What are the current guidelines for managing gout?

Current Guidelines for Gout Management

The 2020 American College of Rheumatology guidelines provide the most comprehensive, evidence-based approach to gout management, emphasizing early initiation of urate-lowering therapy with allopurinol as first-line treatment, treat-to-target strategies with serum urate <6 mg/dL, mandatory anti-inflammatory prophylaxis for 3-6 months when starting therapy, and aggressive treatment of acute flares with colchicine, NSAIDs, or glucocorticoids. 1

Indications for Urate-Lowering Therapy (ULT)

Strongly recommended to initiate ULT in patients with: 1

• Tophaceous gout
• Radiographic damage due to gout
• Frequent gout flares (≥2 per year)

Conditionally recommended for: 1

• First gout flare with serum urate >9 mg/dL
• Chronic kidney disease stage 2 or worse
• Urolithiasis

First-Line Urate-Lowering Therapy

Allopurinol is the preferred first-line agent for all patients, including those with moderate-to-severe chronic kidney disease (stage ≥3). 1, 2

Starting Dose Strategy

• Start low: ≤100 mg/day for most patients 1
• Lower starting doses required in chronic kidney disease 1, 2
• Titrate upward by 100 mg every 2-4 weeks until target serum urate is achieved 3, 2
• Maximum dose: 800 mg/day in patients with normal renal function 3, 2

Dose Adjustments in Renal Impairment

• Creatinine clearance 10-20 mL/min: 200 mg daily 2
• Creatinine clearance <10 mL/min: maximum 100 mg daily 2
• Creatinine clearance <3 mL/min: may need to lengthen interval between doses 2

Target Serum Urate Levels

Primary target: <6 mg/dL for all patients with gout 1, 3

Intensive target: <5 mg/dL for patients with: 3

• Erosive arthropathy
• Tophaceous disease
• Severe gout requiring faster crystal dissolution

Alternative ULT Options

If allopurinol target not achieved or not tolerated: 1, 3

• Switch to febuxostat (start <40 mg/day, titrate to 80-120 mg/day) 1
• Add uricosuric agent (probenecid, fenofibrate, or losartan) to xanthine oxidase inhibitor 1

Pegloticase reserved only for: 1

• Severe gout disease burden
• Refractory to or intolerant of appropriately dosed oral ULT
• Never as first-line therapy

Mandatory Anti-Inflammatory Prophylaxis

When initiating ULT, strongly recommended to start concomitant prophylaxis for at least 3-6 months 1, 4

First-line prophylaxis options: 1

• Low-dose colchicine (0.6 mg once or twice daily)
• Low-dose NSAIDs with proton pump inhibitor
• Low-dose prednisone/prednisolone (≤10 mg/day)

Continue prophylaxis until: 1

• Serum urate at target for at least 3-6 months
• No acute flares for several months
• Complete tophus resolution (if present)

Management of Acute Gout Flares

Strongly recommended first-line options (choose based on patient factors and contraindications): 1

• Oral colchicine: Low-dose regimen (1.2 mg followed by 0.6 mg one hour later) preferred over high-dose due to similar efficacy and fewer adverse effects 1, 5
• NSAIDs: Any NSAID at full anti-inflammatory dose
• Glucocorticoids: Oral, intraarticular, or intramuscular routes

For patients with contraindications to above agents: 1

• IL-1 inhibitors (canakinumab) conditionally recommended
• ACTH is an alternative option

Critical principle: Continue ULT without interruption during acute flares 3

Colchicine Dosing Adjustments

Renal impairment: 5

• Mild-moderate (CrCl 30-80 mL/min): No dose adjustment for acute treatment, but monitor closely
• Severe (CrCl <30 mL/min): Single 0.6 mg dose, repeat no more than once every 2 weeks
• Dialysis: Single 0.6 mg dose, repeat no more than once every 2 weeks

Hepatic impairment: 5

• Mild-moderate: No dose adjustment, but monitor closely
• Severe: Repeat treatment courses no more than once every 2 weeks

Monitoring Protocol

During dose titration: 3, 4

• Check serum urate every 2-4 weeks until target achieved

Once stable on maintenance therapy: 3, 4

• Check serum urate every 6 months
• Monitor for flare frequency
• Assess tophus size reduction (if present)
• Monitor renal function, especially with allopurinol 4

Lifestyle Modifications

Conditionally recommended for all patients with gout: 1

• Limit alcohol intake (beer raises serum urate by 0.16 mg/dL per unit) 1
• Limit purine-rich foods (organ meats, shellfish) 1
• Limit high-fructose corn syrup intake 1
• Weight loss program for overweight/obese patients 1

Not recommended: 1

• Vitamin C supplementation (conditionally recommended against)

Important caveat: Dietary modifications yield only small changes in serum urate (typically 1-2 mg/dL reduction), so pharmacologic ULT remains essential for most patients. 1

Comorbidity Management

Medication adjustments to consider: 3

• Substitute loop or thiazide diuretics if possible (these raise uric acid)
• Consider losartan for hypertension (has uricosuric effects)
• Consider calcium channel blockers for hypertension
• Consider statin or fenofibrate for hyperlipidemia (fenofibrate has uricosuric effects)

Assess cardiovascular risk factors in all gout patients 4

Common Pitfalls to Avoid

Starting ULT without prophylaxis: This precipitates acute flares and leads to poor adherence and treatment discontinuation 1, 4

Starting allopurinol at high doses: Increases risk of acute flares and hypersensitivity reactions; always start low and titrate slowly 1, 2

Stopping ULT during acute flares: This prolongs time to achieving target serum urate and delays disease control 3

Not titrating to target serum urate: Simply prescribing a fixed dose of allopurinol (e.g., 300 mg) without monitoring and titration leads to inadequate disease control in most patients 1, 3

Treating asymptomatic hyperuricemia: ULT is not indicated for elevated uric acid alone without clinical gout 4

Inadequate duration of prophylaxis: Stopping prophylaxis too early (before 3-6 months) increases flare risk 1

Patient-blaming regarding diet: Recognize the strong genetic component to gout; dietary discussions should not stigmatize patients 1