New American College of Rheumatology (ACR) guidelines for diagnosis and treatment of gout
As a #foot
and ankle specialist, I am finding #gout
to be an increasingly common problem I encounter among my patient population. I suspect it is associated with the increasing prevalence of metabolic syndrome and prediabetes. Given that gout is due to metabolic dysfunction, its increased prevalence is likely linked to the increasing numbers of patients with prediabetes-metabolic syndrome => http://1.usa.gov/1hpDn2r
.A group of 12 national scientific committees, with input from 474 practicing rheumatologists developed 10 recommendations for the management of gout.
Here are the main points in a nutshell:
• Regarding a definitive diagnosis of gout - They advised that monosodium urate crystals be obtained if possible. However, the diagnosis also could be "supported" with imaging such as ultrasound and classical findings such as tophi or prompt response to colchicine therapy if aspiration proves difficult. Asymptomatic hyperuricemia without any other findings wasn't considered sufficient.
• Physicians should stress the importance of healthy lifestyle, including weight loss, exercise, and avoidance of alcohol and sugar-sweetened drinks.
• Regular evaluation of renal function, because kidney-related mortality has been reported as being increased fourfold in patients with gout.
• Assessing cardiovascular risk, as some evidence has suggested a link of gout with coronary heart disease. (If that’s the case, how about increased incident peripheral arterial disease?)
ACR recommendations addressing various aspects of treatment:
• For urate-lowering therapy - evidence for efficacy with allopurinol, febuxostat (Uloric), and pegloticase (Krystexxa), but "there was a strong consensus that allopurinol constitutes first-line urate-lowering therapy after consideration of its safety, efficacy, and cost." In most cases, therapy is started at low doses and gradually titrated to reach a target urate level, usually below 6 mg/dL, with an eventual goal of the elimination of tophi and no acute attacks.
• Combined xanthine oxidase inhibition and uricosuric treatment for refractory high urate levels.
• For acute gout flares – nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, and glucocorticoids. There wasn't enough evidence for one treatment over another. The decision is based on patients history and each drug's safety profile.
• Prophylaxis for acute flares in the initial period after urate-lowering therapy also should be considered. Colchicine in doses up to 1.2 mg per day can be used, or if contraindicated, alternatives are NSAIDs and low-dose corticosteroids.
• Most tophi can be managed medically, by reducing serum levels of urate below 5 mg/dL. Surgery should be reserved for special cases such as when there is nerve compression. (How about “shoe compression” or in the case of a chronic ulcerating tophus ?)
• They recommended against the pharmacologic treatment of asymptomatic hyperuricemia for prevention of gout or comorbidities. Asymptomatic hyperuricemia should be addressed with nonpharmacologic lifestyle changes.
Source article with link to full text .pdf of the guidelines: Multinational evidence-based recommendations for the diagnosis and management of gout: integrating systematic literature review and expert opinion of a broad panel of rheumatologists in the 3e initiative