Internationally developed gout guidelines seek to improve clinical practice

Ten recommendations for the diagnosis and management of patients with gout have been developed by a multinational group with the aim of improving daily clinical practice.

The 10 recommendations appeared in the February Annals of the Rheumatic Diseases:

1. 1. Identification of monosodium urate crystals should be performed to definitively diagnose gout; if not possible, a diagnosis of gout can be supported by classical clinical features (such as podagra, tophi, rapid response to colchicine) and/or characteristic imaging findings.
2. 2. In patients with gout, measure renal function and assess cardiovascular risk factors.
3. 3. Treat acute gout with low-dose colchicine (up to 2 mg daily), NSAIDs and/or intra-articular, oral or intramuscular glucocorticoids.
4. 4. Patients should reduce excess body weight, exercise, stop smoking, and avoid excess alcohol and sugar-sweetened drinks.
5. 5. Allopurinol should be the first-line urate-lowering therapy, followed by uricosurics or febuxostat. Uricase as monotherapy should only be considered in patients with severe gout after all other therapies have failed or are contraindicated. Urate-lowering therapy, except uricase, should be started as a low dose and then increased to achieve a target serum urate level.
6. 6. Patient education on flare is essential and prophylaxis, of colchicine up to 1.2 mg daily, should be considered. NSAIDs or low-dose glucocorticoids can be used if colchicine is contraindicated or not tolerated.
7. 7. Patients with mild-moderate renal impairment can consider allopurinol, with close monitoring for adverse events, starting at a daily dose of 50 to 100 mg that can be titrated up to achieve a target serum for uric acid. Febuxostat and benzbromarone can be used as alternative drugs without dose adjustment.
8. 8. Treat to target serum urate level below 0.36 mmol/L (6 mg/dL) and the eventual absence of gout attacks and resolution of tophi. Monitor serum urate level, frequency of gout attacks and tophi size.
9. 9. Tophi should be treated medically by achieving a sustained reduction in serum uric acid, preferably below 0.30 mmol/L (5 mg/dL). Surgery is only indicated in cases such as nerve compression, mechanical impingement or infection.
10. 10. Pharmacological treatment of asymptomatic hyperuricemia is not recommended.

“Even though gout is a potentially curable disease, its management is far from optimal in both primary care and rheumatology clinics,” the authors wrote. “The quality of care provided to gout patients needs to improve.”