“We think the dosing recommendations may be surprising to some primary care practitioners, especially those who tend to use too little prednisone in managing acute attacks and who don’t use it frequently,” Dr. Terkeltaub says.
Pharmacologic treatment should be initiated within 24 hours after onset of symptoms of acute gout because earlier treatment may lead to better outcomes, such as improvement in signs and symptoms and increased productivity at work, with fewer sick days needed, Dr. Puja Khanna says.
Both low-dose daily oral colchicine and low-dose NSAIDs are considered appropriate for first-line therapy for acute gout prophylaxis, with appropriate consideration to concomitant comorbidities and potential drug–drug interactions, Dr. Dinesh Khanna says.
He stresses that urate-lowering therapy should not be discontinued during an acute gout attack, because the attack could worsen.
According to Dr. Fitzgerald, gout is often not treated as aggressively as it should be, and these specific recommendations could serve to remedy that problem. “There has been some complacency about gout therapy without any new drugs on the market over the past 30 years, until recently,” he says. “Historically, with only a few choices, you put patients on those original drugs and in most cases it works. But if that therapy didn’t work, you didn’t have a lot of other choices. There are now more than one or two options, and there is something for fairly advanced chronic gouty arthritis patients as well. There are new drugs, but also important new ways of looking at the old drugs.”
For the Future
Conducting the systematic review of the literature to develop the guidelines made clear the need for more research, particularly randomized controlled trials. According to Dr. Terkeltaub, more direct dietary intervention studies are needed, as well as more randomized controlled trials that compare one therapeutic approach to another, such as different urate-lowering treatments alone and in combination, and with more dose titration in order to “treat to target” than was done in past studies.
About 20% of the recommendations in the guidelines were ranked as Level A, meaning the recommendation was gleaned from more than one randomized clinical trial or meta-analyses, a factor that demonstrates the need for more rigorous research, Dr. Terkeltaub says.
One factor that clearly emerged from the literature review is that patients with gout are often not treated to target, Dr. Fitzgerald says. The hope is that the published guidelines will highlight the need to treat to the target serum uric acid level and the importance of treating gout more aggressively. Dr. Puja Khanna agrees: “It is important to identify patients earlier in the disease process to avoid long-term disability.”
