Gout Guidelines Arm Patients and Physicians with Tools to Fight Painful Disease
Gout is one of the most common forms of inflammatory arthritis, affecting nearly 4% of adult Americans.
Newly approved guidelines educate patients in effective methods to prevent gout attacks and provide physicians with recommended therapies for long-term management of this painful disease (1).
“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 (American College of Rheumatology) funded this collaborative effort among U.S. researchers to produce guidelines, outlining pharmacological therapies and non-drug treatments to manage gout.”
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.
Evidence suggests that increasing rates of gout may be due to factors such as high blood pressure, obesity, metabolic syndrome, type 2 diabetes and extensive use of two types of diuretics -- thiazide (eg. Apo-Hydro) and loop (eg Lasix)-- to treat cardiovascular disease.
Dr. Fitzgerald and fellow researchers (2) 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 systematicnon-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 (Zyloric), 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 (3) 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 prophylacticanti-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.”
- The guidelines were first published online Sept. 28 in Arthritis Care & Research, a peer-reviewed journal of the American College of Rheumatology.
- Khanna D, Khanna PP, Singh MK, Bae S, Neogi T, Pillinger MH, Merill J, Lee S, Prakash S, Kaldas M, Gogia M, Perez-Ruiz F, Taylor W, Lioté F, Choi H, Singh JA, Dalbeth N, Kaplan S, Niyyar V, Jones D, Yarows SA, Roessler B, Kerr G, King C, Levy G, Furst DE, Edwards NL, Mandell B, Schumacher HR, Robbins M, Wenger N, and Terkeltaub R. are members of the research team.
- Allopurinol, a commonly prescribed medication for gout and hyperuricemia, is a frequent cause of severe cutaneous adverse reactions (SCAR), which include the drug hypersensitivity syndrome, Stevens–Johnson syndrome, and toxic epidermal necrolysis. HLA-B*5801 allele is an important genetic risk factor for this life-threatening condition. Click HERE for more information on HLA-B*5801
- Click HERE for more information on gout prepared by The Arthritis Foundation of Malaysia.