New Guidelines Underway for Gout and Vasculitis

Laura Arenschield

November 15, 2019

ATLANTA — A first look at new guidelines for the treatment of gout was presented here at the American College of Rheumatology (ACR) 2019 Annual Meeting.

A key update is to use a treat-to-target strategy with urate-lowering therapy for all patients with gout. The draft guidelines recommend starting patients on a low-dose urate-lowering medication, then increasing the dose to reach and maintain a level below 6 md/dL.

"The concept of treat-to-target has been debated between the specialty societies and the American College of Physicians," said John Fitzgerald, MD, one of the coprincipal investigators on the updated gout guidelines. "The specialties have always focused on a treat-to-target to try to improve outcomes," he said.

"These guidelines restate that, similar to the old guidelines," Fitzgerald told Medscape Medical News, referencing the 2012 guideline publication. "But there's more evidence now supporting and defending that rationale."

The updated gout guidelines also include a strong recommendation to use allopurinol as the first-line urate-lowering therapy, even in patients with chronic kidney disease, and to use an anti-inflammatory prophylaxis when starting urate-lowering therapy for at least 3 to 6 months.

For the first time, the ACR has also put together recommendations on how to manage systemic vasculitis in patients with rheumatic diseases, said Sharon Chung, MD, lead investigator on the guideline development efforts. "There have been no vasculitis guidelines from ACR until now, I think in part because these are relatively rare diseases and there are very few randomized control studies."

Recommendations for Vasculitis

Rituximab should be the front-line treatment for systemic vasculitis in patients with rheumatic diseases, not cyclophosphamide, according to the new draft recommendations.

The guidelines cover a number of conditions related to large vessels, medium vessels, and anti-neutrophilic cytoplasmic autoantibodies (ANCA). Recommended diagnostic tests include serologic, imaging, and biopsy studies, and therapies include remission induction, maintenance therapies, treatment of refractory disease, and surgical intervention.

The recommendation to use rituximab as an alternative to cyclophosphamide is based on a number of studies published over the past 10 years, said Chung. The ACR was looking for an alternative because cyclophosphamide, first developed as a chemotherapy drug, is toxic to a number of cells.

"Its malignancy affects future fertility, among other things," she explained. "And now that we have these randomized control data that offer an alternative, it was time for the ACR to issues guidelines."

These are diseases where patients can present with life-threatening conditions.

"I don't think these should be jarring to the rheumatology community because studies have been out for a while now about rituximab as a treatment for ANCA-associated vasculitis," she told Medscape Medical News. "I think this gives people permission to say, 'Okay, I am going to use this new drug'."

However, "a lot of those outside the rheumatology community still reach for cyclophosphamide first," she pointed out. "We ultimately want to disseminate these to the broader medical community and say, 'This is the way we want to treat these conditions'."

The process to develop the new guidelines involved questions for the broader rheumatology community on the issues patients face with current treatment plans and discussion around the draft recommendations.

"For context, these are diseases where patients can present with life-threatening conditions," said Chung. "We want to give practitioners a blueprint on how they can approach these conditions," she explained.

The annual meeting was the first formal public discussion of these guidelines; manuscripts containing the full list of recommendations are currently under peer review. It is expected that the new guidelines will be published in 2020.

American College of Rheumatology (ACR) 2019 Annual Meeting.

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