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New ACR Guidelines for Treating Gout

Experts suggest approaches to hyperuricemia and acute gouty arthritis (Sept. 28)

Gout is one of the most common forms of inflammatory arthritis, affecting approximately 4% of adult Americans. Newly approved guidelines that educate patients in effective methods to prevent gout attacks and that provide physicians with recommended therapies for long-term disease management were announced by Wiley on September 28 and were published in Arthritis Care & Research, a 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. Physician-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 extensive treatment with thiazide and loop diuretics for cardiovascular disease.

A team of experts reviewed the 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 on recommendations to create the two-part ACR gout guidelines.

Part I guidelines focus on systematic nonpharmacologic and pharmacologic therapeutic approaches to hyperuricemia and include:

  • 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
  • Treating patients with a xanthine oxidase inhibitor (XOI), such as allopurinol (Zyloprim), as a first-line pharmacologic urate-lowering therapy (ULT) approach
  • Recommending that patients’ urate levels be lowered to less than 6 mg/dL, at a minimum, to improve gout symptoms
  • Suggesting that the initial dosage of allopurinol be no greater than 100 mg/day, and less for patients with chronic kidney disease, followed by a gradual increase of the maintenance dose, which may exceed 300 mg even in patients with chronic kidney disease
  • Recommending that HLA-B*5801 prescreening be considered for patients at particularly high risk for severe adverse reactions 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 do not respond to standard treatment; or appropriately dosed ULT

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

  • Initiate pharmacologic therapy within 24 hours of the onset of an acute gouty arthritis attack
  • Continue ULT without interruption during acute gout flares
  • Use nonsteroidal 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
  • Use 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

For more information, visit the Wiley Web site.

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