ACR releases gout management guideline with emphasis on treat-to-target strategy for urate lowering therapy
The American College of Rheumatology (ACR) released the 2020 Guideline for the Management of Gout. 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.
“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 ULT, 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.”
A highlight of the updated guideline is a strong recommendation to use a treat-to-target strategy with ULT for all patients with gout, based on data from newer clinical trials. 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 ULT initiation. Other recommendations include:
• 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.
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.
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 https://www.rheumatology.org/Practice-Quality/Clinical-Support/Clinical-Practice-Guidelines/Gout.