Gout
Also known as: CPPD · crystal arthropathy · hyperuricemia · pseudogout
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2020 American College of Rheumatology Guideline for the Management of Gout
American College of Rheumatology (ACR) · 2020 · 2020 guideline
The ACR guideline page for gout management, hosting the current 2020 recommendations. The guideline covers when to start urate-lowering therapy, how to select and titrate it, treatment of acute flares, anti-inflammatory prophylaxis during urate-lowering therapy, and lifestyle and concomitant-medication considerations.
- The ACR page identifies the 2020 gout guideline as the current version and marks it as published and disseminated. source
- The guideline uses a treat-to-target approach built around a serum urate goal, with allopurinol as the preferred first-line urate-lowering drug. source
- Colchicine, NSAIDs or glucocorticoids are the recommended options for treating gout flares. source
2016 updated EULAR evidence-based recommendations for the management of gout
European Alliance of Associations for Rheumatology (EULAR) · 2017 · 2016 update
EULAR's European recommendations on gout management, published in Annals of the Rheumatic Diseases. They cover treatment of acute flares, early initiation and titration of urate-lowering therapy toward a serum urate target, flare prophylaxis when starting such therapy, patient education and lifestyle advice, and review of concomitant drugs that raise urate.
- Sets out three overarching principles and eleven recommendations covering both flare treatment and long-term urate lowering. source
- Allopurinol is positioned as first-line urate-lowering therapy with dose adjustment for renal function; febuxostat, uricosurics and pegloticase are alternatives in defined situations. source
US vs EU key differences
- Serum urate targets are tiered differently: EULAR uses two targets - below 360 micromol/L (about 6 mg/dL) generally and below 300 micromol/L (about 5 mg/dL) in severe or tophaceous gout until crystals dissolve - whereas ACR applies a single target of under 6 mg/dL to all patients. source
- Timing of urate-lowering therapy differs: EULAR says ULT should be considered and discussed with every patient from the first presentation of definite gout, while ACR conditionally advises against starting ULT after a first flare except in patients with moderate-to-severe CKD, markedly elevated serum urate or urolithiasis. source
- The ACR guideline incorporates post-CARES cardiovascular safety data by advising a switch away from febuxostat in patients with established cardiovascular disease; the 2016 EULAR document predates that trial and lists febuxostat as a straightforward second-line option. source
- Version currency differs by four years: the US guideline is from 2020 while the European recommendations date to 2016, though both name allopurinol as the preferred first-line urate-lowering drug. source
What changed recently
- US2012 guideline → 2020 guideline2020-05-11
Treat-to-target dosing of urate-lowering therapy against serial serum urate measurements, targeting under 6 mg/dL, was upgraded to a strong recommendation on the strength of trials published since 2012. Allopurinol became the explicitly preferred first-line urate-lowering drug for everyone including patients with chronic kidney disease, partly on cost and febuxostat cardiovascular safety concerns, with HLA-B*5801 screening advised first in higher-risk ancestry groups.
source ↗curation confidence 90% - EU2006 recommendations → 2016 update2016-07-25
The update moved urate-lowering therapy much earlier, advising it be considered from the first presentation of gout rather than after repeated flares, and set explicit serum urate targets of under 6 mg/dL, or under 5 mg/dL in severe disease. It also brought in agents unavailable in 2006, naming febuxostat as an alternative when allopurinol fails to reach target, interleukin-1 blockade for frequent flares with contraindications to standard drugs, and pegloticase for refractory gout.
source ↗curation confidence 90%
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