Gout Treatment Guidelines by the American College of Rheumatology

Recommendations for managing gout include both medications and lifestyle changes.


Whether you are newly diagnosed with gout or suffering from an acute attack, your doctor can turn to treatment guidelines when developing your treatment program.

Issued by the American College of Rheumatology (ACR), the guidelines were put together using input from national and international medical experts and published in the October 2012 issue of Arthritis Care & Research.  They include both pharmacologic approaches and lifestyle and dietary changes that could affect the course of gout.Key recommendations for gout management include:

  • Increased intake of vegetables;
  • Decreased intake of purine-rich meat and seafood;
  • Reduced alcohol consumption, especially beer, and no alcohol during an acute gout attack;
  • Consideration of allopurinol (Zyloprim) and febuxostat (Uloric) as first-line pharmacologic agents to lower uric acid levels;
  • Use of screening tests to determine allopurinol hypersensitivity before initiating therapy in susceptible patients;
  • Dosing allopurinol initially at no more than 100 mg/day – and less than that in those with moderate to severe chronic kidney disease, with gradual increases in dose to at least 300 mg/day in both groups;
  • Establishing target serum uric acid levels of less than 6 milligrams per deciliter (mg/dL);
  • Use of combination therapies if allopurinol or febuxostat alone do not sufficiently lower uric acid levels;
  • Use of pegloticase, or Krystexxa, if other therapies fail and gout is severe.

ACR created guidelines for gout both because of the increasing incidence of the disease and the development of new drugs to treat it, says Robert Terkeltaub, MD, chief of rheumatology at the VA Medical Center in San Diego, professor of medicine at the University of California, San Diego, and senior author of the guidelines.

The guidelines also focus on lifestyle recommendations such as getting down to an ideal body weight and drinking enough fluids.

Daniel H. Solomon, MD, a professor of medicine at Harvard Medical School in Boston, who co-authored an editorial in the same issue, reviewing the role of diet in gout, calls lifestyle and dietary changes “very important” in gout management. “They may not yield immediate results,” he says. “However, lifestyle changes and diet can yield clinically significant reductions in uric acid in some people.”

Even so, both Dr. Terkeltaub and Dr. Solomon say most people with gout will require some form of drug treatment.

A second set of recommendations, published in the same issue, addresses the topic of treating an acute attack of gout. Some of the key points include:

  • Treating with medication within 24 hours of the start of an attack;
  • Use of nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine (Colcrys), and oral corticosteroids, either alone or, in some cases, in combination, as first-line options;
  • Use of urate-lowering drugs throughout the attack period;
  • Use of anti-inflammatory therapy after the acute attack if there is any evidence of disease activity and/or if serum uric acid has not reached target levels.

Dr. Terkeltaub says the recommendations do more than just serve as a guide for patients and clinicians. “It brings gout into the limelight more, and that’s something important.”

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