Blog | Wednesday, October 3, 2012

QD: News Every Day--Patient education, lifestyle likely not enough to treat gout


Patient education on diet, lifestyle, treatment objectives, and management of comorbidities isn't likely to be enough to treat gout, according to new guidelines.

The American College of Rheumatology released its guidelines in Arthritis Care & Research, one paper on hyperuricemia and the second on acute gouty arthritis. Authors noted that much of the work isn't based on trials, but rather on expert opinion and case studies.

While counseling is a core measure, especially for alcohol, treatment is likely needed to control hyperuricemia and acute attacks, the authors noted.

New guidelines for hyperuricemia include:
--Serum urate level should be lowered to improve gout symptoms, with the target less than 6 mg/dL at a minimum, and often less than 5 mg/dL.
--Xanthine oxidase inhibitor (XOI) therapy with either allopurinol or febuxostat is recommended as the first-line pharmacologic urate-lowering therapy (ULT) approach in gout.
--For allopurinol, the starting should be no greater than 100 mg/day and less than that in moderate to severe chronic kidney disease (CKD), followed by gradual upward titration to a maintenance dose that can exceed 300 mg daily even in patients with CKD.
--Before starting allopurinol, rapid polymerase chain reaction-HLA-B*5801 screening should be considered as a risk management component groups that have a high frequency of this allele and are prone to oversensitivity, such as Koreans with stage 3 or worse CKD and all those of Han Chinese and Thai descent.
--Adding a uricosuric agent to an XOI agent is appropriate when the serum urate target has not been met by XOI alone.
--Pegloticase is appropriate for patients with severe gout and refractoriness to, or intolerance of, oral ULT options.

New guidelines for acute gouty arthritis include:
--An acute gouty arthritis attack should be treated pharmacologically within 24 hours of onset.
--Established pharmacologic urate-lowering therapy shouldn't be stoped during an acute attack.
--Nonsteroidal antiinflammatory drugs (NSAIDs), corticosteroids, or oral colchicine are appropriate first-line options, and certain combinations can be employed for severe or refractory attacks.
--Pharmacologic anti-inflammatory prophylaxis is recommended for all gout patients when pharmacologic urate lowering is initiated, and should be continued if there is any clinical evidence of continuing gout disease activity and/or the serum urate target has not yet been achieved.
--Oral colchicine is an appropriate first-line prophylaxis, including with appropriate dose adjustment in chronic kidney disease and for drug interactions, unless there is a lack of tolerance or medical contraindication.
--Low-dose NSAID therapy is an appropriate choice for first-line prophylaxis, unless there is a lack of tolerance or medical contraindication.