Frequent Updates Reflect New Evidence
Data published after 2012 supported several important changes, says co-principal investigator Tuhina Neogi, MD, PhD, rheumatology section chief and professor of medicine at Boston University School of Medicine. Recent trials that panelists used to support recommendations include a 2017 randomized, controlled trial on the benefits of febuxostat in patients with early gout and infrequent flares; the 2018 CARES Trial, which compared the cardiovascular safety of febuxostat and allopurinol; and a 2019 study on the benefits of nurse-led gout care, which supported the conditional recommendation for augmenting ULT with evaluation by a non-physician healthcare provider.2-4
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Explore This IssueJune 2020
The ACR’s methodological approach to guideline development, which includes consideration of the totality of the literature, may differ from other societies, she says. The ACR’s recommendations are made largely on the basis of quality of evidence (among other factors), and strong recommendations are usually based on the results of randomized, controlled trials. But Dr. Neogi says, “some specialty societies will only make recommendations in the context of randomized trials. We don’t have randomized trials to address every single clinical question of relevance. We need to be able to look at other evidence to help develop actionable guidelines.”
Susan Bernstein is a freelance journalist based in Atlanta.
John D. FitzGerald, MD, PhD, is clinical chief of rheumatology at the University of California, Los Angeles, and physician researcher at Veteran Affairs Greater Los Angeles Medical Center.
2020 Gout Guideline Updates
Updates from the earlier guideline include:
- Indications for starting ULT have been expanded to conditionally consider patients with infrequent gout flares or after their first gout flare if they also have moderate to severe chronic kidney disease (CKD stage ≥3), marked hyperuricemia (serum urate >9 mg/dL) or kidney stones.
- Allopurinol is strongly recommended as the first-line ULT, including in patients with chronic kidney disease.
- Anti-inflammatory prophylaxis (e.g., colchicine, NSAIDs, prednisone/prednisolone) when starting ULT is now three to six months, with ongoing evaluation and continued prophylaxis as needed if the patient continues to experience flares.
- HLA-B*5801 testing has been expanded to conditionally recommend testing for African American patients with gout.
- FitzGerald JD, Dalbeth N, Mikuls T, et al. ACR guideline for management of gout. 2020 American College of Rheumatology guideline for the management of gout. Arthritis Rheumatol. 2020. [Online ahead of print.]
- Dalbeth N, Saag KG, Palmer WE, et al. Effects of febuxostat in early gout. Arthritis Rheumatol. 2017 Dec;69(12):2386–2395.
- White WB, Saag KG, Becker MA, et al. Cardiovascular safety of febuxostat or allopurinol in patients with gout. N Engl J Med. 2018 Mar 29;378(13):1200–1210.
- Doherty M, Jenkins W, Richardson H, et al. Efficacy and cost-effectiveness of nurse-led care involving education and engagement of patients and a treat-to-target urate-lowering strategy versus usual care for gout: A randomised controlled trial. Lancet. 2018 Oct 20;392(10156):1403–1412.
This article was updated on June 30, 2020, to reflect a correction to an error in the 2020 Gout Guideline Updates sidebar.