Gout

Guidelines for OA, gout, vasculitis previewed at #ACR19


Previews of draft guidelines for gout, vasculitis and osteoarthritis were up for discussion at the 2019 ACR/ARP Annual Meeting in Atlanta.

The guideline documents, currently under peer review, are scheduled for publication in 2020. Here’s a summary of the some of the recommendations.

Gout

Draft clinical guidelines on gout management include a strong recommendation for a treat-to-target over a fixed dose strategy. They recommend starting with a low dose urate-lowering therapy and escalating to achieve and maintain a serum urate level <6 mg/dL.

“While the recommendation differs from the American College of Physicians, a treat-to-target approach was supported by randomised trial data, so we hope this will change how health care providers currently treat the condition,” said guidelines co-lead Dr Tuhina Neogi

Other proposed changes from the 2012 guidelines include:

  • A strong recommendation to use allopurinol as first line therapy even in patients with chronic kidney disease
  • A strong recommendation to use an anti-inflammatory prophylaxis (e.g., colchicine, NSAIDs, prednisone/prednisolone) when starting ULT for at least 3-6 months rather than less than 3 months, with ongoing evaluation and continued prophylaxis if the patient continues to experience flares.
  • Indications for starting ULT have been expanded to conditionally consider patients with infrequent gout flares or after their first gout flare if they also have moderate to severe chronic kidney disease (CKD stage ≥ 3), marked hyperuricaemia (serum urate > 9 mg/dl) or kidney stones.
  • A conditional recommendation for HLA-B*5801 testing prior to starting allopurinol only for patients of Southeast Asian descent (e.g., Han Chinese, Korean, Thai) and African-American descent who have a higher prevalence of HLA-B*5801.

Vasculitis

Lead investigator for the vasculitis guidelines Dr Sandra Chung said the use of glucocorticoids, a significant component of therapy for decades, was one of the important clinical questions they had to answer.

“There is now increasing recognition of the toxicity of glucocorticoids, and thus we are recommending strategies to reduce their usage in patients with giant cell arteritis and ANCA-associated vasculitis and decrease their risk for these toxicities,” she said.

Some of the draft recommendations include:

  • Conditional recommendations to use glucocorticoid-sparing therapies for the initial treatment of giant cell arteritis.
  • Conditional recommendations to use vascular imaging to identify large-vessel involvement in patients newly diagnosed with giant cell arteritis.
  • A conditional recommendation to use a reduced-dose glucocorticoid (e.g., prednisone) dosing strategy for the treatment of granulomatosis with polyangiitis and microscopic polyangiitis.

Osteoarthritis

Exercise remains as an important intervention for osteoarthritis while injections are losing favour in some of the major changes since 2012 guidelines.

  • Strong recommendations (previously conditional) for self-efficacy/self-management programs, use of tai chi for knee and hip OA, topical NSAIDs for knee and hand OA, oral NSAIDs and intra-articular steroids for knee and hip OA.
  • A new conditional recommendation for balance exercises for knee and hip OA and duloxetine for knee OA.
  • A conditional recommendation for using topical capsaicin in patients with knee OA (previously conditional against).
  • New conditional recommendations for using yoga, cognitive behavioural therapy, radiofrequency ablation and kinesiotaping for first carpometacarpal and knee OA
  • A conditional recommendation against using manual therapy with exercise for knee and hip OA (previously was conditionally for usage).
  • A strong recommendation against transcutaneous electric nerve stimulation for knee and hip OA (previously was a conditional recommendation).
  • A new conditional recommendation against using intra-articular hyaluronic acid injections in first carpometacarpal and knee OA.
  • A strong recommendation against using glucosamine, and for using chondroitin, in patients with knee and hip OA (previously were conditional recommendations).
  • A notable addition to the updated guideline is a new strong recommendation against using hyaluronic acid injection in patients with hip OA.

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