Rheumatologists are encouraged to consider the evidence, account for the individuality of their patients and make their own decisions for providing care, Dr. Pillinger said. “The experts may wish to bend the rules,” he added, “but the guidelines needed to be clear enough that nonexperts could use them for guidance in the right circumstances.”
Acute Attacks
The primary recommendations for managing an acute gouty attack, Dr. Pillinger said, are pharmacologic therapy that is initiated within 24 hours of acute attack onset and not interrupting ongoing pharmacologic urate-lowering therapy during an acute attack.
The first line of treatment is using monotherapy or combination therapy. Monotherapies include NSAIDs, COX-2 inhibitors, corticosteroids or colchicine. In the event of inadequate response to monotherapy, an alternative monotherapy or add-on combination therapy can be considered.
In the event that monotherapy and combination therapy are ineffective, off-label therapy with anti-interleukin (IL) 1 treatment may be considered. “Over the last five or six years, it’s come to be understood that a fundamental thing uric acid crystals do when they activate the white cells is activate the inflammasome,” Dr. Pillinger explained. “And this puts IL-1 at the center of the inflammatory process of gout.”
There are three biologic agents available that interfere with IL-1: anakinra, rilonacept and canakinumab. The safety of these agents has been established in a few diseases, although gout is not one of them and they are not FDA approved yet, Dr. Pillinger said. He shared research results in support of these medications for gout:
- Anakinra has demonstrated benefit in gouty attack.
- Canakinumab is equally effective as the standard European therapy of a single injection of triamcinolone.
- Rilonacept has a dose-dependent effect on reducing total flares during urate-lowering therapy.
Established Gout
The baseline plan for managing established gout starts with the following initial considerations:
- Implement dietary and lifestyle alterations (e.g., weight loss for obese patients, healthy overall diet, exercise/activity, smoking cessation, staying well hydrated).
- Consider secondary causes of hyperuricemia (comorbidity checklist).
- Consider eliminating nonessential medications that promote hyperuricemia (e.g., niacin, thiazide and loop diuretics, cyclosporine, tacrolimus; not aspirin). However, particularly in the case of diuretics, the committee emphasized that these drugs may be important in the individual patient and should not be universally discontinued.
- Clinically evaluate gout disease burden/severity (i.e., palpable tophi, frequency and severity of attacks, chronic symptoms and signs).
Dietary considerations are important for patients with established gout. Among the recommendations are to avoid high-purine organ meats and high-fructose corn syrup, limit serving sizes of naturally sweet fruit juices and table sugar, and encourage low- or non-fat dairy intake.
