2020 American College of Rheumatology Guideline for the Management of Gout — Arthritis Care & Research

Claims

1. asymptomatic-hyperuricemia
   The ACR conditionally recommends against drug treatment for asymptomatic hyperuricemia (serum urate above 6.8 mg/dL without prior flares or tophi).

   "For patients with asymptomatic hyperuricemia (SU >6.8 mg/dl with no prior gout flares or subcutaneous tophi), we conditionally recommend against initiating any pharmacologic ULT (allopurinol, febuxostat, probenecid) over initiation of pharmacologic ULT."

   Locator: table: Table 1 · Quote language: en
2. concurrent-medications
   For people with gout, the ACR conditionally recommends switching from hydrochlorothiazide to another antihypertensive when feasible and preferring losartan as an antihypertensive.

   "Switching hydrochlorothiazide to an alternate antihypertensive when feasible is conditionally recommended for patients with gout, regardless of disease activity. Choosing losartan preferentially as an antihypertensive agent when feasible is conditionally recommended for patients with gout, regardless of disease activity."

   Locator: section: Management of concurrent medications · Quote language: en
3. flare-first-line
   Colchicine, NSAIDs or glucocorticoids are strongly recommended as first-line flare treatment over interleukin-1 inhibitors or ACTH, and topical ice is conditionally recommended as an add-on.

   "Using colchicine, NSAIDs, or glucocorticoids (oral, intraarticular, or intramuscular) as appropriate first-line therapy for gout flares over IL-1 inhibitors or adrenocorticotropic hormone (ACTH) is strongly recommended for patients experiencing a gout flare. ... Using topical ice as an adjuvant treatment over no adjuvant treatment is conditionally recommended for patients experiencing a gout flare."

   Locator: section: Gout flare management · Quote language: en
4. hla-b5801
   Testing for the HLA-B*5801 allele, which markedly raises the risk of allopurinol hypersensitivity, is conditionally recommended before starting allopurinol in patients of Southeast Asian descent and African American patients.

   "Testing for the HLA–B*5801 allele prior to starting allopurinol is conditionally recommended for patients of Southeast Asian descent (e.g., Han Chinese, Korean, Thai) and for African American patients, over not testing for the HLA–B*5801 allele. ... The HLA–B*5801 allele is associated with a markedly elevated risk for AHS."

   Locator: section: Recommendations for patients receiving ULT medications: Allopurinol · Quote language: en
5. indefinite-ult
   The ACR conditionally recommends continuing urate-lowering therapy indefinitely rather than stopping it.

   "Continuing ULT indefinitely over stopping ULT is conditionally recommended."

   Locator: section: Duration of ULT · Quote language: en
6. lifestyle
   The ACR conditionally recommends limiting alcohol, purine and high-fructose corn syrup intake, weight loss for overweight or obese patients, and conditionally recommends against vitamin C supplementation.

   "Limiting alcohol intake is conditionally recommended for patients with gout, regardless of disease activity. Limiting purine intake is conditionally recommended ... Limiting high-fructose corn syrup intake is conditionally recommended ... Using a weight loss program (no specific program endorsed) is conditionally recommended for those patients with gout who are overweight/obese ... Adding vitamin C supplementation is conditionally recommended against for patients with gout"

   Locator: section: Management of lifestyle factors · Quote language: en
7. low-dose-colchicine
   When colchicine is used for a flare, low-dose colchicine is strongly recommended over high-dose because efficacy is similar and adverse effects are fewer.

   "Given similar efficacy and a lower risk of adverse effects, low-dose colchicine over high-dose colchicine is strongly recommended when colchicine is the chosen agent."

   Locator: section: Gout flare management · Quote language: en
8. pegloticase
   The ACR strongly recommends switching to pegloticase when xanthine oxidase inhibitors, uricosurics and other interventions have failed to reach the urate target and the patient still has frequent flares or non-resolving tophi.

   "Switching to pegloticase over continuing current ULT is strongly recommended for patients with gout for whom XOI treatment, uricosurics, and other interventions have failed to achieve the SU target, and who continue to have frequent gout flares (≥2 flares/year) OR who have nonresolving subcutaneous tophi."

   Locator: section: Ongoing ULT management · Quote language: en
9. quality-gap
   Although effective and inexpensive gout medications exist, gaps in quality of care persist, and urate-lowering therapy use did not increase over the two decades before 2020.

   "While the etiology of gout is well-understood and there are effective and inexpensive medications to treat gout, gaps in quality of care persist. ... Despite these recommendations, over the past 2 decades there has been no increase in ULT utilization."

   Locator: section: Introduction · Quote language: en
10. strong-recommendations
    The ACR guideline's strong recommendations include allopurinol as preferred first-line urate-lowering therapy (including in chronic kidney disease stage 3 or worse), a low starting dose, a treat-to-target strategy with a serum urate goal below 6 mg/dL, anti-inflammatory prophylaxis for at least 3–6 months when starting therapy, and colchicine, NSAIDs or glucocorticoids for flares.

    "allopurinol as the preferred first-line ULT, including for those with moderate-to-severe chronic kidney disease (CKD; stage ≥3); using a low starting dose of allopurinol (≤100 mg/day, and lower in CKD) or febuxostat (≤40 mg/day); and a treat-to-target management strategy with ULT dose titration guided by serial serum urate (SU) measurements, with an SU target of [less than] 6 mg/dl. When initiating ULT, concomitant antiinflammatory prophylaxis therapy for a duration of at least 3–6 months was strongly recommended. For management of gout flares, colchicine, nonsteroidal antiinflammatory drugs, or glucocorticoids (oral, intraarticular, or intramuscular) were strongly recommended."

    Locator: section: Abstract: Results · Quote language: en
11. ult-indications
    The ACR strongly recommends starting urate-lowering therapy for patients with one or more subcutaneous tophi, radiographic joint damage due to gout, or two or more flares a year.

    "Initiating ULT is strongly recommended for gout patients with any of the following: ≥1 subcutaneous tophi; evidence of radiographic damage (any modality) attributable to gout; OR frequent gout flares, with frequent being defined as ≥2 annually."

    Locator: section: Indications for pharmacologic ULT · Quote language: en
12. us-prevalence
    Gout is the most common form of inflammatory arthritis, affecting about 9.2 million adults (3.9%) in the United States.

    "Gout is the most common form of inflammatory arthritis, affecting ~9.2 million adults (3.9%) in the US."

    Locator: section: Introduction · Quote language: en