The latest recommendations emphasize providing key information about the disease and its treatment.
A guideline for gout management originally published in 2007 has been revised and updated. Strongly emphasized in the latest version of the British Society for Rheumatology/British Health Professionals in Rheumatology guideline are patient education and providing information about gout and its treatment.
Guideline authors Michelle Hui and colleagues in the United Kingdom offered 4 reasons why there’s a clear need for an update:
(1) New drug treatment options have expanded efficacy and safety profiles.
(2) Gout incidence, prevalence, and severity have increased.
(3) Fewer than half of patients with gout receive urate-lowering treatment.
(4) The barriers to patients with gout receiving adequate care can be overcome.
The authors presented the gout update in a recent Rheumatology article. Following are highlights of their recommendations.
Acute gout attacks
• Educate patients to treat gout attacks as soon as they occur and throughout the attack.
• Advise patients that joints affected by gout should be rested, elevated, and cooled. Bed-cages and ice packs may be useful.
• Use a maximally dosed NSAID with colchicine dosed at 500 Î¼g 2 to 4 times a day, the drugs of choice, in the absence of contraindications. Drug choice depends on patient preference, kidney function, and comorbidities. Prescribe gastroprotective agents for patients receiving NSAIDs.
• Aspirate and inject a joint with corticosteroids for acute single-joint gout. This may be the best treatment in patients with acute attacks and comorbidities. A possible alternative: a short course of oral corticosteroid or a single injection of an intramuscular steroid. Systemic steroid therapy is also appropriate for single or multiple joint attacks.
• Combine treatments for patients with acute gout where monotherapy has failed.
• Consider interleukin-1 inhibitors for patients who don’t respond to standard treatment.
Modifying risk factors and lifestyle
• Consider an alternative blood pressure–lowering agent when diuretics are used to treat hypertension and not heart failure, provided the agent controls the hypertension.
• For every patient with gout, give verbal and written information: the causes and consequences of gout and hyperuricemia; how to manage acute attacks; dietary recommendations (eg, alcohol consumption and obesity management); the rationale, use, and goals of urate-lowering therapy; and plans specific to the patient for comorbidities and concurrent medications. Discuss patients’ perceptions of illness and barriers to care.
• In overweight patients with gout, encourage dietary changes aimed at gradual reductions in body weight and continued maintenance. Discuss well-balanced low-fat, low-sugar diets high in vegetables and fiber with all patients.
• Encourage patients with gout and a history of kidney stones to consume > 2 L of water daily and consider using potassium citrate (60 mEq/d) for alkalinization of the urine when stones are recurrent.
• Screen for all cardiovascular risk factors and comorbidities (eg, smoking, hypertension, diabetes, dyslipidemia, obesity, and kidney disease) with at least annual reviews and appropriate management.
Optimal use of urate-lowering therapies
• Explain to patients the option of urate-lowering treatment upon gout diagnosis and involve patients completely in the decision as to when to begin urate-lowering treatment. Emphasize the importance of taking their urate-lowering medications regularly. Support patients when they have increases in gout flares during urate lowering.
• Discuss urate-lowering therapy and offer it to all patients with gout, especially those who have recurring attacks, tophi, chronic gouty arthritis, joint damage, renal impairment, kidney stones, diuretic use, or gout that started at a young age.
• Start urate-lowering therapy after inflammation has settled, when the patient is not in pain.
• Use urate-lowering therapy initially to lower and maintain the serum uric acid level ≤ 300 umol/L to prevent further crystal formation and dissolve existing crystals. The lower the serum uric acid level, the quicker the crystals dissolve. After years of successful treatment, when tophi have gone and the patient is free of symptoms, adjust the dose of urate-lowering therapy to maintain a level ≤ 360 umol/L.
• Start allopurinol, the recommended first-line drug for lowering uric acid levels, at a low dose (50 to 100 mg/d) and increase it in 100-mg increments every 4 weeks until uric acid levels have fallen to target. In patients with kidney impairment, use increments of 50 mg every 4 weeks when increasing dose.
• Prescribe febuxostat as a second-line alternative when allopurinol is not tolerated or when kidney impairment is present. Start with a dose of 80 mg/d and, if needed, increase to 120 mg after 4 weeks.
• Use uricosuric agents in patients resistant to or intolerant of xanthine oxidase inhibitors. These drugs and doses are recommended: sulfinpyrazone, 200-800 mg/d; probenecid, 200-2000 mg/d, suitable for patients with normal or mildly impaired kidney function; benzbromarone, 50-200 mg/d, suitable for patients with mild to moderate kidney impairment.
• Do not use losartan and fenofibrate primarily as urate-lowering therapy unless they are already used in lowering blood pressure and lipids, respectively, because they have a weak uricosuric effect. Vitamin C supplements also have a weak uric acid–lowering effect.
• When the target urate level has not been achieved with monotherapy, combine a uricosuric agent with an xanthine oxidase inhibitor.
• Consider colchicine 500 Î¼g once or twice a day as prophylaxis against acute attacks resulting from starting or increasing any urate-lowering drug and continue for up to 6 months. If colchicine is not tolerated and there are no contraindications, use a low-dose NSAID or coxib with gastroprotection.
Management in special groups
• Reduce colchicine in patients with glomerular filtration rates of 10-50 mL/min/1.73 m2 and avoid it for patients who have more severe renal failure.
• Do not use high-dose NSAIDs if any level of kidney disease is present.
• Corticosteroids may be used in patients with chronic kidney disease but have not been examined in randomized trials.
• Use great caution when doing flare prophylaxis with colchicine or NSAIDs in patients with kidney insufficiency and gout; colchicine is preferred to nonsteroidals.
• Refer patients who have severe symptomatic tophaceous gout with uncontrolled hyperuricemia to a rheumatologist for consideration of the polyethylene glycol modified mammalian uricase treatment, pegloticase.
• Although gout is rare in pregnancy, conservative measures may be used (eg, ice, nonsteroidals in the second trimester, steroids, and lifestyle modifications).
• Avoid colchicine in pregnancy.
Michelle Hui, Alison Carr, Stewart Cameron, et al. “The British Society for Rheumatology Guideline for the Management of Gout.” Rheumatology (Oxford). 2017 Jun 12. doi: 10.1093/rheumatology/kex250. [Epub ahead of print]