What are the ACR guidelines on the management of hyperuricemia and gout?

Updated: Nov 03, 2020
  • Author: James W Lohr, MD; Chief Editor: Vecihi Batuman, MD, FASN  more...
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Answer

In 2020, the American College of Rheumatology released updated guidelines on the management of gout. The guidelines strongly recommend initiation of urate-lowering therapy (ULT) for patients the following indications [39] :

  • 1 or more subcutaneous tophi
  • Evidince of radiographic damage attributable to gout
  • Frequent gout flares (>2/year)

ULT is conditional recommended for patients with following indications [39] :

  • History of  >1 flare and infrequent flares (< 2/year)
  • First flare and CKD stage >3, SU >9 mg/dl, or urolithiasis

The guidelines included the following additional strong recommendations [39] :

  • Allopurinol is the preferred first-line urate-lowering therapy (ULT) for all patients
  • An xanthine oxidase inhibitor is recommended over probenecid for patients with CKD stage >3.
  • Allopurinol and febuxostat should be initiated at a low dose with subsequent titration to target
  • Concomitant antiinflammatory prophylaxis therapy (e.g., colchicine, NSAIDs, prednisone/prednisolone) for 3–6 months with ongoing evaluation and continued prophylaxis as needed if the patient continues to experience flares.
  • The choice of specific antiinflammatory prophylaxis should be based upon patient factors.
  • Oral colchicine, NSAIDs, or glucocorticoids (oral, intraarticular, or intramuscular) are appropriate first-line therapy for gout flares over IL-1 inhibitors or ACTH
  • The choice of colchicine, NSAIDs, or glucocorticoids should be made based on patient factors and preferences
  • When colchicine is the chosen agent, low-dose colchicine is preferred over high-dose colchicine given its similar efficacy and fewer adverse effects.

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