Overarching principles and final set of 11 recommendations for the treatment of gout
| Overarching principles | |
| A | Every person with gout should be fully informed about the pathophysiology of the disease, the existence of effective treatments, associated comorbidities and the principles of managing acute attacks and eliminating urate crystals through lifelong lowering of SUA level below a target level. |
| B | Every person with gout should receive advice regarding lifestyle: weight loss if appropriate and avoidance of alcohol (especially beer and spirits) and sugar-sweetened drinks, heavy meals and excessive intake of meat and seafood. Low-fat dairy products should be encouraged. Regular exercise should be advised. |
| C | Every person with gout should be systematically screened for associated comorbidities and cardiovascular risk factors, including renal impairment, coronary heart disease, heart failure, stroke, peripheral arterial disease, obesity, hyperlipidaemia, hypertension, diabetes and smoking, which should be addressed as an integral part of the management of gout. |
| Final set of 11 recommendations | |
| 1 | Acute flares of gout should be treated as early as possible. Fully informed patients should be educated to self-medicate at the first warning symptoms. The choice of drug(s) should be based on the presence of contraindications, the patient's previous experience with treatments, time of initiation after flare onset and the number and type of joint(s) involved. |
| 2 | Recommended first-line options for acute flares are colchicine (within 12 hours of flare onset) at a loading dose of 1 mg followed 1 hour later by 0.5 mg on day 1 and/or an NSAID (plus proton pump inhibitors if appropriate), oral corticosteroid (30–35 mg/day of equivalent prednisolone for 3–5 days) or articular aspiration and injection of corticosteroids. Colchicine and NSAIDs should be avoided in patients with severe renal impairment. Colchicine should not be given to patients receiving strong P-glycoprotein and/or CYP3A4 inhibitors such as cyclosporin or clarithromycin. |
| 3 | In patients with frequent flares and contraindications to colchicine, NSAIDs and corticosteroid (oral and injectable), IL-1 blockers should be considered for treating flares. Current infection is a contraindication to the use of IL-1 blockers. ULT should be adjusted to achieve the uricaemia target following an IL-1 blocker treatment for flare. |
| 4 | Prophylaxis against flares should be fully explained and discussed with the patient. Prophylaxis is recommended during the first 6 months of ULT. Recommended prophylactic treatment is colchicine, 0.5–1 mg/day, a dose that should be reduced in patients with renal impairment. In cases of renal impairment or statin treatment, patients and physicians should be aware of potential neurotoxicity and/or muscular toxicity with prophylactic colchicine. Co-prescription of colchicine with strong P-glycoprotein and/or CYP3A4 inhibitors should be avoided. If colchicine is not tolerated or is contraindicated, prophylaxis with NSAIDs at low dosage, if not contraindicated, should be considered. |
| 5 | ULT should be considered and discussed with every patient with a definite diagnosis of gout from the first presentation. ULT is indicated in all patients with recurrent flares, tophi, urate arthropathy and/or renal stones. Initiation of ULT is recommended close to the time of first diagnosis in patients presenting at a young age (<40 years) or with a very high SUA level (>8.0 mg/dL; 480 µmol/L) and/or comorbidities (renal impairment, hypertension, ischaemic heart disease, heart failure). Patients with gout should receive full information and be fully involved in decision-making concerning the use of ULT. |
| 6 | For patients on ULT, SUA level should be monitored and maintained to <6 mg/dL (360 µmol/L). A lower SUA target (<5 mg/dL; 300 µmol/L) to facilitate faster dissolution of crystals is recommended for patients with severe gout (tophi, chronic arthropathy, frequent attacks) until total crystal dissolution and resolution of gout. SUA level <3 mg/dL is not recommended in the long term. |
| 7 | All ULTs should be started at a low dose and then titrated upwards until the SUA target is reached. SUA <6 mg/dL (360 µmol/L) should be maintained lifelong. |
| 8 | In patients with normal kidney function, allopurinol is recommended for first-line ULT, starting at a low dose (100 mg/day) and increasing by 100 mg increments every 2–4 weeks if required, to reach the uricaemia target. If the SUA target cannot be reached by an appropriate dose of allopurinol, allopurinol should be switched to febuxostat or a uricosuric or combined with a uricosuric. Febuxostat or a uricosuric are also indicated if allopurinol cannot be tolerated. |
| 9 | In patients with renal impairment, the allopurinol maximum dosage should be adjusted to creatinine clearance. If the SUA target cannot be achieved at this dose, the patient should be switched to febuxostat or given benzbromarone with or without allopurinol, except in patients with estimated glomerular filtration rate <30 mL/min. |
| 10 | In patients with crystal-proven, severe debilitating chronic tophaceous gout and poor quality of life, in whom the SUA target cannot be reached with any other available drug at the maximal dosage (including combinations), pegloticase is indicated. |
| 11 | When gout occurs in a patient receiving loop or thiazide diuretics, substitute the diuretic if possible; for hypertension consider losartan or calcium channel blockers; for hyperlipidaemia, consider a statin or fenofibrate. |
IL, interleukin; NSAID, non-steroidal anti-inflammatory drug; SUA, serum uric acid; ULT, urate-lowering therapy.