New Gout Guidelines: Primary Care Pointers

Neil Skolnik, MD


March 02, 2021

This transcript has been edited for clarity.

I'm Dr Neil Skolnik. Today we are going to talk about the 2020 American College of Rheumatology Guideline for the Management of Gout and get some really clear evidence-based guidance about treating gout in primary care. The guidelines recommend a treat-to-target approach utilizing urate-lowering therapy for prevention of recurrent episodes of gout. Let's talk about the details.

Urate-lowering therapy with allopurinol is strongly recommended for patients who have had two or more gout flares a year, one or more tophi, or x-ray evidence of damage to joints due to gout. We can consider treatment for patients who have had multiple episodes in the past but are currently experiencing fewer than two flares a year. Urate-lowering therapy will reduce the frequency of their flares, but the benefit is less in a patient who has less frequent flares.

The guidelines recommend not starting allopurinol after a first gout attack, although it may be considered in patients with chronic kidney disease (CKD) stage 3 or higher, uric acid levels of 9 mg/dL or higher, or if kidney stones are present. These are risk factors for future episodes of gout. Urate-lowering therapy should not be used in patients with asymptomatic hyperuricemia. In addition, we might consider urate-lowering therapy in patients who also have kidney stones.

We shouldn't be using urate-lowering therapy in patients with asymptomatic hyperuricemia. Probenecid, which used to be prescribed a fair amount, is now relegated to add-on therapy for patients who do not reach their target uric acid levels with urate-lowering therapy.

Now let's talk about specifics around starting urate-lowering therapy.

First-line agent: allopurinol. We used to think that you needed to wait a while after a flare to start prophylactic therapy because of the fear of provoking another attack. That's no longer the case. The guidelines clearly recommend starting prophylactic therapy during an episode of gout. This approach is now preferred over waiting.

Before starting allopurinol, however, consider testing for the HLA-B*5801 allele in patients of Southeast Asian descent and for African American patients because the prevalence of this allele is about 7% among Southeast Asians and 4% among African Americans. The presence of this allele increases the risk for an allopurinol hypersensitivity reaction.

Starting dose. It's recommended to start with low-dose allopurinol to reduce the likelihood of a hypersensitivity reaction or gout flare. Begin with 100 mg daily for most patients, which in most people will reduce the likelihood of an allopurinol hypersensitivity reaction or a flare. Consider starting with 50 mg daily in patients with CKD.

We know that starting prophylactic therapy can transiently increase the risk for a flare, so it is strongly recommended to start anti-inflammatory prophylaxis with either colchicine, prednisone, or an NSAID to reduce this risk. Prophylactic anti-inflammatory therapy should be continued for 3-6 months after urate-lowering therapy is begun.

We can also recommend limiting alcohol, purine, and high-fructose corn syrup intake. If the patient is overweight, we might also discuss weight loss.

A key recommendation. With allopurinol, a "treat-to-target" approach should be used, which means starting with low-dose allopurinol and then rechecking uric acid level. If this level is higher than 6 mg/dL, increase the dose, and continue to increase it incrementally until the maximum dose (800 mg) of allopurinol is reached.

The management of gouty flare is straightforward. The recommendations have not changed: colchicine, NSAIDs, or steroids.

To recap, start with allopurinol; use a treat-to-target approach with a uric acid target of 6 mg/dL or less; and prescribe colchicine, NSAIDs, or steroids for acute attacks.

I'm Neil Skolnik, and this is Medscape.

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