Written by: Donna Jose, MD and Marven Cabling, MD; Loma Linda University Rheumatology Fellowship Program
In May 2020, the American College of Rheumatology debuted the new guidelines for the management of gout. This latest set is a direct answer to criticisms on the prior guidelines released in 2012 where there were low quality evidence supporting some of its core recommendations, especially for treat to target strategy. This update reflects new data from recent studies and input from a panel of experts and patients.
Gout is the most common inflammatory arthritis, affecting about 9.2 million adults in the United States. Its incidence has doubled over the past 20 years. Even though the underlying etiology of the disease is well-elucidated and appropriate therapies exist, there are still significant gaps of care. The overall management of gout remains suboptimal with a chronic underutilization and poor patient adherence to the drugs that lower the uric acid burden. It is the hope of the ACR that the new guidelines would help improve gout management in our patients.
The 2020 ACR Guidelines has 42 recommendations, including 16 that are considered strong recommendations. The guidelines feature recommendations for the following key areas: indications for urate lowering therapy (ULT), approaches to the initiation and management of ULT, management of gout flares, asymptomatic hyperuricemia, and management of concomitant drugs and lifestyle modification.
Here is a quick summary of notable recommendations:
- ULT is indicated for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flare (³2 per year).
- Initiation of ULT is conditionally recommended in patients with >1 flare but <2 per year; or those with first flare and CKD³3, serum uric acid level of >9mg/dl or urolithiasis.
- ULT is not indicated in patients with asymptomatic hyperuricemia (no prior flare or subcutaneous tophi), even in those with evidence of MSU crystal deposition on DECT or ultrasound imaging (conditional).
- Allopurinol is the preferred first line ULT, including for those with moderate to severe chronic kidney disease. However, a lower starting dose is to be used (£100mg/day). Febuxostat is another option.
- Prophylaxis using anti-inflammatory drugs (colchicine, NSAIDs or steroids) for 3-6 months to prevent mobilization flares is strongly recommended.
- Treat to target strategy is strongly recommended (SU target of <6mg/dl)
- Continue ULT indefinitely (conditional)
- Test for HLA-B*5801 prior to starting allopurinol in patients of Southeast Asian descent or are African American as this allele is associated with a high risk for developing allopurinol hypersensitivity syndrome. (conditional)
- For patients with gout taking febuxostat with a history of CVD or a new CV event, it is conditionally recommended to switch to an alternative ULT agent if available (conditional)
- For gout flare: may use colchicine, NSAIDs, or glucocorticoids. IL-1 inhibitors or ACTH may be used as second line agent. Topical ice is recommended as adjuvant therapy.
- The guidelines have also commented on weight loss, diet (including limiting alcohol, high purines and high fructose corn syrup), intake of vitamin C, use of HCTZ, aspirin, losartan and fibrates.
Implications for Patients, Providers, & Researchers:
Current Implications: Gout is certainly an old disease with most clinicians confident of its management. However, in reality, most of us can learn a few more things in caring for our patients with gout. It is easy to dismiss gout, either intentionally or not, as unimportant or easy to manage. Yet, the data on the quality indicators reveal that most of us do a suboptimal job in caring for our patients with gout. The new guidelines should serve as a reminder, if not a wake-up call, to up our game and improve the care we provide to our patients.
The strengths of this new set of guidelines lie in the team effort and collaboration between researchers, field experts and patient representatives. The voices and preferences of patients, cost of therapy have been reflected against emerging evidence, resulting in a robust set of new recommendations. It now includes an expanded indication for the use of ULT with greater emphasis on the use of allopurinol as the first choice for gout therapy. A treat to target strategy with SU <6mg/dl is strongly recommended. This was recommended in the 2012 guidelines but now reemphasized based on newer and stronger evidence. Wider testing for the presence of HLA-B*5801 is recommended for certain populations due to higher risks of developing allopurinol hypersensitivity syndrome. Furthermore, bonus inclusions in the guidelines are some practical points such as dietary modifications, guidance on how to manage common drugs that may affect serum urate levels (hydrochlorothiazide, losartan, vitamin C and aspirin) and the use of ice compress as adjunct flare therapy.
Future implications: While the new guidelines are comprehensive, there are still questions that have been left unanswered. We look forward to the next iteration of the ACR guidelines in the future answering these questions:
- What is the best strategy for titrating ULT?
- What is the optimal serum uric acid threshold for patients with more severe gout?
- Would there be a different SU target based on patient’s race, sex or comorbidities?
- Would prolonged and profound hyperuricemia be safe especially since there has been a link to low SU<3mg/dl with neurodegenerative disorders?
- Would ULT be beneficial in patients with asymptomatic hyperuricemia and comorbidies such as CVD, CKD or hypertension?
Will the 2020 ACR Guideline for the Management of Gout win its first round match up?
Yep, just a simple yes. No question, the ACR Gout Guidelines will beat its first-round opponent, the FAST Trial. While the FAST trial is certainly important tackling the risks (or non-risks) of febuxostat in gout, the comprehensive nature of the ACR Guidelines and its wide implication in patient care will most surely knock the FAST trial off its feet. However, the FAST trial may possibly pull a fast one and swoop a win when you consider how the trial found non-inferiority of febuxostat over allopurinol for risk of cardiovascular events. This result contrasts with those of the CARES trial, which is one of the evidence used to conditionally recommend other ULTs over febuxostat in patients with cardiovascular disease.
Could the 2020 ACR Guideline for the Management of Gout win it all?
Optimistically speaking, it is possible. The 16 strong recommendations stated in the new guidelines were based on the gold standard RCT trials that compared treat to target regimens with usual care. These higher quality studies also details recommendations on lifestyle factors and use of concurrent medications, which together provides much needed information on how to better manage gout to improve quality of care for our patients. Other studies such as Avocapan and Belimumab for Lupus Nephritis provide new and exciting treatment options and might have a fair chance at winning it all but the extensive data and quality behind the new 2020 ACR guideline for gout management is unbeatable. This new guideline could pave the way to close the care gap in out gout patients with the assistance of evidence-based medicine.