2020 American College of Rheumatology Guideline for the Management of Gout

TLDR

The guideline provides comprehensive recommendations for gout management, covering urate‑lowering therapy, flare treatment, and lifestyle and medication advice. It was developed through systematic reviews, network meta‑analyses, GRADE assessment, patient input, and a consensus process that graded recommendations as strong or conditional. The guideline issued 42 recommendations, including 16 strong ones that endorse initiating urate‑lowering therapy for all patients with tophaceous gout, radiographic damage, or frequent flares; recommend allopurinol as first‑line therapy even in moderate‑to‑severe CKD; advise low starting doses, treat‑to‑target titration to serum urate <6 mg/dl, 3–6 month anti‑inflammatory prophylaxis, and strong endorsement of colchicine, NSAIDs, or glucocorticoids for flare management.

Abstract

Objective To provide guidance for the management of gout, including indications for and optimal use of urate‐lowering therapy ( ULT ), treatment of gout flares, and lifestyle and other medication recommendations. Methods Fifty‐seven population, intervention, comparator, and outcomes questions were developed, followed by a systematic literature review, including network meta‐analyses with ratings of the available evidence according to the Grading of Recommendations Assessment, Development and Evaluation ( GRADE ) methodology, and patient input. A group consensus process was used to compose the final recommendations and grade their strength as strong or conditional. Results Forty‐two recommendations (including 16 strong recommendations) were generated. Strong recommendations included initiation of ULT for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares; allopurinol as the preferred first‐line ULT , including for those with moderate‐to‐severe chronic kidney disease ( CKD ; stage &gt; 3); using a low starting dose of allopurinol (≤100 mg/day, and lower in CKD ) or febuxostat ( &lt; 40 mg/day); and a treat‐to‐target management strategy with ULT dose titration guided by serial serum urate ( SU ) measurements, with an SU target of &lt;6 mg/dl. When initiating ULT , concomitant antiinflammatory prophylaxis therapy for a duration of at least 3–6 months was strongly recommended. For management of gout flares, colchicine, nonsteroidal antiinflammatory drugs, or glucocorticoids (oral, intraarticular, or intramuscular) were strongly recommended. Conclusion Using GRADE methodology and informed by a consensus process based on evidence from the current literature and patient preferences, this guideline provides direction for clinicians and patients making decisions on the management of gout.