Background
Characteristics of acute gout:
- Sudden onset
- Monoarticular (<20% polyarticular)
- Severe pain, redness, swelling
- Pain peaks in 12-24h, lasts days to weeks
- +/- presence of tophi
Who’s at risk?
Diagnostic Criteria
Multiple criteria exist:
- New York criteria
- American Rheumatology Association criteria
- Janssens diagnostic rule
- Clinical Gout Diagnosis criteria
- Monoarthritis of the first metatarsophalangeal joint
- SUGAR (Study for Updated Gout Classification Criteria)
- 2015 American College of Rheumatology and European League Against Rheumatism gout classification criteria
- Recommendation: ACP recommends that clinicians use synovial fluid analysis when clinical judgment indicates that diagnostic testing is necessary in patients with possible acute gout. (Grade: weak recommendation, low-quality evidence)
- Clinical considerations:
- Synovial fluid analysis is considered the reference standard for gout diagnosis, although it may be difficult to perform in primary care.
- Synovial fluid analysis should be used in the following clinical circumstances:
- The joint can be aspirated without substantial patient discomfort by an experienced clinician who can minimize the risk of infection.
- A reliable and accurate source (including a polarizing microscope and a trained operator) is available to detect the presence of urate crystals.
- The clinical situation is ambiguous, and a probability of infection exists.
- Clinical algorithms are shown to have sensitivities and specificities >80%, although little evidence exists that they can be used to distinguish septic joints.
Clinical adjuncts for gout diagnosis:
- Dual energy CT
- Ultrasound
- Serum urate
- XR
Treatment: Traditional
- Acute gout:
- NSAIDS, colchicine, and/or oral corticosteroids
- Maybe intraarticular steroid injections (less evidence), ice
- Prevention:
- Lifestyle modifications: DASH or low-purine diet, exercise, weight loss, decrease alcohol consumption
- Urate lowering therapy (ULT): allopurinol, probenicid, or febuxistat (increased risk of CV-related death according to CARES trial)
Treatment: What’s New?
NSAIDs vs colchicine
- A 2019 multicenter randomized trial by Roddy et al compared the effectiveness and safety of naproxen and low-dose colchicine for treating gout flares in primary care:
- 200 patients received naproxen 750mg loading dose followed by 250mg q8h for 7 days
- 199 patients received colchicine 0.5mg TID for 4 days
- Outcomes:
- Primary: change in worst pain intensity from baseline daily over 7 days and at week 4
- Secondary: self-reported side effects (n/v, headache, rash, GI upset), other analgesic use
- Results:
- No significant difference in pain intensity over 7 days among people with gout flare between naproxen and colchicine groups
- Naproxen caused fewer side effects (diarrhea, analgesic use)
- Conclusions: No difference in pain intensity over 7 days between people with a gout flare randomised to either naproxen or low-dose colchicine. Naproxen caused fewer side effects supporting naproxen as first-line treatment for gout flares in primary care in the absence of contraindications.
New 2020 ACR guideline for the Management of Gout
The ACR has a ton of evidence-based recommendations for urate lowering therapy (ULT):
- Indications for ULT:
- Initiating ULT is strongly recommended for gout patients with any of the following: ≥1 subcutaneous tophi; evidence of radiographic damage (any modality) attributable to gout; OR frequent gout flares, with frequent being defined as ≥2 annually.
- Initiating ULT is conditionally recommended for patients who have previously experienced >1 flare but have infrequent flares (<2/year).
- Initiating ULT is conditionally recommended against in patients with gout experiencing their first gout flare. However, initiating ULT is conditionally recommended for patients with comorbid moderate-to-severe CKD (stage ≥3), serum urate concentration >9 mg/dl, or urolithiasis.
- Initiating ULT is conditionally recommended against in patients with asymptomatic hyperuricemia.
- Recommendations for choice of initial ULT for patients with gout:
- Treatment with allopurinol as the preferred first-line agent, over all other ULTs, is strongly recommended for all patients, including those with moderate-to-severe CKD (stage ≥3).
- The choice of either allopurinol or febuxostat over probenecid is strongly recommended for patients with moderate-to-severe CKD (stage ≥3).
- The choice of pegloticase as a first-line therapy is strongly recommended against.
- Starting treatment with low-dose allopurinol (≤100 mg/day and lower in patients with CKD [stage ≥3]) and febuxostat (≤40 mg/day) with subsequent dose titration over starting at a higher dose is strongly recommended.
- Starting treatment with low-dose probenecid (500 mg once to twice daily) with subsequent dose titration over starting at a higher dose is conditionally recommended.
- Administering concomitant antiinflammatory prophylaxis therapy (e.g., colchicine, NSAIDs, prednisone/prednisolone) over no antiinflammatory prophylaxis therapy is strongly recommended.
- Continuing concomitant antiinflammatory prophylaxis therapy for 3-6 months over <3 months, with ongoing evaluation and continued prophylaxis as needed if the patient continues to experience gout flares, is strongly recommended.
- Timing of ULT initiation:
- When the decision is made that ULT is indicated while the patient is experiencing a gout flare, starting ULT during the gout flare over starting ULT after the gout flare has resolved is conditionally recommended.
- A treat-to-target management strategy that includes ULT dose titration and subsequent dosing guided by serial serum urate (SU) measurements to achieve a target SU, over a fixed-dose ULT strategy, is strongly recommended for all patients receiving ULT.
- Achieving and maintaining an SU target of <6 mg/dl over the use of no target is strongly recommended for all patients receiving ULT.
- Delivery of an augmented protocol of ULT dose management by nonphysician providers to optimize the treat-to-target strategy that includes patient education, shared decision-making, and treat-to-target protocol is conditionally recommended for all patients receiving ULT.
- Duration of ULT:
- Continuing ULT indefinitely over stopping ULT is conditionally recommended.
Does allopurinol slow CKD?
- Given the association of hyperuricemia and CKD, two 2020 RCTs attempt to evaluate whether allopurinol can slow progression of CKD
- Both studies found that despite reduced uric acid levels in allopurinol recipients, there were no differences between the allopurinol and placebo groups in the rate of decline in renal function at 2-3 years follow-up
- Both studies support the general recommendations against treating patients with asymptomatic hyperuricemia
Take-Home Points!
- In absence of contraindications, naproxen may be just as good as colchicine (with fewer side effects) for treatment of acute gout flares
- Start ULT in presence of
- Tophi
- Radiographic damage
- ≥2 flares/year
- First flare in presence of CKD (≥III), serum urate >9, or urolithiasis
- Allopurinol is first line for ULT
- Start low and titrate to target serum urate <6
- Start prophylaxis with NSAIDS or colchicine when initiating ULT
- Don’t treat asymptomatic hyperuricemia
Blog post based on Med-Peds Forum talk by Chelsea Boyd, PGY2