Guidelines for Treating Gout

The American College of Rheumatology (ACR) has updated its recommendations for managing gout, an inflammatory type of arthritis that affects an estimated 9.2 million adults in the United States. The 2020 guidelines update those issued in 2012, based on new evidence from recent studies and input from experts and patients. Among other points, they clarify the use of medications that lower uric acid levels and the use of treat-to-target strategy to control the disease. The 2012 guideline's treat-to-target recommendation had raised questions due to poor evidence. Since then, several clinical trials have produced more evidence in favor of using this strategy with urate-lowering medications.

The new guidelines include 42 recommendations, including 16 “strong” recommendations, which means there’s a “moderate or high certainty of evidence where the benefits consistently outweigh the risks,” and where doctors are likely to make the same recommendation. For “conditional” recommendations, “benefits and risks may be more closely balanced and/or only low certainty of evidence or no data are available,” according to the guideline, published May 10 in Arthritis & Rheumatology.

While these recommendations are based on evidence, they might not be right for every patient. The final decisions about your treatment lie with you and your doctor. Following are some of the recommendations in the guideline.

• Treating gout with urate-lowering medications is strongly recommended for patients who have tophi (nodules that form from a mass of uric acid crystals at joints or in soft tissues), radiographic evidence (X-ray or other imaging) of damage due to gout, or two or more gout flares per year.
• Allopurinol is strongly recommended as a first-line urate-lowering medication over all others for all patients.
• Allopurinol or febuxostat is strongly recommended over probenecid as a first-line treatment for patients with moderate-to-severe chronic kidney disease.
• The use of pegloticase is strongly recommended against as a first-line treatment.
• Starting with a low dose of allopurinol and febuxostat is strongly recommended over starting at a higher dose.
• Using anti-inflammatory medication, such as colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs) or prednisone or prednisolone as a preventive measure along with urate-lowering meds is strongly recommended over not using anti-inflammatory meds. Continuing the anti-inflammatory meds for three to six months with regular monitoring and adjustments if gout flares continue is also strongly recommended.
• Using treat-to-target strategy by adjusting urate-lowing meds to reach a target uric acid level of less than 6 mg/dl (milligrams per deciliter) is strongly recommended over using a fixed dose of the medication and no target.
• When using other medications and interventions fails to reach the target urate level and the patient continues to have frequent (two or more a year) gout flares or tophi, it is strongly recommended that they switch to pegloticase instead of continuing the current urate-lowering drug. But switching to pegloticase is strongly recommended against for patients who haven’t reached a target urate level but don’t have frequent flares.
• Using colchicine, NSAIDs or glucocorticoids (corticosteroids) as a first-line treatment for the management of flares is strongly recommended over interleukin-1 inhibitors (biologic medications) or hormone treatments (ACTH). Low-dose colchicine is strongly recommended over high-dose. For those who can’t take oral medications, glucocorticoid shots are strongly recommended.

• For those taking urate-lowering drugs who are not having flares or tophi, continuing on the medication is conditionally recommended over stopping it.
• Adding or switching to fenofibrate from another cholesterol-lowering drug is conditionally recommended against.
• Switching from hydrochlorothiazide to a different medication for hypertension if possible – preferably losartan – is conditionally recommended.
• Limiting consumption of alcohol, purines and high-fructose corn syrup are conditionally recommended.
• Using some weight-loss program is conditionally recommended for gout patients who are overweight or obese.
• Supplementing vitamin C is conditionally recommended against.
• For patients who have been advised to take low-dose aspirin, stopping it is conditionally recommended against.

Genes play a distinct role in the development of gout. Although some healthy lifestyle habits are conditionally recommended, these measures may not be as effective for some patients.

Talk to your doctor before making any changes in your gout treatment and if your gout is not well controlled, ask if these guidelines might help.