The new guideline was published online in Arthritis Care & Research on May 11, 2020.
Why Update the Gout Care Guideline Now?
According to the ACR, the guideline has been updated because new clinical research has become available since 2012 that will impact management and treatment.
There’s More Scientific Evidence Supporting Earlier Recommendations
“These guidelines provide a stronger level of evidence for many prior and familiar recommendations, including reinforcing a treat-to-target strategy to achieve optimal outcomes for patients with gout. There has been better evidence in the last eight years to support our recommendations with greater certainty,” says John FitzGerald, MD, a rheumatologist at UCLA Medical Center in Los Angeles and a coauthor of the guideline update. The most important changes are outlined below.
Treat-to-Target Protocol Emphasized
Treat-to-target (T2T) is an approach to disease management in which doctor and patient work together to outline goals. “We recommended this in the 2012 guideline but, at the time, this was based on a lot of observational data. Since the 2012 guideline, there have been randomized controlled trials looking at this strategy that have had good results. The 2020 guideline reinforces the T2T recommendation, with more rigorous data to back it up,” says Dr. FitzGerald. In addition, the guideline defines a clear goal for serum urate levels as less than 6 milligrams per deciliter (mg/dL).
Early Diagnosis Is Stressed, Especially for People With Kidney Disease and Other Comorbidities
The guideline urges physicians to treat patients with gout early on, particularly those who have other medical conditions that might make their gout worse, such as extremely high uric acid levels, kidney disease, or gouty kidney stones. “This is important because getting treatment sooner could reduce the risk for long-term damage,” says Daniel Hernandez, MD, the director of medical affairs and Hispanic outreach for CreakyJoints.
Stronger Emphasis on Early Use, Proper Dosing With Allopurinol
The drug Zyloprim (allopurinol) was recommended in the 2012 guideline. The new version strongly recommends this drug as the first-line agent and to start it earlier rather than later, especially if patients have comorbidities. Allopurinol is much less expensive, while Uloric (febuxostat) has possible cardiovascular safety concerns. “In order to limit side effects, such as drug rash or a gout flare when starting urate-lowering treatment, it’s important to start any urate-lowering therapy at a low dose and increase to a dose that gets the right urate level, down to target,” says FitzGerald.
Test to Limit the Risk of an Allergic Reaction to Medication
Some people have a genetic marker (HLA-B*5801) that can predict a severe drug rash called allopurinol hypersensitivity syndrome. In the 2012 guideline, Asian groups were recommended to be tested prior to starting allopurinol. Based on newer data, the 2020 guideline has added African American patients to that group.
Use Anti-Inflammatories for 3 to 6 Months When Starting Allopurinol
When starting any urate-lowering therapy, there is a three- to six-month period when gout flares may increase. “The way I describe it to patients is that when you start treating the gout, it can get angry, and you can have increased flares before you have fewer flares,” says FitzGerald. The new recommendation is to take anti-inflammatory drugs for three to six months; the old recommendation was for six or more months. The risk of gout flares with the initiation of urate-lowering treatment becomes less after each month, so shorter courses of anti-inflammatory prophylaxis are likely sufficient. “By following the guideline recommendations, starting with the lower dose and using the anti-inflammatory as a preventive, side effects of urate-lowering therapy (including the risk of gout flare) can be lowered. The hope is that by following the recommendations, patients won’t abandon their treatment and will have more successful outcomes,” he says.
No More Patient Blame Game
“For the first time, the ACR has acknowledged that the onset of gout is not the patient’s fault (based on lifestyle and dietary choices) and that there should be no ‘patient-blaming’ for its onset, given its strong genetic determinants,” says Dr. Hernandez.
