Two-part ACR guidelines on gout

Sep 28 2012

Gout is one of the most common forms of inflammatory arthritis, affecting nearly 4% of adult Americans. Newly approved guidelines that educate patients in effective methods to prevent gout attacks and provide physicians with recommended therapies for long-term management of this painful disease are published in Arthritis Care & Research, a peer-reviewed journal of the American College of Rheumatology (ACR).

Uric acid is produced by the metabolism of purines, which are found in foods and human tissue. When uric acid levels increase, crystals can form and deposit in joints, causing excruciating pain and swelling typical of an acute gout flare. Doctor-diagnosed gout has risen over the past 20 years and now affects 8.3 million individuals in the U.S., according to a July 2011 study published in Arthritis & Rheumatism. Medical evidence suggests that the increased prevalence of elevated uric acid levels (hyperuricemia) and gout may be attributed to such factors as hypertension, obesity, metabolic syndrome, type 2 diabetes, and the extensive treatment with thiazide and loop diuretics for cardiovascular disease.

"Acute gout attacks can be debilitating and adversely affect patients' quality of life," says lead investigator John D. Fitzgerald, MD, PhD, Acting Rheumatology Division Chief at the University of California, Los Angeles (UCLA). "In order to improve patient care, the ACR funded this collaborative effort among U.S. researchers to produce guidelines, outlining pharmacological therapies and non-drug treatments to manage gout."

Dr. Fitzgerald and fellow co-leaders Drs. Robert Terkeltaub (senior and corresponding author, from the VA and UCSD system), Dinesh Khanna and Puja P. Khanna (from the University of Michigan and VA system) reviewed medical literature from the 1950s to the present. A task force panel including seven rheumatologists, two primary care physicians, a nephrologist, and a patient representative then ranked and voted upon recommendations to create the two-part ACR gout guidelines.

Part I guidelines focus on the systematic non-pharmacologic and pharmacologic therapeutic approaches to hyperuricemia and include:

• Educating patients on diet, lifestyle choices, treatment objectives, and management of concomitant diseases; this includes recommendations on specific dietary items to encourage, limit, and avoid.
• Treating patients with a xanthine oxidase inhibitor (XOI), such as allopurinol (Zyloprim), as first-line pharmacologic urate-lowering therapy approach.
• Recommending that patients' urate levels be lowered to less than 6 mg/dL, at a minimum, to improve gout symptoms.
• Suggesting that the initial dose of allopurinol be no greater than 100 mg/day, and less for patients with chronic kidney disease; followed by gradual increase of the maintenance dose, which can exceed 300 mg even in those with chronic kidney disease.
• Consideration of HLA-B*5801 pre-screening of patients at particularly high risk for severe adverse reaction to allopurinol (e.g., Koreans with stage 3 or worse kidney disease, and all those of Han Chinese and Thai descent).
• Prescribing combination therapy, with one XOI and one uriocosuric agent, when target urate levels are not achieved; pegloticase in patients with severe gout disease who to not respond to standard, appropriately dosed ULT therapy.

Part II guidelines cover therapy and prophylactic anti-inflammatory treatment for acute gouty arthritis. These guidelines recommend that physicians:

• Initiate pharmacologic therapy within 24 hours of onset of acute gouty arthritis attack.
• Continue ULT therapy, without interruption, during acute gout flares.
• Use non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, or oral colchicine as first-line treatment for acute gout, and combinations of these medications for severe or unresponsive cases.
• Utilize oral colchicine or low-dose NSAIDs as the first-line therapy options to prevent gout attacks when initiating ULT, as long as there is no medical contraindication or lack of tolerance.

Dr. Fitzgerald concludes, "The ACR gout guidelines are designed to emphasize safety, quality of therapy, and to reflect best practice based upon medical evidence available at this time. Our goal is that these guidelines, along with educating gout patients in effective treatment, will improve adherence, quality of care and management of this painful and potentially chronically debilitating condition."