New Gout Guidelines

New Guidelines for Treating and Preventing Gout

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Gout is one of the most common forms of inflammatory arthritis, affecting nearly 4% of adult Americans. Newly approved guidelines that educate patients in effective methods to prevent gout attacks and provide primary care providers with recommended therapies for long-term management of this painful disease were recently published in Arthritis Care & Research.[1][2]

Clinician-diagnosed gout has risen over the past 20 years and now affects 8.3 million people in the U.S.[1] Medical evidence suggests that the increased prevalence of elevated uric acid levels and gout may be attributed to such factors as hypertension, obesity, metabolic syndrome, type 2 diabetes, and extensive treatment with thiazide and loop diuretics for cardiovascular disease.

A writing team reviewed medical literature from the 1950s to the present. A task force panel including seven rheumatologists, two primary care physicians, a nephrologist, and a patient representative then ranked and voted upon recommendations to create the two-part ACR gout guidelines.

Part I of the guidelines focuses on the systematic nonpharmacologic and pharmacologic therapeutic approaches to hyperuricemia. Part I guidelines include:

  • Educating patients on diet, lifestyle choices, treatment objectives, and management of concomitant diseases.
  • Treating patients with a xanthine oxidase inhibitor (XOI), such as allopurinol (Zyloprim), as first-line pharmacologic urate-lowering therapy (ULT) approach.
  • Reducing urate levels to less than 6 mg/dL.
  • Maintain the initial dose of allopurinol to less than 100 mg/day, and less for patients with chronic kidney disease. Maintenance dose can exceed 300 mg even in those with chronic kidney disease.
  • Consideration of HLA-B*5801 pre-screening of patients at particularly high risk for severe adverse reaction to allopurinol (e.g., Koreans with stage 3 or worse kidney disease, and all those of Han Chinese and Thai descent).
  • Prescribing combination therapy, with one XOI and one uriocosuric agent, when target urate levels are not achieved; pegloticase in patients with severe gout disease who do not respond to standard, appropriately dosed ULT therapy.

Part II guidelines cover therapy and prophylactic anti-inflammatory treatment for acute gouty arthritis. Part II guidelines recommend that physicians:

  • Initiate pharmacologic therapy within 24 hours of gout attack.
  • Continue uninterrupted ULT therapy during acute gout flares.
  • Use non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, or oral colchicine as first-line treatment for acute gout, and combinations of these medications for severe or unresponsive cases.
  • Unless otherwise contradicted, use oral colchicine or low-dose NSAIDs as the first-line therapy options to prevent gout attacks when initiating ULT.

 

References

  1. Khanna D, FitzGerald JD, Khanna PP, et al. 2012 American College of Rheumatology Guidelines for Management of Gout Part I: Systematic Non-pharmacologic and Pharmacologic Therapeutic Approaches to Hyperuricemia. Arthritis Care Res (Hoboken). 2012 Oct;64(10):1431-46.
  2. Khanna D, Khanna P, Fitzgerald JD, et al. 2012 American College of Rheumatology Guidelines for Management of Gout Part II: Therapy and Anti-inflammatory Prophylaxis of Acute Gouty Arthritis. Arthritis Care Res (Hoboken). 2012 Oct;64(10):1447-61.