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Treat-to-target With Urate Lowering Therapy Recommended for All Gout Patients

The American College of Rheumatology has issued new treatment guidelines for gout strongly supporting a treat-to-target strategy for urate lowing therapy with a serum urate target of less than 6 mg/dl.

New treatment guidelines for gout strongly support a treat-to-target strategy for urate lowing therapy with a serum urate target of less than 6 mg/dl.

The 2020 iteration of the guidelines by the American College of Rheumatology (ACR) are based on a review of data from recently published research clinical trials. There are 42 recommendations of which 16 are considered strong due to the high quality of the evidence. The strong recommendations address indications, initiation of treatment, titration and treat-to-target, treatment approaches post urate lowering therapy (ULT) failure, and treatment protocols for managing flares.

“With this update, we sought to look at new and emerging clinical evidence that would be beneficial for treating patients with gout ,” said John FitzGerald, M.D., Ph.D., a rheumatologist and one of the guideline’s co-principal investigators. “The guideline now includes expanded indications for starting ULT, a greater emphasis to use allopurinol as the first line agent for all patients with gout that require urate lowering therapy including those patients with chronic kidney disease, and broadened recommendations about who needs HLA-B*5801 testing prior to starting allopurinol.”

The 2020 and 2012 versions both support the use of treat-to-target strategies for urate-lowering therapy (ULT).  In 2012, the recommendation was made conditionally due to poor quality evidence, but in 2020, it was bumped up to a strong recommendation due to higher quality evidence.

"Data from more recent research clinical trials comparing treat-to-target protocols versus usual care provide the basis for the strong recommendation to use a treat-to-target strategy with urate lowering therapy that includes a plan to achieve and maintain an serum urate target of less than 6 mg/dl to optimize patient outcomes," wrote the authors of the guidelines published this month in the journal Arthritis Care and Research. "These guidelines reinforce the strategy of starting with low-dose ULT and titrating up to achieve the serum urate (SU) target."

RELATED:  "The 2020 Treatment Guidelines for Gout"

Adherence to urate lowering therapies is poor in the U.S. and over the last 20 years, there has been no increase in the use of urate lowering therapies among gout patients. The authors speculated this may be due to conditional recommendations made in 2012, but adherence to ULT in gout is lowest among seven common chronic medical conditions so there may be factors at play.

Among the most noteworthy recommendation, allopurinol is recommended as the first-line treatment for all patients, including patients with chronic kidney disease. This recommendation was made, in part, due to the cost of medications and concerns over cardiovascular-related issues with febuxostat.

For patients with severe disease, the guideline does not support achieving serum urate levels of below 6 mg/dl. "There is ample evidence that lower serum urate levels hasten the resolution of tophi and are associated with less frequent gout flares, suggesting that lower serum urate thresholds may be preferable for patients with more burdensome gout."

The authors note that while there have been extensive clinical trials on treatment strategies for achieving a serum urate target of less than 6 mg/dl, to date, there are no data to support targeting lower serum urate levels for patients with severe disease.

While it wasn't included in the 2012 guidelines, the indications for receiving urate lowering therapies have been expanded to include individuals with evidence of radiographic damage due to gout. This is important because gout presents in a number ways, including joint damage.

REFERFENCE:  "2020 American College of Rheumatology Guideline for the Management of Gout," Arthritis Care and Research, May 6, 2020. DOI:10.1002/art.41247