Highlights from ACR's 2020 Gout Guidelines

In this week's news roundup, we highlight two studies that examine risks associated with biologics used to treat rheumatic disease. We also highlight the 2020 treatment guidelines for gout issued this week by the American College of Rheumatology. In today's video, we feature an interview with John D. Fitzgerald, M.D., Ph.D., chief of rheumatology at Ronald Reagan UCLA Medical Center in Santa Monica. Dr. Fitzgerald served as the corresponding author of the guidelines.

The most important recommendations are focusing on the treat to target strategies, Dr. FItzgerald says in this interview. "Those were recommended in 2012, but at the time, those recommendations were based on more observational studies. Since 2012, there have been a few trials most notably, a UK nursing trial…which was a randomized trial that showed using a treat to target protocol and treat-to-target strategy that outcomes were much better than usual care plan the patients were on.

"It resulted in much higher adherence rates, much higher utilization of allopurinol, better serum urate outcomes, but importantly greater reductions in tophi when present and fewer gout flares. So that resulted in a strong recommenation which means that we have a high degree of certainty that patients who are well informed would almost without exception agree to that treatment strategy.

"Gout and adherence is very interesting. The medicines work well to treat gout. Gout has historically been noted to have high issues with adherence: Patients stopping therapy and not continuing therapy. But like any chronic disease, the meds need to be taken for a long time.

"In gout we see lower adherence rates than in other conditions such as thyroid disease, diabetes, hypertension, cholesterol medicine. The understanding behind that is when you start these medicines to lower the uric acid levels, you can see higher rates of gout during the first few months. When you improve the uric acid, the crystals can become unstable and they can cause inflammation and a gout attack. So by starting the medicine in the first few months there’s a known increased risk of gout attack and this is called ULT, or urate lowering therapies reduced flares.

"In 2012, we recommended an anti-prophylaxis regiment to prevent this. That was to be for six months. In the new 2020 guidelines, it’s shortened for three to six months. The risk is greatest when starting the urate lowering medicines and then it decreases monthly as you get out and then eventually you get your desired outcomes of fewer flares. The three to six months is the new recommendations. It may be longer if someone is continuing to have active disease that should prevent those increased attacks.

"The other strategy to try and reduce the increased attacks with urate lowering drugs when you start them and also to prevent side effects…is to start with a low dose and then increase slowly."

For more information about the new guidelines, click on the video link above to hear the entire conversation.