guidelines
Current management guidelines
This article summarises the core components of the guidelines on gout management
and highlights their differences when relevant
Alexandre Dumusc MD
Alexander So MD
Rheumatology
Department, Lausanne
University Hospital,
Lausanne, Switzerland
Clinical guidelines are meant to help
clinicians in their decision-making process
in the choice of available treatments. Several
guidelines on treating patients with gout are
currently available. They are in general developed
by experts, with or without the help of general
physicians and patients, and should be based on the
best available evidence at the time of preparation
of the guideline. The American College of
Rheumatology (ACR) issued guidelines in 2012 1,2 and
the European League Against Rheumatism (EULAR)
issued recommendations in 2016. 3 A group of
international experts published treat-to-target (T2T)
recommendations highlighting the use of several
targets including serum urate level in gout
management. 4 The American College of Physicians
(ACP) issued practical guidelines in 2017 that have
generated a certain amount of controversy. 5 National
guidelines were published by the British Society for
Rheumatology (BSR) in 2017. 6
Management of acute attacks of gout
A gout flare should be treated promptly with anti-
inflammatory drugs. Ideally, patients should be
educated to self-medicate as soon as they notice
symptoms of a flare. The affected joint should be
rested and elevated. The use of topical ice could
reduce pain. During an acute attack of gout, urate-
lowering therapies (ULT) should not be discontinued;
thus patients should be educated accordingly as this
fact could seem counter-intuitive.
Non-steroidal anti-inflammatory drugs (NSAIDs),
colchicine and corticosteroids (intra-articular
injection or systemic) are effective to treat acute
gout. Interleukin-1 (IL-1) blockers are sometimes
used for selected patients. 7 Guidelines are in
agreement that the choice of treatment depends on
comorbidities, contraindications (especially renal
impairment), previous experience, time of initiation
after flare onset, number/type of joint involved and
patient preferences. If these drugs are insufficient,
they can be combined, especially for a polyarticular
attack or when multiples large joints are involved.
NSAIDs should be used at full dose with gastric
protection. There is some minor discordance about
the use of colchicine between guidelines. A starting
dose of 1mg (EULAR) or 1.2mg (ACR) followed 1 hour
later with 0.5mg (EULAR) or 0.6mg (ACR), or 0.5mg
2–4-times a day (BSR) is proposed. 1,3,6 NSAIDs and
colchicine should be avoided in patients with severe
renal insufficiency. Colchicine should be prescribed
with caution in patients treated with strong
P-glycoprotein and/or CYP3A4 inhibitors, such as
cyclosporine or clarithromycin.
Oral corticosteroids, 30–35mg/day (EULAR),
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0.5mg/kg/day (ACR) for 3–5 days (EULAR) or 5–10
days (ACR) are an option when colchicine and
NSAIDs are contraindicated or not tolerated. 1,3 ACR
also suggests an alternative corticosteroid regimen
of 2–5 days at full dose followed by 7–10 days with
a tapered dose. Joint aspiration with corticosteroid
injections is also highly effective, and might be
treatment of choice when a single large joint is
involved.
IL-1 inhibitors (anakinra, canakinumab) may
be considered in case of frequent flares and
contraindications to colchicine, NSAIDs and
corticosteroids. 7
Prophylaxis of gout flares when initiating ULT is
generally recommended and should be explained
and discussed with the patient. All guidelines
recommend a prophylaxis of six months’ duration
after starting ULT or three to six months after
reaching serum urate level target (ACR). ACR
suggests continuing prophylaxis if there are
ongoing symptoms of gout. 1 The drug of choice
for prophylaxis is colchicine. The recommended
dose for colchicine is 0.5–1 mg/day (0.6–1.2mg/
day; ACR), which should be reduced in case of
renal impairment. 1 BSR suggests a colchicine dose
of 0.5mg/day for glomerular filtration rate (GFR)
of 30–60ml/min and 0.5mg every two or three
days for GFR 10–30ml/min. Colchicine should be
avoided when GFR is <10ml/min (BSR). 8 Low-dose
NSAIDs (with gastroprotection) might be considered
when colchicine is not tolerated or contraindicated
(EULAR, ACR, BSR). Use of low-dose prednisone
(≤10mg/day) is suggested by ACR for prophylaxis
when both NSAIDs and colchicine are ineffective,
not tolerated or contraindicated.
Management of ULT
ULT should be considered in every patient having
a definite diagnosis of gout. Patients should be fully
involved in the decision-making process of starting
ULT. The importance of a regular intake of the
treatment should be emphasised to optimise long-
term adherence to ULT.
ULT is indicated in all patients with tophi, chronic
gouty arthritis, urate arthropathy, past urolithiasis,
recurrent flares or impaired renal function. Primary
gout starting at young age (<40 years) is also an
indication for ULT. Guidelines differ substantially in
defining the number of gout flares needed to start
ULT. Ideally, ULT should be initiated when the gout
flare has settled.
Most guidelines agree that treatment should
aim to reduce serum urate levels (sUA) to a defined
target. sUA should be measured on a regular basis
and ULT adjusted accordingly. A sUA target of