A strong focus on a treat-to-target strategy for gout is one of the key changes in new guideline released by the American College of Rheumatology (ACR) this week.

In the first major update since 2012, new ACR guidelines now also include expanded indications for starting urate-lowering therapy (ULT), a focus on allopurinol as the preferred first-line ULT including in patients with chronic kidney disease, and broadened recommendations about who needs HLA-B*5801 testing prior to starting allopurinol.

The 2020 Guideline for the Management of Gout comprises 42 recommendations and 16 strong recommendations, including the use of a treat-to-target strategy over a fixed dose strategy with ULT for all patients with gout.

The guidelines recommend a management strategy of starting with a low-dose of a ULT medication and titrating up to achieve and maintain a serum urate level of less than 6 mg/dL (0.36 mmol/L).

However, in contrast to previous ACR and EULAR guidelines, the new ACR guidelines do not specify serum urate thresholds beyond the 0.36 mmol/L level for patient subsets with more severe disease (e.g., those with tophi).

Another major change is a recommendation to use anti-inflammatory prophylaxis when starting ULT for at least three to six months rather than less than three months.

The new strong recommendation for allopurinol as the preferred first-line ULT for all patients, including those with CKD, is “due to respective cost of each medication and potential [cardiovascular] safety concerns that have recently emerged with febuxostat.

The expanded indication for starting ULT now includes individuals with evidence of radiographic damage attributable to gout, regardless of subcutaneous tophi or flare frequency, in an effort to recognise the various ways in which gout may present, and that joint damage is reflective of an active biologic process.

For patients who do not achieve serum urate targets with a xanthine oxidase inhibitor, uricosurics, or other interventions there is a strong recommendation to switch to pegloticase if they continue to have frequent gout flares (>2 /year) or non-resolving subcutaneous tophi, but a strong recommendation against this if there are less frequent flares and no tophi.

For patients experiencing a gout flare, the guidelines strongly recommend using colchicine, NSAIDs, or glucocorticoids (oral, intra-articular or intramuscular) as appropriate first-line therapy for gout flares over IL-1 inhibitors or ACTH

“With this update, we sought to look at new and emerging clinical evidence that would be beneficial for treating patients with gout ,” said Dr John FitzGerald, a rheumatologist at the UCLA Health and one of one of the guideline’s co-principal investigators.

“Gout has been characterized as a “curable disease” As data continue to emerge supporting best practices in management, implementation of these recommendations will ideally lead to improved quality of care for patients with gout.”