Gout’s increasing prevalence along with recent treatment advances have prompted the American College of Rheumatology to issue new clinical guidelines for managing the painful inflammatory disease.
Appearing today in Arthritis Care & Research, the guidelines are published in 2 parts. The first part addresses educating patients about gout and treatment goals, diet and lifestyle recommendations, and medications. Part 2 covers treatment and prevention of acute gout attacks.
“Our goal is that these guidelines, along with educating gout patients in effective treatment, will improve adherence, quality of care, and management of this painful and potentially chronically debilitating condition,” lead investigator John D. Fitzgerald, MD, PhD, of the University of California, Los Angeles, said in a statement.
Gout results when the body produces too much uric acid or the kidneys don’t excrete enough of it. Uric acid production occurs when the body breaks down purines—substances in all body tissues and in foods including liver and anchovies. A build-up of uric acid deposits sharp urate crystals in joints or surrounding tissue, causing severe pain, swelling, and inflammation.
Fitzgerald and his colleagues noted in the guidelines that about 4% of US adults have gout. Increases in conditions that promote elevated urate levels—obesity, hypertension, metabolic syndrome, type 2 diabetes, and chronic kidney disease, for example—have driven gout’s increased prevalence over the past 4 decades, the authors explained. In addition, increasing numbers of elderly patients have co-occurring conditions and complex medication regimens that complicate appropriate care for their gout.
The recommendations include treatment with xanthine oxidase inhibitors (XOIs) to lower urate levels, with allopurinol or febuxostat as a first-line treatment. Patients should be screened for allopurinol hypersensitivity before they start taking the drug.
To improve gout symptoms, urate levels should be lowered to less than 6 mg/dL. If the target urate level isn’t met using 1 XOI, a uricosuric agent, which promotes the excretion of uric acid in the urine, can be added. Pegloticase is appropriate for patients with severe disease who can’t tolerate or don’t respond to standard urate-lowering treatment.
Acute gout attacks require medication within 24 hours of onset, for the duration of the attack. Nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, and oral colchicine are appropriate first-line options to treat acute attacks. The guidelines recommend prophylaxis with anti-inflammatory medication for all patients when urate-lowering treatment begins. Oral colchicine or a low-dose NSAID is appropriate first-line therapy to prevent acute gout attacks, the guidelines indicate.