ACR Issues New Guideline for The Management of Gout

The American College of Rheumatology (ACR) recently released updated guidelines for managing gout.

As the most prevalent inflammatory arthritis, gout afflicts about 9.2 million U.S. adults; still, quality of care gaps remain. Previous guidelines—including the 2012 ACR Guidelines for the Management of Gout—suggest that treat-to-target strategies with urate-lowering therapy (ULT) be used. However, ULT utilization has not increased in two decades, and adherence is still poor—in fact, it’s the lowest adherence among treatments for seven chronic conditions. Improving adherence has been difficult in part because the ACR’s guidelines from 2012 had low-quality evidence for its treat-to-target recommendations.

“Since the 2012 ACR Guidelines for the Management of Gout were published, several clinical trials have been conducted that provide additional evidence regarding the management of gout, leading the ACR Guidelines Subcommittee to determine that new guidelines were warranted,” the researchers explained.

For the updated guidelines, researchers crafted 57 population, intervention, comparator, and outcomes questions, and then conducted a systematic literature review, including network meta-analyses, and patient input. The final recommendations were decided, with their strength graded as strong or conditional, using a group consensus process.

ACR Has 16 Strong Gout Recommendations

ACR generated 42 recommendations, of which 16 were strong. Among the strong recommendations were:

  • Initiating ULT 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
  • Treatment with allopurinol as the preferred first‐line agent, over all other ULTs, for all patients, including those with moderate‐to‐severe CKD (stage ≥3)
  • The choice of either allopurinol or febuxostat over probenecid for patients with moderate‐to‐severe CKD (stage ≥3)
  • 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
  • Administering concomitant antiinflammatory prophylaxis therapy (e.g., colchicine, nonsteroidal antiinflammatory drugs [NSAIDs], prednisone/prednisolone) over no antiinflammatory prophylaxis therapy
  • Continuing concomitant antiinflammatory 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
  • 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, for all patients receiving ULT
  • Achieving and maintaining an SU target of <6 mg/dl over the use of no target for all patients receiving ULT
  • Switching to pegloticase over continuing current ULT 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 current ULT is strongly recommended againstfor 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
  • Using colchicine, NSAIDs, or glucocorticoids (oral, intraarticular, or intramuscular) as appropriate first‐line therapy for gout flares over IL‐1 inhibitors or adrenocorticotropic hormone (ACTH) for patients experiencing a gout flare
  • Given similar efficacy and a lower risk of adverse effects, low‐dose colchicine over high‐dose colchicine is strongly recommended when colchicine is the chosen agent
  • Treatment with glucocorticoids (intramuscular, intravenous, or intraarticular) over IL‐1 inhibitors or ACTH for patients who are unable to take oral medications

In their conclusion ACR emphazied that “gout has been characterized as a ‘curable disease’. As data continue to emerge supporting best practices in management, implementation of these recommendations will ideally lead to improved quality of care for patients with gout.”