Allopurinol is the preferred first-line treatment for urate-lowering therapy in patients with gout, including those with moderate to severe chronic kidney disease, the American College of Rheumatology (ACR) recommended in a new guideline.
Other strong recommendations in the guideline, which updates the ACR's 2012 recommendations on this topic, include the following:
- Urate-lowering therapy should be initiated for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares (defined as at least two flares annually).
- A low starting dose of allopurinol (≤100 mg/d in patients without chronic kidney disease, lower in those with chronic kidney disease) or febuxostat (<40 mg/d) should be used. Pegloticase is strongly recommended against as a first-line therapy.
- A treat-to-target management strategy with dose titration of urate-lowering therapy should be instituted and should be guided by serial serum urate measurements, with a serum urate target below 6 mg/dL.
- When urate-lowering therapy is initiated, concomitant anti-inflammatory prophylaxis therapy should be used for at least three to six months.
- Colchicine, NSAIDs, or glucocorticoids (oral, intra-articular, or intramuscular) should be used rather than interleukin-1 inhibitors or adrenocorticotropic hormone for first-line management of gout flares.
- If xanthinoxidase inhibitors, uricosurics, and other interventions have not achieved serum urate targets and patients have frequent gout flares or nonresolving subcutaneous tophi, therapy should be switched to pegloticase. Pegloticase therapy should be reserved for patients with severe symptoms unresponsive to first-line agents.
The guideline, which also includes recommendations on management of lifestyle factors and concurrent medications, was published by Arthritis & Rheumatology on May 10.