Management of acute gout - Guideline update

A new guideline from the American College of Physicians for the management of acute and recurrent gout makes a few recommendations based on updated data through March 20161.  Some recommendations and strengths differ from the 2012 recommendations from the American College of Rheumatology.  Here are the main recommendations from the updated guideline:

About acute treatment (Recommendation 1):

Corticosteroids, NSAIDs, or colchicine are the recommended treatment options.  All three are effective for reducing pain but there are differences in cost, adverse effects, and contraindications.  Here are the take home points:

• Corticosteroids are recommended as first-line therapy based on their proven efficacy, general tolerability, and low-cost.
• Prednisolone 35 mg orally daily for 5 days has proven efficacy (compared to naproxen 500 mg po bid) in a randomized controlled trial²
• This is equal to 35 mg of prednisone (see more about steroid conversions here)
• There is no difference in efficacy among NSAIDs (including indomethacin, which is a popular choice)
• Colchicine is still more expensive than the above two choices
• Check for renal & hepatic impairment and CYP450 3A4 and p-glycoprotein interactions because there are specific dosage adjustment and contraindications in some instances

About dosing colchicine (Recommendation 2):

A lower-dose strategy is as effective as a higher dose strategy and has less gastrointestinal adverse effects.

• Use 1.2 mg orally, followed by 0.6 mg in one hour (the old strategy involved hourly dosing)
• See more about the dosing of colchicine and the evidence here

About starting urate-lowering therapy (Recommendation 3):

Urate-lowering therapy is not recommended after the first attack or in someone with infrequent attacks.

• Consider urate-lowering therapy if ≥2 attacks per year or problematic gout (ie. tophi, CKD, urolithiasis)

About prophylaxis (Recommendation 4):

Because patients' frequencies of attacks vary from none to many over years, discuss options for prophylaxis with them.  Some may opt to just treat each episode while others will opt for urate-lowering therapy.

• Allopurinol and febuxostat are equally effective in lowering urate
• Data suggests (not from RCTs, unfortunately) that acute attacks are reduced with daily urate-lowering therapy after 1 year, but not within the first 6 months 
• Prophylaxis during these several months with low dose NSAIDs or colchicine is effective

Some other points:

• Of note, the guideline does not endorse a "treat-to-target" uric acid strategy (the previous goal was usually <6mg/dL or <5mg/dL).  They state that a "treat-to-avoid-symptoms" approach is reasonable.
• Long-term benefits and harms of febuxostat are unknown
• Dietary recommendations could not be recommended due to insufficient evidence

References:
1.  Qaseem A, Harris RP, Forciea MA.  Management of acute and recurrent gout:  A clinical practice guideline from the American College of Physicians.  Ann Intern Med  2016;November:1-11.
2.  Janssens HJ, Janssen M, van de Lisdonk EH, et al.  Use of oral prednisolone or naproxen for the treatment of gout arthritis: a double-blind, randomised equivalence trial.  Lancet  2008;371:1854-60.