The American College of Rheumatology (ACR) has issued new guidelines for
the management of gout that reflect the broadening range of therapeutic
options, greater awareness of the need for urate control, and the
increasing burden and prevalence of this disease.

Note that either of the xanthine oxidase inhibitors, allopurinol or the
newer agent febuxostat, can be used as a first-line urate-lowering
therapy, and the target serum urate levels should be below 6 mg/dL.

The American College of Rheumatology (ACR) has issued new guidelines for
the management of gout that are intended to reflect the broadening range
of therapeutic options, greater awareness of the need for urate control,
and the increasing burden and prevalence of this disease.

For instance, either of the xanthine oxidase inhibitors, allopurinol or
the newer agent febuxostat (Uloric), can be used as a first-line
urate-lowering therapy, according to Robert Terkeltaub, MD, of the
University of California San Diego, and colleagues.

Furthermore, the target serum urate levels should be below 6 mg/dL, and
in many patients may need to be below 5 mg/dL, their task force reported
in the October Arthritis Care & Research.

"Long-term morbidity and impairment of health-related quality of life
are now better appreciated in many gout patients, particularly those
with multiple comorbidities and/or chronic gouty arthritis," the authors
wrote.

Initial measures should include patient education about the role of uric
acid in the disease, and nonpharmacologic approaches such as limiting
intake of purine-rich meat and seafood, as well as alcohol, they
explained.

But in the majority of patients, lifestyle efforts are unlikely to
suffice and pharmacotherapy will need to be instituted.

An important aspect of initial treatment decision-making, according to
the task force, must be identification of patient comorbidities such as
kidney disease and cardiovascular conditions, along with recognition of
drug interactions and the use of medications such as thiazide diuretics
that can influence serum urate levels.

Allopurinol is the most commonly used urate lowering agent, but flares
often occur early in treatment that can interfere with adherence, so the
task force emphasized that the initial dosage should not exceed 100 mg
per day, or 50 mg per day for patients with advanced chronic kidney
disease.

This dose should be titrated upwards, typically to 300 mg per day, but
higher doses can be used if the urate remains high and the patient is
monitored for hypersensitivity.

Another recommendation was that patients who are of Korean, Han Chinese,
or Thai origin be screened for the HLA-B*5801 allele, which confers a
very high risk for allopurinol sensitivity.

If the initial agent chosen is febuxostat, the highest FDA approved dose
is 80 mg per day, but the ACR task force noted that in other countries,
doses up to 120 mg are used and may be tried if needed.

If the target serum urate level cannot be achieved with the xanthine
oxidase inhibitors, a uricosuric agent such as probenecid (Benemid),
fenofibrate, or losartan (Cozaar) can be added, but more work will be
needed to determine the optimal combination approach.

"The authors believe that ongoing and further studies will help
understand how to optimize combinations of uricosuric agents with
[xanthine oxidase inhibitor] therapy to decrease the risk of
uricosuric-induced urolithiasis, while increasing the velocity of size
reduction of body urate stores and tophi," they wrote.

If that approach is inadequate or the patient is intolerant, pegloticase
(Krystexxa) can be used for severe disease, although the duration of
treatment with this agent remains uncertain.

The authors noted their recommendations do not take into account cost of
treatment, so physicians will need to consider this in conjunction with
patient preferences and long-term safety.

"Importantly, societal cost of healthcare and cost and
cost-effectiveness differences between therapies are excluded from
analysis by the RAND/UCLA Appropriateness Method" used in developing
these recommendations, they stated.

The guidelines also addressed the treatment of the acute attack,
emphasizing that any attack should be treated pharmacologically,
preferably beginning within 24 hours of symptom onset, while
urate-lowering therapy continues.

Several options are available depending on symptom severity, usually
with monotherapy as the initial approach.

For mild-to-moderate symptoms in a few joints, oral nonsteroidal
anti-inflammatory drugs (NSAIDs), colchicine, or systemic
corticosteroids can be tried.

"It is at the discretion of the prescribing physicians to choose the
most appropriate monotherapy based on the patient's preference, prior
response to pharmacologic therapy for an acute gout attack, and
associated comorbidities," the authors advised.

Colchicine is an additional recommended first-line treatment for the
acute attack, but must be initiated within 36 hours of symptom onset,
they cautioned.

Treatment with colchicine typically begins with a loading dose of 1.2
mg, followed by a second 0.6 mg dose an hour later, and then once or
twice per day until symptoms resolve.

But if pain is severe and multiple or large joints are affected,
combination therapy may be appropriate, using colchicine and NSAIDs,
oral steroids and colchicine, or these drugs plus intra-articular
steroid injections.

The authors further recommended that for patients with ongoing disease
activity after the acute symptoms resolve, consideration be given for
anti-inflammatory prophylaxis using lower doses of colchicine or NSAIDs,
possibly for 3 to 6 months after the target urate level is reached.

The panel did not recommend a specific NSAID, noting that the FDA has
approved naproxen, indomethacin, and sulindac for gout attacks, but
others may also be effective.

They did not advise the use of complementary or alternative therapies
for acute flares.

Ongoing research also will be needed to determine the role of advanced
imaging techniques such as high resolution ultrasound and dual-energy CT
for assessment of disease status and response to treatment.

"It is hoped that publication of these guidelines, along with effective
patient education in gout treatments and the objectives and safety
issues of management, will improve patient adherence, quality of care,
and outcomes in management of gout," they concluded.

The authors noted that a limitation of the recommendations are that only
about one-third were based on the highest (A) level of evidence --
signifying evidence from more than one clinical trial -- and that half
were level C -- derived from expert opinion or case studies.

Therefore, more studies will be needed to fully develop the optimal
treatment approaches for prophylaxis and treatment.

The study was supported by the ACR and the National Institute of
Arthritis and Musculoskeletal and Skin Diseases.

The authors disclosed receiving financial support from multiple
companies, including Novartis, Savient, Takeda, Ardea, Regeneron,
Pfizer, EnzymeRx, BioCryst, and Chugai.
Primary source: Arthritis Care & Research

Source reference:

Khanna D, et al. "2012 American College of Rheumatology guidelines for
management of gout. Part 1: Systematic nonpharmacologic and
pharmacologic therapeutic approaches to hyperuricemia" Arthritis Care
Res 2012; 64: 1431-1446.

Additional source: Arthritis Care & Research
Source reference:

Khanna D, et al. "2012 American College of Rheumatology guidelines for
management of gout. Part 2: Therapy and anti-inflammatory prophylaxis of
acute gouty arthritis" Arthritis Care Res 2012; 64: 1447-1461.

..
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Donna G.
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1) Rejoice always, Pray continually, Give thanks in all circumstances,
For this is God's will for you in Christ Jesus. ( I Thessalonians
5:16-18 NIV )

2) ANGELS EXIST, but some times, since they don't all have wings, we
call them FRIENDS......

3) Just because you're in pain, doesn't mean you have to be one!