Atlanta, GA—A central focus of new American College of Rheumatology (ACR) guidelines for management of gout is standard treat-to-target urate-lowering therapy (ULT).

The update 2020 Guideline for the Management of Gout includes new clinical evidence that became available since the ACR last released a treatment guideline for the condition in 2012. The document was published in Arthritis Care & Research.

“With this update, we sought to look at new and emerging clinical evidence that would be beneficial for treating patients with gout,” explained coprincipal investigator John FitzGerald, MD, PhD, a rheumatologist at UCLA.

“The guideline now includes expanded indications for starting ULT, a greater emphasis to use allopurinol as the first line agent for all patients with gout that require urate lowering therapy including those patients with chronic kidney disease, and broadened recommendations about who needs HLA-B*5801 testing prior to starting allopurinol.”

The guidance strongly recommends using a treat-to-target strategy with ULT for all patients with gout, based on data from newer clinical trials. The management strategy includes initiating a low dose of a ULT medication and escalating the dosage to achieve and maintain a serum-urate level of less than 6 mg/dL to optimize patient outcomes over a fixed-dose strategy.

The authors explain that the strategy mitigates the risk of treatment-related adverse effects, such as hypersensitivity and the risk of flares.

Other changes include:
• Indications for starting ULT have been expanded so that patients with infrequent gout flares or have a first gout flare can be considered if they also have moderate-to-severe chronic kidney disease (CKD stage ≥ 3), marked hyperuricemia (serum urate > 9 mg/dl), or kidney stones.
• A conditional recommendation against initiating ULT for patients experiencing their first gout flare without the comorbidities listed above.
• A strong recommendation to use allopurinol as the first-line ULT, including in patients with chronic kidney disease.
• A strong recommendation to use an anti-inflammatory prophylaxis, such as colchicine, nonsteroidal anti-inflammatory drugs, or prednisone/prednisolone, for at least 3 to 6 months, rather than less than 3 months when initiating ULT, with ongoing evaluation and continued prophylaxis as needed if the patient continues to experience flares.
• A conditional recommendation for HLA-B*5801 testing prior to starting allopurinol for patients of Southeast Asian descent, e.g., Han Chinese, Korean, Thai, and African-American descent who have a higher prevalence of HLA-B*5801, but against HLA-B*5801 testing in patients of other ethnic or racial backgrounds. 

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