Gout Clinical Practice Guidelines (ACR, 2020)

American College of Rheumatology

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

November 24, 2020

Guidelines for managing gout were published in June 2020 by the American College of Rheumatology (ACR).[1]

Indications for Pharmacologic Urate-Lowering Therapy (ULT)  

Initiating ULT is strongly recommended for gout patients with ≥1 subcutaneous tophi, evidence of radiographic damage (any modality) attributable to gout, or frequent gout flares (≥2 annually).

Initiating ULT is conditionally recommended for patients who have previously experienced >1 flare but have infrequent flares.

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 (stage ≥3) chronic kidney disease (CKD), serum urate concentration >9 mg/dL, or urolithiasis.

Initiating ULT is conditionally recommended against in patients with asymptomatic hyperuricemia.

Choosing 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—lower in patients with CKD [stage ≥3]) and febuxostat (≤40 mg/day)—with subsequent dose titration is strongly recommended over starting at a higher dose.

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 prophylaxis 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.

Initiating ULT  

Starting ULT while the patient is experiencing a gout flare is conditionally recommended over starting ULT after the gout flare has resolved.

A treat-to-target management strategy that includes ULT dose titration and subsequent dosing guided by serial serum urate measurements to achieve a target serum urate level is strongly recommended over a fixed-dose ULT strategy for all patients receiving ULT.

For all patients receiving ULT, achieving and maintaining a serum uric acid 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 nonphysician 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.

Managing Gout Flares

For treatment of a gout flare, first-line therapy with colchicine, NSAIDs, or glucocorticoids (oral, intra-articular, or intramuscular) is strongly recommended over interleukin-1 (IL-1) inhibitors or adrenocorticotropic hormone (ACTH). 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.

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 ineffective, poorly tolerated, or contraindicated.

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

For more Clinical Practice Guidelines, go to Guidelines.

For more information, go to Gout and Pseduogout.


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