New Gout Guidelines Previewed at ACR 2019

In an attempt to improve treatment of gout, the American College of Rheumatology has announced new guidelines will debut in 2020, but clinicians were offered a preview of those same guidelines during the 2019 American College of Rheumatology (ACR) annual meeting in Atlanta, GA.

Using data from the 2012 treatment guidelines and a multitude of clinical trials, ACR officials previewed the draft version of their updated gout treatment guideline, which is highlighted by a strong recommendation for a treat-to-target strategy for urate-lowering therapy for all patients with gout.

“The updated guideline provides clinicians with evidence-based guidance on important topics such as the optimal usage of urate-lowering therapy (ULT), treatment of gout flares, managing lifestyle factors and other medication recommendations to help them be successful in optimally managing gout in their patients,” said Tuhina Neogi, MD, PhD, one of the co-principal investigators on the treatment guideline.

Citing additional evidence regarding the management of patients with gout, the ACR Practice Guidelines Subcommittee began to examine and update the most recently updated guidelines from 2012. While the full list of recommendations and supporting evidence from the ACR Practice Guidelines Subcommittee is still under peer review, the organization highlighted multiple new recommendations and changes as part of their 2020 guidelines.

In regard to the treat-to-target strategy with urate-lowering therapy, draft guidelines suggest a management strategy of starting with a low-dose urate-lowering therapy and escalating dosage to achieve and maintain a serum rate level less than 6 mg/dL to optimize patient outcomes over a fixed-dose strategy. Adherence to the updated guideline should mitigate the risk of treatment-related adverse events and flare risk accompanying urate-lowering therapy initiation, according to a release from the ACR.

The same release highlighted 5 additional changes from the 2012 guidelines including strong recommendation to use allopurinol as the first-line urate-lowering therapy—this includes patients with chronic kidney disease(CKD). Other recommended changes included a strong recommendation to use an anti-inflammatory prophylaxis when starting urate-lowering therapy for at least 3 to 6 months rather than less than 3 months, and indications for starting urate-lowering therapy were expanded to conditionally consider patients with infrequent gout flares or after their first gout flare if they also have moderate to severe CKD, marked hyperuricemia, or kidney stones.

Also included was a conditional recommendation for HLA-B*5802 texting prior to starting allopurinol for patients of Southeast Asian descent and African-American dece nt with a higher prevalence of HLA-B*5801 and against HLA-B*5801 testing in patients of other backgrounds. The last change highlighted in the release was a conditional recommendation for an augmented protocol of urate-lowering therapy dose management by non-physician providers to optimize the treat-to-target strategy.

“While the recommendation differs from the American College of Physicians, a treat-to-target approach was supported by randomized trial data, so we hope this will change how health care providers currently treat the condition,” Neogi said. “Gout management remains largely suboptimal due to many providers only managing flares without also treating the underlying hyperuricemia that causes gout or starting a patient on a urate-lowering therapy medication without escalating the dose or monitoring the serum urate response to guide dose escalation.”