication dosing, when to consider pegloticase, when to consider HLA testing, and so forth.
Reviewer
Henry C. Barry, MD, MS
Professor
Michigan State University
East Lansing, MI