Overview
Chronic gouty arthritis is a form of gout characterized by recurrent flares, tophi, and/or radiographic damage. Management focuses on urate-lowering therapy (ULT) to achieve a target serum urate level, alongside treatment for acute flares and lifestyle modifications 12.Management
Initiate urate-lowering therapy (ULT) for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares 12.
Allopurinol is the preferred first-line ULT, including for those with moderate-to-severe chronic kidney disease (CKD; stage >3) 12.
Start ULT with a low dose: allopurinol ≤100 mg/day (lower in CKD) or febuxostat <40 mg/day 12.
Employ a treat-to-target strategy, titrating ULT dose based on serial serum urate (SU) measurements to achieve an SU target of <6 mg/dl 12.
When initiating ULT, provide concomitant antiinflammatory prophylaxis therapy for at least 3-6 months 12.
Manage acute gout flares with colchicine, nonsteroidal antiinflammatory drugs (NSAIDs), or glucocorticoids 12.Special Populations
For patients with moderate-to-severe chronic kidney disease (CKD; stage >3), allopurinol is the preferred first-line ULT, initiated at a lower dose 12.Key Recommendations
Initiate urate-lowering therapy (ULT) for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares 12. (Evidence: Strong)
Allopurinol is the preferred first-line ULT, including for those with moderate-to-severe chronic kidney disease (CKD; stage >3) 12. (Evidence: Strong)
Use a low starting dose of allopurinol (≤100 mg/day, and lower in CKD) or febuxostat (<40 mg/day) 12. (Evidence: Strong)
Employ a treat-to-target management strategy with ULT dose titration guided by serial serum urate (SU) measurements, aiming for an SU target of <6 mg/dl 12. (Evidence: Strong)
When initiating ULT, provide concomitant antiinflammatory prophylaxis therapy for a duration of at least 3-6 months 12. (Evidence: Strong)References
1 FitzGerald JD, Dalbeth N, Mikuls T, Brignardello-Petersen R, Guyatt G, Abeles AM et al.. 2020 American College of Rheumatology Guideline for the Management of Gout. Arthritis care & research 2020. link
2 FitzGerald JD, Dalbeth N, Mikuls T, Brignardello-Petersen R, Guyatt G, Abeles AM et al.. 2020 American College of Rheumatology Guideline for the Management of Gout. Arthritis & rheumatology (Hoboken, N.J.) 2020. link