2020 American College of Rheumatology Guideline for the Management of Gout

Abstract

Objective To provide guidance for the management of gout including indications for and optimal use of urate‐lowering therapy (ULT), treatment of gout flares, and lifestyle and other medication recommendations. Methods Fifty‐seven patient intervention comparator outcome (PICO) questions were developed. This was followed by a systematic literature review including network meta‐analyses with rating of the available evidence according to GRADE methodology, and patient input. A group consensus process was used to compose the final recommendations and grade their strength as strong or conditional. Results Forty‐two recommendations (including 16 strong recommendations) were generated. Strong recommendations included initiation of urate‐lowering therapy (ULT) for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares; allopurinol as the preferred first‐line ULT, including in those with moderate‐to‐severe chronic kidney disease (CKD≥3); using a low starting dose of allopurinol (≤100 mg/day, and lower in CKD) or febuxostat (≤40 mg/day); a treat‐to‐target management strategy with ULT dose titration guided by serial serum urate (SU) measurements with a SU target of <6 mg/dL. When initiating ULT, concomitant anti‐inflammatory prophylaxis therapy was strongly recommended for a duration of at least 3‐6 months. For management of gout flares, colchicine, NSAIDs, or glucocorticoids (oral, intra‐articular, or intramuscular) were strongly recommended. Discussion This guideline provides direction for clinicians and patients making decisions on the management of gout, using GRADE methodology and informed by a consensus process based on evidence from the current literature and patient preferences.