American College of Rheumatology
Management of Gout
This guideline holds 42 recommendations, 118 references and 8 tables.
Summary
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
Initiation of urate-lowering therapy (ULT) is strongly recommended for patients with tophaceous gout, radiographic damage, or frequent gout flares.
Allopurinol is the strongly preferred first-line ULT agent, including for patients with moderate-to-severe CKD.
A treat-to-target strategy is strongly recommended, involving dose titration guided by serial SU measurements to achieve a target of <6 mg/dl.
Concomitant antiinflammatory prophylaxis (colchicine, NSAIDs, or glucocorticoids) is strongly recommended for at least 3-6 months when initiating ULT.
Colchicine, NSAIDs, or glucocorticoids are the strongly recommended first-line therapies for acute gout flares.
What is new in this version
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.
Recommendations
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