American College of Rheumatology Releases 2020 Gout Guidelines
By Jessica Pyhtila, PharmD, BCGP, BCPS
The American College of Rheumatology recently authored a 2020 update to its 2012 gout guidelines. The update addressed both pharmacologic and nonpharmacologic treatment strategies for gout management.
The guidelines recommend initiating urate-lowering therapy (ULT) in patients with tophi, any radiographic damage, or at least 2 gout flares annually. Those with less frequent gout flares may consider ULT but may have less clinical benefit. Although the guideline panel generally recommends against ULT in those with their first gout flare, they note that it may be appropriate in some patients such as those with chronic kidney disease. Further, they recommend against ULT in asymptomatic hyperuricemia.
Allopurinol remains the first-line drug of choice among ULTs, even in those with chronic kidney disease. However, the authors recommend testing for the HLA–B*5801 allele in those of Southeast Asian and African American descent, due to the risk of allopurinol hypersensitivity syndrome in these populations. The authors recommend that ULT is best started during a gout flare as opposed to after the flare. Further, the authors recommend starting anti-inflammatory prophylactic therapy when ULT Is started and continuing prophylaxis for 3 to 6 months. Serum urate levels should be monitored during this time, with a treatment goal of less than 7 mg/dL. Although the guideline panel considered the option of ULT tapering in patients in clinical remission, they recommend continuing ULT indefinitely. The panel additionally recommended the use of colchicine, NSAIDs, or steroids as treatment for patients undergoing a gout flare.
The authors additionally addressed medications that may be involved in triggering gout flares. They recommend that patients on hydrochlorothiazide be considered for other antihypertensives when feasible, and specifically recommend the consideration of losartan in these cases.
The guidelines made further recommendations about lifestyle factors linked to gout. The authors advocate limiting alcohol and purine intake as well as the intake of high-fructose corn syrup. They also recommend a weight loss program for those who are overweight or obese.
References:
FitzGerald, John D.; Dalbeth, Nicola; Mikuls, Ted; et al. “2020 American College of Rheumatology Guideline for the Management of Gout.” Arthritis Care & Research, June 2020. Retrieved from https://www.rheumatology.org/Portals/0/Files/Gout-Guideline-Final-2020.pdf
