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Awaiting decision about preventive tx Initiate urate-lowering tx (ULT) for pts w/ severe, destructive dz or frequent gout flares; consider ULT for other pts; ULT can be considered during acute flare - Initiate ULT if any tophi, joint destruction on radiography, ≥2 flares/yr,1,2 or renal stones2
- Consider ULT in pts w/ recurrent gout, but <2 flares/yr1
- Consider ULT w/ 1st flare if: age <40 yo,2 very high uric acid (>8 mg/dL per EULAR, >9 mg/dL per ACR), and/or comorbidity (renal impairment, HTN, ischemic heart dz, CHF)2
- Don’t start ULT in pts w/ asymptomatic hyperuricemia1
View epocrates drug info: Footnotes 1 ACR 2020. FitzGerald JD, et al. 2020 American College of Rheumatology Guideline for the Management of Gout. Arthritis Care Res. 2020. Jun;72(6):744-760. PubMed abstract | free full-text PDF
2 EULAR 2016. Richette P, et al. 2016 Updated EULAR Evidence-based Recommendations for the Management of Gout. Ann Rheum Dis. 2017. Jan;76(1):29-42. PubMed abstract | free full-text PDF
Colchicine, NSAIDs or steroids 1st line for acute flares1-3; consider ice as a useful adjunct - Start 1st-line tx agent early based on pt factors (comorbidity, access, past experience, DDI);2 avoid colchicine and NSAIDs if severe renal failure;3 avoid colchicine if strong CYP3A4 or P-glycoprotein inhibitor3
- Choose dose/duration by severity of flare, except colchicine; low-dose colchicine as effective as high-dose, tolerated better1,2
- Consider low-dose colchicine + anti-inflammatory (NSAID, steroid), per EULAR3
- If recurrent, pts prefer “pill-in-pocket” approach2
- If pt unable to tolerate PO, use steroid (IM, IA) over IL-1 inhibitor or ACTH2
- Consider IL-1 inhibitor over analgesic if can’t use any 1st-line meds2,3
- Consider topical ice as adjunct, per ACR2
Manage other meds, lifestyle - Consider limiting EtOH, purines, high-fructose corn syrup2
- Wt loss assoc w/ ↓ risk of recurrent flare, if pt overweight2
- If HTN, consider switching HCTZ to losartan2,3 or CCB3
- If ↑ lipids, don’t add/switch to fenofibrate for urate-lowering effect;2 EULAR supports fenofibrate or statin3
- Don’t stop low-dose aspirin, when indicated2
- Don’t use vit C, cherries/extract2
View epocrates drug info: Footnotes 1 ACP 2017. Qaseem A, et al. Management of Acute and Recurrent Gout: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017. Jan 3;166(1):58-68. PubMed abstract | full-text article online• Low-dose colchicine: 1.2 mg PO immediately, followed by single dose 0.6 mg PO 1h later (vs 1.2 mg PO, followed by 0.6 mg/h x6h)
2 ACR 2020. FitzGerald JD, et al. 2020 American College of Rheumatology Guideline for the Management of Gout. Arthritis Care Res. 2020. Jun;72(6):744-760. PubMed abstract | free full-text PDF
• Low-dose colchicine: 1.2 mg PO immediately, followed by single dose 0.6 mg PO 1h later; additional anti-inflammatory may be needed
3 EULAR 2016. Richette P, et al. 2016 Updated EULAR Evidence-based Recommendations for the Management of Gout. Ann Rheum Dis. 2017. Jan;76(1):29-42. PubMed abstract | free full-text PDF
• Strong CYP3A4 or P-glycoprotein inhibitors include: clarithromycin, cyclosporine, ketoconazole, ritonavir
Needs acute & preventive tx Colchicine, NSAIDs or steroids 1st line for acute flares;1-3 consider ice as a useful adjunct - Start 1st-line tx agent early based on pt factors (comorbidity, access, past experience, DDI);2 avoid colchicine and NSAIDs if severe renal failure;3 avoid colchicine if strong CYP3A4 or P-glycoprotein inhibitor3
- Choose dose/duration by severity of flare, except colchicine; low-dose colchicine as effective as high-dose, tolerated better1,2
- Consider low-dose colchicine + anti-inflammatory (NSAID, steroid), per EULAR3
- If recurrent, pts prefer “pill-in-pocket” approach2
- If pt unable to tolerate PO, use steroid (IM, IA) over IL-1 inhibitor or ACTH2
- Consider IL-1 inhibitor over analgesic if can’t use any 1st-line meds2,3
- Consider topical ice as adjunct, per ACR2
Start low-dose xanthine oxidase inhibitors as 1st-line ULT, titrate to serum urate <6 mg/dL in most pts; use flare ppx 1st 3-6mo; treat indefinitely; can consider starting ULT during acute flare - Allopurinol strongly preferred 1st-line agent in all pts; start 100 mg/day2,3
- If mod/severe CKD (stage ≥3): allopurinol, febuxostat preferred over probenecid; start lower dose, depending on CKD stage (allopurinol ≤100 mg/day, febuxostat ≤40 mg/day)2
- Avoid febuxostat in pts w/ hx of CVD2
- If using probenecid, start low dose (500 mg qd or bid)2
- ULT may be started during an acute flare, per ACR2
- Start anti-inflammatory ppx (colchicine, NSAID, steroid) w/ ULT, continue 3-6mo1-3
- Consider HLA-B*5801 allele testing before starting allopurinol in African American and certain Asian pts2
- Don’t use pegloticase as 1st-line ULT, reserve for select resistant cases2,3
- Titrate ULT to target serum urate <6 mg/dL;2,3 lower target (<5 mg/dL) may be appropriate for severe/tophaceous gout, but don’t maintain <3 mg/dL in long run, per EULAR
- Consider maintaining ULT for life2,3
- Don’t routinely check urinary uric acid or alkalinize urine when considering/using uricosurics2
Manage other meds, lifestyle - Consider limiting EtOH, purines, high-fructose corn syrup2
- Wt loss assoc w/ ↓ risk of recurrent flare, if pt overweight2
- If HTN, consider switching HCTZ to losartan2,3 or CCB3
- If ↑ lipids, don’t add/switch to fenofibrate for urate-lowering effect;2 EULAR supports fenofibrate or statin3
- Don’t stop low-dose aspirin, when indicated2
- Don’t use vit C, cherries/extract2
View epocrates drug info: Footnotes 1 ACP 2017. Qaseem A, et al. Management of Acute and Recurrent Gout: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017. Jan 3;166(1):58-68. PubMed abstract | full-text article online
• Low-dose colchicine: 1.2 mg PO immediately, followed by single dose 0.6 mg PO 1h later (vs 1.2 mg PO, followed by 0.6 mg/h x6h)
2 ACR 2020. FitzGerald JD, et al. 2020 American College of Rheumatology Guideline for the Management of Gout. Arthritis Care Res. 2020. Jun;72(6):744-760. PubMed abstract | free full-text PDF
• Low-dose colchicine: 1.2 mg PO immediately, followed by single dose 0.6 mg PO 1h later. Additional anti-inflammatory may be needed
• The HLA-B*5801 allele is assoc w/ ↑ risk of allopurinol hypersensitivity; it is present in 7.4% of persons of Han Chinese, Korean, and Thai descent, and 3.8% of African Americans (vs 0.7% of white and Hispanic pts).
3 EULAR 2016. Richette P, et al. 2016 Updated EULAR Evidence-based Recommendations for the Management of Gout. Ann Rheum Dis. 2017. Jan;76(1):29-42. PubMed abstract | free full-text PDF
• Strong CYP3A4 or P-glycoprotein inhibitors include: clarithromycin, cyclosporine, ketoconazole, ritonavir
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Chronic/recurrent gout, not active
Awaiting decision about preventive tx Initiate urate-lowering tx (ULT) for pts w/ severe, destructive dz or frequent gout flares; consider ULT for other pts; ULT can be considered during acute flare - Initiate ULT if any tophi, joint destruction on radiography, ≥2 flares/yr,1,2 or renal stones2
- Consider ULT in pts w/ recurrent gout, but <2 flares/yr1
- Consider ULT w/ 1st flare if: age <40 yo,2 very high uric acid (>8 mg/dL per EULAR, >9 mg/dL per ACR), and/or comorbidity (renal impairment, HTN, ischemic heart dz, CHF)2
- Don’t start ULT in pts w/ asymptomatic hyperuricemia1
View epocrates drug info: Footnotes 1 ACR 2020. FitzGerald JD, et al. 2020 American College of Rheumatology Guideline for the Management of Gout. Arthritis Care Res. 2020. Jun;72(6):744-760. PubMed abstract | free full-text PDF
2 EULAR 2016. Richette P, et al. 2016 Updated EULAR Evidence-based Recommendations for the Management of Gout. Ann Rheum Dis. 2017. Jan;76(1):29-42. PubMed abstract | free full-text PDF
Needs lifestyle mgmt only Manage other meds, lifestyle - Consider limiting EtOH, purines, high-fructose corn syrup1
- Wt loss assoc w/ ↓ risk of recurrent flare, if pt overweight1
- If HTN, consider switching HCTZ to losartan1,2 or CCB2
- If ↑ lipids, don’t add/switch to fenofibrate for urate-lowering effect;1 EULAR supports fenofibrate or statin2
- Don’t stop low-dose aspirin, when indicated1
- Don’t use vit C, cherries/extract1
Footnotes 1 ACR 2020. FitzGerald JD, et al. 2020 American College of Rheumatology Guideline for the Management of Gout. Arthritis Care Res. 2020. Jun;72(6):744-760. PubMed abstract | free full-text PDF
2 EULAR 2016. Richette P, et al. 2016 Updated EULAR Evidence-based Recommendations for the Management of Gout. Ann Rheum Dis. 2017. Jan;76(1):29-42. PubMed abstract | free full-text PDF
Start low-dose xanthine oxidase inhibitors (XOI) as 1st-line ULT, titrate to serum urate <6 mg/dL in most pts; use flare ppx 1st 3-6mo; treat indefinitely; can consider starting ULT during acute flare - Allopurinol strongly preferred 1st-line agent in all pts; start 100 mg/day1,2
- If mod/severe CKD (stage ≥3): allopurinol, febuxostat preferred over probenecid; start lower dose, depending on CKD stage (allopurinol ≤100 mg/day, febuxostat ≤40 mg/day)1
- Avoid febuxostat in pts w/ hx of CVD1
- If using probenecid, start low dose (500 mg qd or bid)1
- ULT may be started during an acute flare, per ACR1
- Start anti-inflammatory ppx (colchicine, NSAID, steroid) w/ ULT, continue 3-6mo1-3
- Consider HLA-B*5801 allele testing before starting allopurinol in African American and certain Asian pts1
- Don’t use pegloticase as 1st-line ULT, reserve for select resistant cases1,2
- Titrate ULT to target serum urate <6 mg/dL;1,2 lower target (<5 mg/dL) may be appropriate for severe/tophaceous gout, but don’t maintain <3 mg/dL in long run, per EULAR
- Consider maintaining ULT for life1,2
- Don’t routinely check urinary uric acid or alkalinize urine when considering/using uricosurics1
Manage other meds, lifestyle - Consider limiting EtOH, purines, high-fructose corn syrup1
- Wt loss assoc w/ ↓ risk of recurrent flare, if pt overweight1
- If HTN, consider switching HCTZ to losartan1,2 or CCB2
- If ↑ lipids, don’t add/switch to fenofibrate for urate-lowering effect;1 EULAR supports fenofibrate or statin2
- Don’t stop low-dose aspirin, when indicated1
- Don’t use vit C, cherries/extract1
Switch initial XOI if serum urate (SU) not at target, ≥2 flares/yr, or tophi not resolved; add uricosuric if lone XOI not effective; reserve pegloticase for select resistant pts - Consider switch to alt XOI in pts w/ SU not at target, ≥2 flares/yr, or tophi not resolved, per ACR; switch to uricosuric after initial XOI failure an option, per EULAR
- Consider combo-tx (XOI + uricosuric) in pts failing 2nd-line tx (whether second XOI or uricosuric)2
- Reserve pegloticase only for pts w/ SU above target on all other tx and either ≥2 flares/yr or tophi not resolved, per ACR;1 per EULAR, reserve for pts w/ severe crystal-proven tophaceous gout and poor QOL who fail all other tx2
View epocrates drug info: Footnotes 1 ACR 2020. FitzGerald JD, et al. 2020 American College of Rheumatology Guideline for the Management of Gout. Arthritis Care Res. 2020. Jun;72(6):744-760. PubMed abstract | free full-text PDF
• The HLA-B*5801 allele is assoc w/ ↑ risk of allopurinol hypersensitivity; it is present in 7.4% of persons of Han Chinese, Korean, and Thai descent, and 3.8% of African Americans (vs 0.7% of white and Hispanic pts).
2 EULAR 2016. Richette P, et al. 2016 Updated EULAR Evidence-based Recommendations for the Management of Gout. Ann Rheum Dis. 2017. Jan;76(1):29-42. PubMed abstract | free full-text PDF
3 ACP 2017. Qaseem A, et al. Management of Acute and Recurrent Gout: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017. Jan 3;166(1):58-68. PubMed abstract | full-text article online
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