2020 American College of Rheumatology Guideline for the Management of Gout

Gout is rather common in Mauritius and, as a nephrologist, I’m surprised by the high occurrence of kidney stones here, many related to gout. Raised serum uric acid (SU) is even more prevalent and often misleadingly referred by ‘gout’ by many local patients and even some doctors.

The American College of Rheumatology (ACR) recommends against treating asymptomatic patients with raised SU. This is particularly important in Mauritius where we have people of Chinese and African ancestry who carry the HLA–B*5801 allele. Carriers are at risk of severe hypersensitivity reactions with allopurinol which remains the first line ULT.

A new ‘take home’ message for me is that we can now start a urate lowering therapy (ULT) during an acute gout flare if indicated. Treatment is to a target of 360mmol/l. Colchicine is listed ahead of NSAIDS (eternal bane of the nephrologist) and corticosteroids for the relief of acute gout.

I invite you to visit the gout page of the ACR and read in detail the 2020 American College of Rheumatology Guideline for the Management of Gout. If you’re in a hurry, I have compiled all the recommendations for you below. Note that for uric acid 1mg/dl is almost the same as 60mmol/l and our cane sugar is almost as bad as high-fructose corn syrup.

2020 American College of Rheumatology Guideline for the Management of Gout 

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 (<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 comorbid moderate-to-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 anti-inflammatory prophylaxis therapy (e.g., colchicine, nonsteroidal anti-inflammatory drugs [NSAIDs], prednisone/ prednisolone) over no anti-inflammatory prophy- laxis therapy is strongly recommended. 

Continuing concomitant anti-inflammatory 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. 

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 condition- ally 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 non-physician 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. 

Duration of ULT

Continuing ULT indefinitely over stopping ULT is conditionally recommended. 

Allopurinol 

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 pri- or to starting allopurinol is conditionally recommended against in patients of other ethnic or racial background over testing for the HLA–B*5801 allele. 

As noted above, starting allopurinol in daily doses of ≤100 mg (and lower doses in patients with CKD) is strongly recommended over starting at a higher dose. 

Allopurinol desensitization is conditionally recommended for patients with a prior allergic response to allopurinol who cannot be treated with other oral ULT agents. 

Febuxostat 

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. 

Uricosurics 

Checking urinary uric acid is conditionally recommend against for patients considered for or receiving uricosuric treatment. 

Alkalinizing the urine is conditionally recommended against for patients receiving uricosuric treatment. 

When to consider changing ULT strategy 

Switching to a second XOI over adding a uricosuric agent is conditionally recommended for patients taking their first XOI, who have persistently high SU concentrations (>6 mg/dl) de- spite maximum-tolerated or FDA-indicated XOI dose, and who have continued frequent gout flares (>2 flares/year) OR who have non-resolving subcutaneous tophi. 

Switching to pegloticase over continuing cur- rent 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 cur- rent 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 

Using colchicine, NSAIDs, or glucocorticoids (oral, intra-articular, 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. 

Given similar efficacy and a lower risk of ad- verse effects, low-dose colchicine over high-dose colchicine is strongly recommended when colchicine is the chosen agent. 

Using topical ice as an adjuvant treatment over no adjuvant treatment is conditionally 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 anti-inflammatory therapies are either ineffective, poorly tolerated, or contraindicated. 

Treatment with glucocorticoids (intramuscular, intravenous, or intra-articular) over IL-1 inhibitors or ACTH is strongly recommended for patients who are unable to take oral medications. 

Management of lifestyle factors 

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. 

Management of 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. 

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