The European League Against Rheumatism (EULAR) issued new gout treatment guidelines this week, the first since 2006.
Much has changed in the understanding of gout since the guidelines were last issued.
There has been a dramatic increase in the prevalence of gout in developed countries and there is now mounting evidence for a clear association between gout and cardiovascular events, kidney failure and mortality. This “has heightened the realization that gout should never be neglected and should be treated properly,” wrote Pascal Richette, M.D., Ph.D., and colleagues in the July 25 issue of the Annals of the Rheumatic Diseases.
The 2016 recommendations are based on a systematic literature review of 984 references of studies that focused on treating flares and long-term management of gout. The guidelines were written, in part, with the primary care physician in mind since they often treat gout patients first.
While colchicine, non-steroidal anti-inflammatory drugs (NSAIDs) and glucocorticoids have traditionally been used to manage gout flares, now patients have new treatment options, such as allopurinol (Zyloprim), febuxostat (Uloric), pegloticase (Krystexxa) and interleukin-1 inhibitors (anakinra, canakinumab, rilonacept) for frequent and poorly controlled flares. Because of the high cost of IL-1 blockers and an increased likelihood of infection, the EULAR task force recommends they be prescribed only for patients who have contraindications to colchicine, NSAIDs and corticosteroids.
Citing multiple studies, the authors say that urate-lowering therapy (ULT), specifically allopurinol, should be considered at first presentation of a flare. If this fails, then febuxostat, or a combination of a xanthine oxidase inhibitor with a uricosuric, should be considered. For refractory gout, EULAR recommends pegloticase.
They recommend serum uric acid (SUA) target levels of less than 6 mg/dL (360 mmol/L) for mild to moderate gout and for patients with severe gout, less than 5 mg/dL (300 mmol/L).
How the EULAR and ACR Gout Recommendations Differ
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P Richette, M Doherty, et al. "2016 updated EULAR evidence-based recommendations for the management of gout," Annals of the Rheumatic Diseases. July 25, 2016. DOI:10.1136/annrheumdis-2016-209707