Guidelines for the Management of Gouty Arthritis

New guidelines* for the management of gout – a condition affecting almost 4% of adults or about 8.3 million people in the United States^[1] – have been published in the October 2012 issue of Arthritis Care & Research ^[2,3]. Developed by a task force of physicians and researchers, the guidelines are based on extensive review of the available literature and expert opinion in the field. The guidelines cover treatment of acute attacks of gout; agents used to lower uric acid and thereby prevent attacks; and medications that can (and should) be given along with uric-acid-lowering medications to prevent increased attacks that can occur when patients begin this type of therapy. Some conclusions of the guidelines follow.

Strategies to lower uric acid levels and prevent attacks of gout

1. All patients with gout need to learn about diet and lifestyle issues related to gout, and to understand the goals of therapy. Patients should also understand how other conditions (such as hypertension, diabetes or kidney disease) can impact their gout and its treatment.
2. In gout patients, the goal of therapy is to reduce uric acid levels to less than 6 mg/dL; for some patients (eg, those with tophi, collections of uric acid that can be felt on the skin surface) the goal is lower.
3. When starting allopurinol, the dose should be low, generally at 100 mg daily and gradually increased until the uric acid level is less than 6 mg/dL (as noted above). In patients with significant kidney disease, allopurinol should likely be started at an even lower dose (eg, 50 mg daily).
4. Certain groups of patients, including Koreans with severe kidney problems and patients of Han Chinese or Thai descent, can benefit from a genetic test that predicts the risk of a severe allergic reaction to allopurinol. This test is not helpful for other populations.
5. Allopurinol and febuxostat are both options in the initial management of gout, but cost and individual patient factors need to be considered. These issues were not part of the scope of the guidelines.
6. Gout patients should take special care to limit their consumption of purine-rich meat and seafood along with soft drinks and energy drinks sweetened with high-fructose corn syrup.
7. Low fat dairy products may reduce the risk of gout.
8. Avoid overuse of all types of alcohol, especially beer.
9. Patients in whom adequate doses of both allopurinol and febuxostat fail to lower uric acid levels sufficiently, may be eligible for intravenous therapy with pegloticase to lower uric acid levels.

Treating the acute attack of gout and preventing attacks while starting uric-acid-lowering therapy

1. Treatment for an attack of gout should start within the first 24 hours, as soon as is practical.
2. If a patient is on a uric-acid-lowering medication, such as allopurinol or febuxostat, it should not be stopped if an attack occurs.
3. Treatment options are: nonsteroidal anti-inflammatory agents (eg, naproxen), oral colchicine (two tabs, each 0.6mg, followed by one tab an hour later and no more for 12 hours) and steroids administered by a variety of routes, including local joint injection. In some severe cases, a combination of these treatments can be used. The guidelines did not suggest one treatment over another, but noted that the individual patient’s other medical history can help determine which choice is best.
4. All patients starting on medication to lower uric acid levels should be treated with prophylactic (preventive) therapy to address the early increase in attacks that can occur, unless there is a specific reason in an individual patient not to use such prophylaxis. Colchicine is the best studied agent to use in this setting, and a nonsteroidal anti-inflammatory agent (eg, naproxen 250mg bid) is considered acceptable.
5. The duration of prophylaxis should be at least six months and longer if the patient continues to experience attacks or has tophi.
6. Patients with kidney disease who take colchicine may require dose adjustments of this drug or other medications that might interact with colchicine.
7. The guidelines state that there is not adequate data to support the use of complementary agents, such as cherry juice (or extract) or celery root, for treatment of attacks of gout.

*Note: This article reviews the gout guidelines as published in 2012. For an updated discussion of the management of gout, see Gout: Risk Factors, Diagnosis and Treatment.

Updated: 4/18/2017

Authors

Theodore R. Fields, MD, FACP
Attending Physician, Hospital for Special Surgery
Professor of Clinical Medicine, Weill Cornell Medical College

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References

1. Zhu Y, et al: Prevalence of gout and hyperuricemia in the US general population: the National Health and Nutrition Examination Survey 2007-2008. Arthritis Rheum 63:3136-41, 2011.
2. Khanna D, et al: 2012 American College of Rheumatology Guidelines for Management of Gout. Part 1: Systematic Nonpharmacologic and Pharmacologic Therapeutic Approaches to Hyperuricemia. Arthritis Care & Research 64:10, 1431-1446, 2012.
3. Khanna D, et al: 2012 American College of Rheumatology Guidelines for Management of Gout. Part 2: Therapy and Anti-inflammatory Prophylaxis of Gouty Arthritis. Arthritis Care & Research 64:10, 1447-1461, 2012.