Updated Guidelines Enhance Gout Management and Care

Author: Wiley
Published: 2012/09/29 - Updated: 2025/05/27
Publication Details: Peer-Reviewed, Informative
Category Topic: Autoimmune Diseases - Academic Publications

Page Content: Synopsis - Introduction - Main - Insights, Updates

Synopsis: This paper presents updated clinical guidelines for the management of gout, developed by a multidisciplinary panel and published in the peer-reviewed journal Arthritis Care & Research . The guidelines emphasize a comprehensive approach that includes both pharmacologic and non-pharmacologic strategies. Key recommendations involve initiating urate-lowering therapy with xanthine oxidase inhibitors like allopurinol, starting at low doses (≤100 mg/day) and titrating upward to achieve serum urate levels below 6 mg/dL.

For patients with chronic kidney disease or of certain ethnicities (e.g., Han Chinese, Thai, Korean), HLA-B*5801 screening is advised to mitigate the risk of severe hypersensitivity reactions. In cases where target urate levels are not met, combination therapy or pegloticase may be considered. The guidelines also recommend initiating anti-inflammatory treatment within 24 hours of an acute gout flare and continuing urate-lowering therapy during flares, using NSAIDs, corticosteroids, or colchicine as first-line treatments.

These evidence-based recommendations aim to improve patient outcomes by providing clear, actionable strategies for clinicians, which is particularly beneficial for populations such as seniors and individuals with disabilities who may be more susceptible to the complications of gout - Disabled World (DW).

Introduction

What is Gout?

Gout is also known as Gouty arthritis - acute; Gout - acute; Hyperuricemia; Tophaceous gout; Tophi; Podagra; Gout - chronic; Chronic gout; Acute gout; Acute gouty arthritis.

Main Content

Gout is a kind of arthritis that occurs when uric acid builds up in blood and causes joint inflammation. Gout is caused by having higher-than-normal levels of uric acid in your body. The exact cause is unknown. Gout may run in families. It is more common in men, in women after menopause, and those who drink alcohol. People who take certain medicines, such as hydrochlorothiazide and other water pills, may have higher levels of uric acid in the blood.

Gout is one of the most common forms of inflammatory arthritis, affecting nearly 4% of adult Americans. Newly approved guidelines that educate patients in effective methods to prevent gout attacks and provide physicians with recommended therapies for long-term management of this painful disease are published in Arthritis Care & Research, a peer-reviewed journal of the American College of Rheumatology (ACR).

Uric acid is produced by the metabolism of purines, which are found in foods and human tissue. When uric acid levels increase, crystals can form and deposit in joints, causing excruciating pain and swelling typical of an acute gout flare.

Doctor-diagnosed gout has risen over the past 20 years and now affects 8.3 million individuals in the U.S., according to a July 2011 study published in Arthritis & Rheumatism.

Medical evidence suggests that the increased prevalence of elevated uric acid levels (hyperuricemia) and gout may be attributed to such factors as hypertension, obesity, metabolic syndrome, type 2 diabetes, and the extensive treatment with thiazide and loop diuretics for cardiovascular disease.

"Acute gout attacks can be debilitating and adversely affect patients' quality of life," says lead investigator John D. Fitzgerald, MD, PhD, Acting Rheumatology Division Chief at the University of California, Los Angeles (UCLA).

"In order to improve patient care, the ACR funded this collaborative effort among U.S. researchers to produce guidelines, outlining pharmacological therapies and non-drug treatments to manage gout."

Dr. Fitzgerald and fellow co-leaders Drs. Robert Terkeltaub (senior and corresponding author, from the VA and UCSD system), Dinesh Khanna and Puja P. Khanna (from the University of Michigan and VA system) reviewed medical literature from the 1950s to the present.

A task force panel including seven rheumatologists, two primary care physicians, a nephrologist, and a patient representative then ranked and voted upon recommendations to create the two-part ACR gout guidelines.

Part 1: Guidelines

Focus on the systematic non-pharmacologic and pharmacologic therapeutic approaches to hyperuricemia and include:

• Recommending that patients' urate levels be lowered to less than 6 mg/dL, at a minimum, to improve gout symptoms.
• Treating patients with a xanthine oxidase inhibitor (XOI), such as allopurinol (Zyloprim), as first-line pharmacologic urate-lowering therapy approach.
• Educating patients on diet, lifestyle choices, treatment objectives, and management of concomitant diseases; this includes recommendations on specific dietary items to encourage, limit, and avoid.
• Consideration of HLA-B*5801 pre-screening of patients at particularly high risk for severe adverse reaction to allopurinol (e.g., Koreans with stage 3 or worse kidney disease, and all those of Han Chinese and Thai descent).
• Prescribing combination therapy, with one XOI and one uriocosuric agent, when target urate levels are not achieved; pegloticase in patients with severe gout disease who to not respond to standard, appropriately dosed ULT therapy.
• Suggesting that the initial dose of allopurinol be no greater than 100 mg/day, and less for patients with chronic kidney disease; followed by gradual increase of the maintenance dose, which can exceed 300 mg even in those with chronic kidney disease.

Part 2: Guidelines

Cover therapy and prophylactic anti-inflammatory treatment for acute gouty arthritis. These guidelines recommend that physicians:

• Continue ULT therapy, without interruption, during acute gout flares.
• Initiate pharmacologic therapy within 24 hours of onset of acute gouty arthritis attack.
• Utilize oral colchicine or low-dose NSAIDs as the first-line therapy options to prevent gout attacks when initiating ULT, as long as there is no medical contraindication or lack of tolerance.
• Use non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, or oral colchicine as first-line treatment for acute gout, and combinations of these medications for severe or unresponsive cases.

Dr. Fitzgerald concludes:

"The ACR gout guidelines are designed to emphasize safety, quality of therapy, and to reflect best practice based upon medical evidence available at this time. Our goal is that these guidelines, along with educating gout patients in effective treatment, will improve adherence, quality of care and management of this painful and potentially chronically debilitating condition."

These studies are published in Arthritis Care & Research.

Citations

2012 American College of Rheumatology Guidelines for Management of Gout Part I: Systematic Non-pharmacologic and Pharmacologic Therapeutic Approaches to Hyperuricemia. Dinesh Khanna, John D. FitzGerald, Puja P. Khanna, Sangmee Bae, Manjit Singh, Tuhina Neogi, Michael H. Pillinger, Joan Merill, Susan Lee, Shraddha Prakash, Marian Kaldas, Maneesh Gogia, Fernando Perez-Ruiz, Will Taylor, Frederic Liote, Hyon Choi, Jasvinder A. Singh,Nicola Dalbeth, Sanford Kaplan, Vandana Niyyar, Danielle Jones, Steven A. Yarows, Blake Roessler, Gail Kerr, Charles King, Gerald Levy, Daniel E. Furst, N. Lawrence Edwards, Brian Mandell, H. Ralph Schumacher, Mark Robbins, Neil Wenger, Robert Terkeltaub. Arthritis Care and Research; Published Online: September 28, 2012.

2012 American College of Rheumatology Guidelines for Management of Gout Part II: Therapy and Anti-inflammatory Prophylaxis of Acute Gouty Arthritis. Dinesh Khanna, Puja P. Khanna, John D. FitzGerald, Manjit K. Singh, Sangmee Bae, Tuhina Neogi, Michael H. Pillinger, Joan Merill, Susan Lee, Shraddha Prakash, Marian Kaldas, Maneesh Gogia, Fernando Perez-Ruiz, Will Taylor, Frederic Liote, Hyon Choi, Jasvinder A. Singh, Nicola Dalbeth, Sanford Kaplan, Vandana Niyyar, Danielle Jones, Steven A. Yarows, Blake Roessler, Gail Kerr, Charles King, Gerald Levy, Daniel E. Furst, N. Lawrence Edwards, Brian Mandell, H. Ralph Schumacher, Mark Robbins, Neil Wenger, Robert Terkeltaub. Arthritis Care and Research; Published Online: September 28, 2012.

Insights, Analysis, and Developments

Attribution/Source(s): This peer reviewed publication was selected for publishing by the editors of Disabled World (DW) due to its relevance to the disability community. Originally authored by Wiley and published on 2012/09/29, this content may have been edited for style, clarity, or brevity.