Gout Clinical Practice Guidelines (ACR, 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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Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.

Cite this: Gout Clinical Practice Guidelines (ACR, 2020) - Medscape - Nov 24, 2020.