The 2020 ACR Guideline for the Management of Gout is intended to provide guidance for the management of patients with gout, and includes recommendations on the indications for and optimal use of urate-lowering therapy (ULT), treatment of gout flares, and lifestyle and other medication recommendations.1 The guideline includes 42 recommendations, of which 16 are strong. As with other guidelines developed by the ACR, the process involved the development of population, intervention, comparator and outcomes questions; followed by a systematic literature review and rating of the available evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, and patient input.
Clinical data reinforce the strong recommendation for following a treat-to-target strategy of dose management when treating all gout patients with serum ULT. To limit potential side effects, including gout flare with ULT initiation, initiating low-dose ULT is recommended, with subsequent dose titration guided by serial serum urate values to achieve a serum urate target of 6 mg/dL.
Other strong recommendations include:
- Initiating ULT in gout patients with one or more subcutaneous tophi over no ULT;
- Initiating ULT in patients with radiographic damage, using any modality, that is attributable to gout;
- Initiating ULT in patients with frequent gout flares, or two or more per year;
- Use of allopurinol as the first-line ULT, including in gout patients with stage 3 or worse chronic kidney disease;
- When using allopurinol or febuxostat as ULT, starting at low dose, with subsequent dose titration to target over a higher dose (e.g., 100 mg/day or less for patients taking allopurinol or a lower dose for patients with chronic kidney disease, and 40 mg/day or less for patients taking febuxostat);
- Use of concomitant anti-inflammatory prophylaxis over no prophylaxis when patients start ULT for at least three to six months, rather than less than three months, with evaluation and continued prophylaxis if the patient keeps having flares;
- Use of colchicine, non-steroidal anti-inflammatory drugs or glucocorticoids as appropriate first-line therapy for gout flares over interleukin 1 inhibitors or adrenocorticotropic hormone;
- When colchicine is the chosen agent for managing a gout flare, use of low-dose over high-dose colchicine given its similar efficacy and fewer adverse effects; and
- For patients with gout who have failed to achieve serum urate targets with xanthine oxidase inhibitors (XOIs), uricosurics and other interventions, and who have frequent gout flares or non-resolving tophi, switching to pegloticase over continuing the current ULT.
Refer to the guideline for all the recommendations and the supporting evidence.