The American College of Rheumatology (ACR) has released a preview of the updated practice guideline on the management of gout at the 2019 ACR/Association of Rheumatology Professionals (ARP) Annual Meeting. The guideline will highlight the importance of a treat-to-target strategy in gout management, how to optimize urate-lowering therapy (ULT), and more.

“The majority of gout is managed by primary care, and so a lot of these messages need to get out to primary care to improve the care of our patients with gout,” Tuhina Neogi, MD, PhD, chief of rheumatology at Boston Medical Center and coprincipal investigator of the guideline, said during a press conference at the meeting.

The full list of recommendations and supporting evidence are currently under review and are anticipated to be published in early 2020.

Several clinical trials have provided additional evidence on the management of patients with gout since the publication of the previous version of the practice guideline in 2012. Thus, the ACR Practice Guidelines Subcommittee determined that updated recommendations were warranted.

“Unfortunately, gout is poorly managed, with over 70% of patients experiencing recurrent flares,” Dr Neogi said. “If gout is not properly managed, not only do patients continue to have recurrent flares, they can develop tophi; these deposits can deposit anywhere in the body, are very biologically active, and can lead to joint destruction.”

The guideline highlighted by Dr Neogi includes the following recommendations based on strong evidence:

• A treat-to-target strategy with ULT for all patients with gout. It is recommended that management begin with a low dose of a ULT medication and the dosage be escalated to achieve and maintain a serum urate level of less than 6 mg/dL.
• The use of allopurinol as first-line ULT, including among patients with chronic kidney disease (CKD).
• Anti-inflammatory prophylaxis is recommended when starting ULT for at least 3 to 6 months rather than less than 3 months. Ongoing evaluation and continued prophylaxis as needed is suggested if the patient continues to experience flares.

The guideline includes the following recommendations based on conditional evidence:

• HLA-B*5801 testing prior to the start of allopurinol in patients of Southeast Asian descent and African American descent who have a high prevalence of HLA-B*5801. A recommendation against HLA-B*5801 testing in patients of other ethnic or racial backgrounds is included.
• An augmented protocol of ULT dose management by nonphysician providers to optimize the treat-to-target strategy.

The guideline will also include expanded indications for starting ULT to conditionally consider patients with infrequent gout flares or after their first gout flare if they also have moderate to severe CKD, marked hyperuricemia, or kidney stones.

The key take-home messages for rheumatologists from the updated guideline, according to Dr Neogi, are that patients with gout should be treated with ULT if they have frequent flares, tophi, or radiographic evidence of damage from gout; people who have a first flare with some other features such as very elevated serum urate or CKD stage 3 or worse can be considered in a shared decision-making capacity for starting ULT; and people with kidney stones can also be considered for starting ULT.

“Management of hyperuricemia is the foundation of managing gout,” Dr Neogi said. “The No. 1 choice of therapy for lowering urate should be allopurinol, and this is in all cases,” adding that the drug should be started at a low dose and titrated to have the patient achieve the target of less than 6 mg/dL.

“This has been very controversial,” Dr Neogi said. “There is a professional organization that does not believe there is sufficient evidence to support a treat-to-target strategy. We believe that the intervening years with additional data and trials that have been published since the last guidelines, and also a trial that was published prior to the other society’s guidelines, support the fact that lowering serum urate to below 6 has meaningful, clinically relevant reductions in flares and improvements in tophi.”

Allopurinol dose can also be increased to above 300 mg per day, even among those with renal impairment, Dr Neogi said. “There is good data to support this,” she said.

“As per the prior guidelines, we still recommend starting with anti-inflammatory prophylaxis when initiating management of hyperuricemia, and the choice of agent should be based on patient factors,” Dr Neogi said.

—Melinda Stevens

Reference:

American College of Rheumatology previews draft of updated gout treatment guideline at the 2019 ACR/ARP Annual Meeting [press release]. Atlanta, GA: 2019 ACR/ARP Annual Meeting; November 9, 2019. https://www.rheumatology.org/About-Us/Newsroom/Press-Releases/ID/1071. Accessed November 12, 2019.