What are the ACR guidelines for the use of uricosuric urate-lowering therapy (ULT) in gout?

Updated: Jan 26, 2021
  • Author: Bruce M Rothschild, MD; Chief Editor: Herbert S Diamond, MD  more...
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Answer

Choice of initial ULT for patients with gout

  • Treatment with allopurinol as the preferred first-line agent, over all other ULTs, is strongly recommended for all patients, including those with moderate-to-severe CKD (stage ≥3).
  • The choice of either allopurinol or febuxostat over probenecid is strongly recommended for patients with moderate-to-severe CKD (stage ≥3).
  • The choice of pegloticase as a first-line therapy is strongly recommended against.
  • Starting treatment with low-dose allopurinol (≤100 mg/day—lower in patients with CKD [stage ≥3]) and febuxostat (≤40 mg/day)—with subsequent dose titration is strongly recommended over starting at a higher dose.
  • Starting treatment with low-dose probenecid (500 mg once to twice daily) with subsequent dose titration over starting at a higher dose is conditionally recommended.
  • Administering concomitant anti-inflammatory prophylaxis therapy (eg, colchicine, nonsteroidal anti-inflammatory drugs [NSAIDs], prednisone/ prednisolone) over no anti-inflammatory prophylaxis therapy is strongly recommended.
  • Continuing concomitant anti-inflammatory prophylaxis therapy for 3–6 months over < 3 months, with ongoing evaluation and continued prophylaxis as needed if the patient continues to experience gout flares, is strongly recommended.

Timing of ULT initiation:

  • Starting ULT while the patient is experiencing a gout flare is conditionally recommended over starting ULT after the gout flare has resolved.
  • A treat-to-target management strategy that includes ULT dose titration and subsequent dosing guided by serial serum urate measurements to achieve a target serum urate level is strongly recommended over a fixed-dose ULT strategy for all patients receiving ULT.
  • For all patients receiving ULT, achieving and maintaining a serum uric acid target of < 6 mg/dL over the use of no target is strongly recommended for all patients receiving ULT.
  • Delivery of an augmented protocol of ULT dose management by nonphysician providers to optimize the treat-to-target strategy that includes patient education, shared decision-making, and treat-to-target protocol is conditionally recommended for all patients receiving ULT.

Duration of ULT:

  • Continuing ULT indefinitely over stopping ULT is conditionally recommended.

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