Although gout is a common disease that may have serious consequences, numerous studies show that gout is often misdiagnosed and that its management is suboptimal. New evidence-based guidelines for the management of gout from the European League Against Rheumatism (EULAR), published on July 25, 2016,1 have been developed in the hopes of remedying these issues.
“The increase in prevalence of gout in developed countries, the severity of the arthritis itself, and the increasing evidence for an association between gout with cardiovascular events, kidney failure and mortality have heightened the realization that gout should never be neglected and should be treated properly,” explained Pascal Richette, MD, PhD, Professor, Rheumatology, Department of Rheumatology, Lariboisière Hospital, Paris, France, and colleagues in their report.
These are the first new EULAR guidelines for gout published since 2006, and they reflect advances in the field over the past decade, including novel agents, newly established doses of drugs, and recognition of increased cardiovascular mortality associated with the disease.
The updated guidelines were developed by a EULAR task force consisting of 15 rheumatologists, 1 radiologist, 2 general practitioners, 1 research fellow, 2 patients, and 3 epidemiology experts representing 12 European nations. The updates were based on a review of the 2006 guidelines, as well as a meta-analysis of studies published between January 2005 and June 2013.
“The current task force included 2 GPs (general practitioners) and 2 patients to broaden the involvement of stakeholders involved in the disease,” the investigators wrote.
Key Points from the Updated Guidelines
- Treat acute gout flares as soon as they are diagnosed
- First-line treatment options for acute flare include colchicine (loading dose of 1 mg, 0.5 mg on day 1, or a nonsteroidal anti-inflammatory drug [NSAID]), oral corticosteroids (equivalent prednisone dose of 30-35 mg daily for 3-5 days), or joint aspiration with intra-articular injection of corticosteroids. Avoid colchicine and NSAID administration in patients with renal impairment
- Consider using interleukin-1 blockers in patients with frequent disease flares and contraindications to receiving colchicine, NSAIDs, or corticosteroids
- Urate-lowering therapy (ULT) should be accompanied by prophylaxis during the first 6 months of treatment. The task force recommends colchicine (0.5-1 mg daily, with adjustments for renal impairment). In patients who cannot tolerate colchicine well, or in whom it is contraindicated, consider prophylaxis with low dosages of NSAIDs
- ULT should be considered for patients with a definitive diagnosis of gout, ≥2 flares per year, and recurrent tophi, urate arthropathy, or kidney stones. Early ULT should be used for patients aged <40 years with serum uric acid (SUA) levels >8 mg/dL (480 µmol/L), or who have other comorbidities
- SUA levels of <6 mg/dL (360 µmol/L) should be targeted in patients with ULT. For patients with severe gout, target SUA levels of <5 mg/dL (300 µmol/L) may be appropriate. Long-term SUA levels of <3 mg/dL are not generally recommended
- ULT should be initiated at low doses, with upward titration to achieve SUA level goals
- Allopurinol is recommended as first-line ULT in patients with normal kidney function, initiating it at 100 mg daily and increasing it by 100-mg increments every 2 to 4 weeks as needed to attain target SUA levels. Febuxostat or a uricosuric should be started if allopurinol alone does not achieve SUA level goal, or if it is not well-tolerated
- For patients with renal impairment, creatine clearance should be used to adjust maximum daily doses of allopurinol
- When target SUA levels cannot be attained in patients with debilitating, crystal-proven, chronic tophaceous gout, pegloticase is indicated
- In a patient who presents with gout and takes loop or thiazide diuretics, it is recommended that the diuretic be switched. Losartan or calcium channel blockers should be considered as a replacement for a diuretic indicated for hypertension, and a statin should be considered for hyperlipidemia.
These new recommendations can be used to further educate clinicians and patients on pharmaceutical and non-pharmaceutical therapies for gout and to provide optimal strategies to achieve the predefined urate target to manage the disease.
- Richette P, Doherty M, Pascual E, et al. 2016 updated EULAR evidence-based recommendations for the management of gout. Ann Rheum Dis. 2016 Jul 25. Epub ahead of print.