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Published by American College of Rheumatology · GRADE
Gout is the most common form of inflammatory arthritis, affecting approximately 9.2 million adults in the US. Despite the availability of effective and inexpensive medications, gaps in quality of care persist. The 2020 guideline was developed using GRADE methodology to update the 2012 recommendations, incorporating new clinical trial evidence regarding treat-to-target strategies, urate-lowering therapies (ULT), and patient preferences to improve gout management.
Key Takeaways
This 2020 guideline updates the 2012 ACR Guidelines. It breaks from prior ACR and EULAR guidelines by not specifying SU thresholds lower than <6 mg/dl for severe disease. It firmly establishes allopurinol as the preferred first-line ULT for all patients, including those with CKD. Indications for ULT are expanded to include evidence of radiographic damage regardless of tophi or flare frequency.
For patients with 1 or more subcutaneous tophi, we strongly recommend initiating ULT over no ULT.
For patients with radiographic damage (any modality) attributable to gout, we strongly recommend initiating ULT over no ULT.
For patients with frequent gout flares (≥2/year), we strongly recommend initiating ULT over no ULT.
For patients with asymptomatic hyperuricemia (SU >6.8 mg/dl with no prior gout flares or subcutaneous tophi), we conditionally recommend against initiating any pharmacologic ULT.
For patients starting any ULT, we strongly recommend allopurinol over all other ULT as the preferred first-line agent for all patients, including in those with CKD stage ≥3.
For allopurinol and febuxostat, we strongly recommend starting at a low dose with subsequent dose titration to target over starting at a higher dose.
We strongly recommend initiating concomitant antiinflammatory prophylaxis therapy (e.g., colchicine, NSAIDs, prednisone/prednisolone) over no antiinflammatory prophylaxis for 3–6 months.
For all patients taking ULT, we strongly recommend a treat-to-target strategy of ULT dose management that includes dose titration and subsequent dosing guided by serial SU values to achieve an SU target.
For all patients taking ULT, we strongly recommend continuing ULT to achieve and maintain an SU target of <6 mg/dl over no target.
For patients experiencing a gout flare, we strongly recommend using oral colchicine, NSAIDs, or glucocorticoids as appropriate first-line therapy for gout flares over IL-1 inhibitors or ACTH.
For patients with gout, regardless of disease activity, we conditionally recommend limiting alcohol intake.
Clinical Topic
Management of Gout
Objectives
To provide guidance for the management of gout, including indications for and optimal use of urate-lowering therapy (ULT), treatment of gout flares, and lifestyle and other medication recommendations.
Target Patient Population
Patients with gout and individuals with asymptomatic hyperuricemia
Target Providers
Therapeutic Area
RheumatologyGuideline Scope
Special Populations
System: GRADE
Evidence Distribution
Evidence Levels
Recommendation Strength
Contraindications
Monitoring Guidance
Serial serum urate (SU) measurements should be checked after each dose titration to guide ULT management and ensure an SU target of <6 mg/dl is achieved and maintained.
Difficulty
advanced
Learning Paths