This is my review of the 2020 American College of Rheumatology (ACR) Gout Management Guideline. In which I will explain the key points for gout sufferers. So this is for people who accept they must get involved in their gout management. Because it introduces the need to manage gout in partnership with health professionals. In the hope that you can work with your doctor to make better treatment plans.
Citation for 2020 Gout Management Guideline
This is a GoutPal review of:
FitzGerald, John D., Nicola Dalbeth, Ted Mikuls, Romina Brignardello‐Petersen, Gordon Guyatt, Aryeh M. Abeles, Allan C. Gelber et al. “2020 American College of Rheumatology Guideline for the Management of Gout.” Arthritis Care & Research (2020).
At the time of writing, this study has not been cited by any other studies.
2020 Gout Management Guideline Background
The purpose of this guideline is to resolve criticisms of its 2012 predecessor. Because that version contained insufficient evidence to support its recommended treat-to-target approach. So this version incorporates new guidelines based on evidence from several additional clinical trials.
Complicating the efforts to improve adherence is the fact that the prior 2012 ACR Guidelines for the Management of Gout have been criticized due to low quality of evidence supporting treat‐to‐target recommendations. Since the 2012 ACR Guidelines for the Management of Gout were published, several clinical trials have been conducted that provide additional evidence regarding the management of gout, leading the ACR Guidelines Subcommittee to determine that new guidelines were warranted.
In the jargon-free abstract I present the key points of the original abstract. Replacing jargon with terms more familiar to unqualified people interested in gout. Note that my selection of jargon terms might not match yours. So please ask in the feedback form near the end of the page if you need clarification.
- Purpose / Objective
- To provide gout management recommendations including:
- Uric acid treatment
- Gout flare treatment
- Lifestyle and other medication
- A group of patients and professionals reviewed evidence relating to 57 gout management questions. They agreed evidence-based recommendations, graded as strong or conditional.
- Results / Findings
- 16 strong recommendations, from 42 total, include:
- Uric acid treatment for all patients with
- Lumps of uric acid crystals,
- Gouty joint damage, or
- Frequent gout flares.
- Allopurinol as preferred uric acid treatment. Including patients with kidney disease.
- Low starting dose of allopurinol (not more than 100 mg) or febuxostat (less than 40 mg).
- Personal target for uric acid level less than 6 mg/dL (Treat-to-target).
- Regular dose adjustment following uric acid blood tests to achieve target.
- Preventative gout pain relief alongside uric acid treatment for at least 3 to 6 months.
- Gout pain relief using colchicine, Non-Steroidal Anti-Inflammatories (NSAIDs), or steroids.
- Uric acid treatment for all patients with
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.
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.
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 >3); using a low starting dose of allopurinol (≤100 mg/day, and lower in CKD) or febuxostat (<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 <6 mg/dl. When initiating ULT, concomitant anti-inflammatory prophylaxis therapy for a duration of at least 3–6 months was strongly recommended. For management of gout flares, colchicine, non-steroidal anti-inflammatory drugs, or glucocorticoids (oral, intraarticular, or intramuscular) were strongly recommended.
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.
2020 Gout Management Guideline Conclusions
The guideline emphasizes the importance of patient participation in shared decision-making for effective gout management. Concluding that clinicians and patients together can cure gout by adopting modern data-driven management practices.
Where certainty of data is less than moderate or high, conditional recommendations made herein are meant to highlight those decisions that would benefit from a shared patient‐provider decision‐making process. This would include areas such as diet, lifestyle, or concomitant medications that might affect SU levels, and for which the Patient Panel requested guidance. The Voting Panel aimed to provide guidance without implying any “patient‐blaming” for the manifestations of gout given its strong genetic determinants. […] Gout has been characterized as a “curable disease”. As data continue to emerge supporting best practices in management, implementation of these recommendations will ideally lead to improved quality of care for patients with gout.
- Is Allopurinol Taken For Life?
- Gout patients wonder if allopurinol is a lifetime drug. New evidence shows ways to get a break. Can you take time off allopurinol? Get allopurinol facts now.
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2020 Gout Management Guideline Vocabulary
⇢ a class of steroid that is very effective at reducing inflammation and suppressing the immune system
⇢ liquid part of the blood
⇢ having, or related to lumps of uric acid crystals (see tophus)
ULT (Urate Lowering Therapy)
⇢ uric acid treatment
⇢ uric acid (see MSU – monosodium urate)