American College of Rheumatology Guideline for the Management of Gout

SUMMARY

Gout is the most common form of inflammatory arthritis and affects roughly 4% of the US adult population. Anti-inflammatory medications remain the mainstay of treatment for acute gout flares, but managing gout as a chronic condition is often overlooked with only about 20% of patients being appropriately placed on urate-lowering therapy (ULT) for long term care. The American College of Rheumatology has released updated guidelines for the management of gout, stressing the importance of ULT to prevent recurrent flares of this debilitating chronic illness.

Clinical Manifestations
Diagnosis
Treatment

Clinical Manifestations

Severe joint pain| Swelling | Erythema
Most often occurs at night
Improves in days to weeks without treatment
Typically monoarticular
Lower extremities most common location (e.g., first toe MTP or knee)
May have evidence of soft tissue deposits of uric acid (tophaceous gout)
Can have associated nephrolithiasis or chronic urate nephropathy

Diagnosis

Visualization of urate crystals on synovial fluid sample or tissue histology OR
ACR/EULAR gout classification criteria calculator to calculate likelihood of gout (see ‘Learn More – Primary Sources’ below) includes
- Pattern of joint/bursa involvement
- Characteristics during episode
- Number of episodes
- Evidence of tophus
- Serum urate level
- Synovial fluid analysis
- Imaging evidence

Tap to view ACR/EULAR Gout Classification Criteria

Treatment

Acute Flare Management

Initiate anti-inflammatory medications to manage a flare
- Colchicine
  - Low dose is favored over high dose
  - 1.2 mg immediately followed by 0.6 mg an hour later, with ongoing therapy until the flare resolves
- NSAIDs
- Corticosteroids
  - PO | IV | IM all acceptable
Topical ice may be used as an adjuvant for pain control
If above anti-inflammatory medications are unable to be used
- Consider IL-1 inhibitors (e.g., anakinra, rilonacept)
ULT
- Start during an acute flare when indicated and continue in patients already on ULT during a flare

Chronic Management

Initiate ULT for all patients with
- ≥2 gout flares a year
- ≥1 subcutaneous tophi
- Radiologic damage attributable to gout
Consider initiating ULT for patients with a history of infrequent flares (<2 a year)
Consider initiating for patients with their 1^st flare and
- Evidence of CKD stage ≥3
- Evidence of urolithiasis
- Serum urate >9 mg/dL
‘Treat to Target’
- Titrate ULT to a target serum urate level of <6 mg/dL
When starting ULT
- Administer prophylactic anti-inflammatory medications (e.g., NSAIDs, colchicine, prednisone)
- Continue anti-inflammatory prophylaxis for 3 to 6 months
- Monitor clinically and continue prophylaxis as needed
Continue ULT indefinitely if well tolerated, even in cases of long-term remission

Urate Lowering Therapy

Allopurinol is 1^st line for ULT
- Start at ≤100 mg/day and titrate dose to target
- Renally dose for patients with CKD
- HLA-B*5801 testing should be done prior to starting allopurinol for patients of Southeast Asian descent and African American patients due to high risk of Allopurinol Hypersensitivity Syndrome associated with this haplotype
- Allopurinol desensitization should be done for patients with prior documented allergy who are unable to take other oral ULT agents
Xanthine Oxidase Inhibitors (e.g., Febuxostat) are 2nd line for ULT
- Start at ≤40 mg/day and titrate dose to target
- Switch to another ULT agent if patient has history of CVD or a new CV event
Probenecid is 3^rd line for ULT
- Start at 500mg 1 to 2 times daily and titrate dose to target
- Do NOT monitor with urine uric acid testing
Pegloticase (Krystexxa) is used for chronic gout in patients who have failed the above therapies as evidenced by
- Failure to reach serum urate target
- Frequent gout flares (2 or more a year)
- Nonrevolving subcutaneous tophi

Lifestyle Modifications

Limit: Alcohol | Purine intake | High fructose corn syrup
Weight loss is recommended for patients obese or overweight
Consider switching hydrochlorothiazide to alternate agent when feasible
- Losartan is the preferred anti-hypertensive agent for patients with gout

KEY POINTS

Gout is a debilitating chronic illness and the majority of patients should be managed with long term urate lowering therapies
Allopurinol is the preferred ULT agent
Treat to target: Get patients to a serum urate level of <6 mg/dL