EULAR Releases Updated Gout Management Guidelines

The European League Against Rheumatism (EULAR) has published its updated recommendations for the management of gout, reflecting updated data included in a meta-analysis by a task force consisting of 15 rheumatologists, 1 radiologist, 2 general practitioners, 1 research fellow, 2 patients, and 3 epidemiology experts representing 12 European countries. 

The last recommendations from 2006 were reviewed by each task force member and assigned scores according to expert opinion. A literature search of  MEDLINE, EMBASE, and Cochrane Library databases, including work published between January 2005 in in June 2013, was conducted utilizing the Oxford Centre for Evidence-Based Medicine standards to assign levels of evidence and recommendation grades. 

• Patients should receive information regarding gout pathophysiology, treatment options, burden of comorbidities, general medical management of acute attack management, and the lifelong need to reduce serum uric acid (SUA) to target certain levels
• Regular counseling on lifestyle modifications, including weight loss, avoidance of alcohol, and adherence to certain dietary recommendations should be given in addition to advocating exercise
• Routine, systematic screening for known disease comorbities, including renal impairment, coronary artery disease, stroke, dyslipidemia, diabetes, and peripheral arterial disease should be performed

1. Acute gout flares should be treated as soon as diagnosed.
2. First line options identified for acute flare include:  colchicine, loading dose of 1 mg, 0.5 mg on day 1, or a nonsteroidal antiinflammatory drug (NSAID), oral corticosteroids (equivalent prednisolone dose of 30–35 mg/day for 3–5 days), or joint aspiration with intraarticular injection of corticosteroids.  Avoid colchicine and NSAID administration in patients with renal impairment.
3. Interleukin(IL)-1 blockers should be considered in patients with both frequent disease flares and contraindications to receiving colchicine, NSAIDs, or corticosteroids.
4. Urate-lowering therapy (ULT) should be accompanied by prophylaxis in the first 6 months of treatment. This panel recommends colchicine, at a dose of 0.5–1 mg/day, with adjustments for renal impairment. When colchicine is not tolerated well or is contraindicated, prophylaxis with NSAIDs at a low dosage can be considered.
5. Patients with definitive gout diagnosis and ≥2 gout flares/year, tophi, urate arthropathy, or recurrent kidney stones should be considered for ULT. Patients who are <40 years old or have SUA levels >8 mg/dL (480 µmol/L), or other comorbidities should receive early ULT.
6. SUA targets of <6 mg/dL (360 µmol/L) should be targeted with ULT therapy, SUA targets of <5 mg/dL (300 µmol/L) may be appropriate in patients with severe gout.  Long-term SUA levels of  <3 mg/dL are generally not recommended.
7. Initiation of low-dose ULTs are recommended, with upward titration until SUA goal is attained.
8. Allopurinol is recommended by the task force as first-line ULT, beginning with 100 mg/day and increasing by 100 mg increments every 2–4 weeks if needed to attain SUA goal. Febuxostat or a uricosuric should be started if allopurinol alone cannot be used to attain target SUA, or if it is not well tolerated.
9. Creatinine clearance should be used to adjust allopurinol maximum daily doses for patients with renal impairment.
10. When target SUA levels cannot be attained in patients with debilitating chronic tophaceous gout and crystal-proven disease, pegloticase is indicated.
11. If a patient presents with gout and is on loop or thiazide diuretics, it is recommended that the diuretic be switched. Losartan or calcium channel blockers should be considered to replace diuretic indicated for hypertension and a statin should be considered for hyperlipidemia.

Reference

Richette P, Doherty M, Pascual E, et al. 2016 updated EULAR evidence-based recommendations for the management of gout. Ann Rheum Dis. 2016;  doi:10.1136/annrheumdis-2016-eular.3734

follow @RheumAdvisor