Current management of gout: practical messages from EULAR 2016 guidelines

Abstract

REVIEW ARTICLE Current management of gout: practical messages from 2016 EULAR guidelines 267 where these differ significantly from the earli er guidelines and other recent national and in ternational recommendations for the manage ment of gout.Why do we need updated recommendations? There were at least half a dozen good reasons why the EULAR recommendations needed to be up dated in 2016. 1 Knowledge of the pathophysiology of uric acid (UA) transport, urate crystal inflammation, and the comorbidities associated with gout had ad vanced considerably. 2 New pharmaceutical options had become available and the evidence base for the efficacy and safety of available drugs had expanded in the last decade. 3 The incidence, prevalence, and severity of gout had continued to increase 7 despite the availability Introduction Gout is a chronic crystal deposition disorder in which crystals of monosodium urate can cause chronic arthritis, tophi, urolithiasis and renal disease, as well as recurrent acute arthritis and bursitis. Gouty arthritis and tophi can lead to chronic disability and impairment of health related quality of life, 1 but gout is also frequently associated with comorbidities such as obesity, di abetes mellitus, hypertension, and cardiovascular disease, 2,3 as well as with increased mortality. 3,4 The ABSTRACTThe European League Against Rheumatism published updated recommendations for the management of gout in 2016, comprising 3 overarching principles and 11 key recommendations for clinical practice. Patient education about the pathophysiology of gout and its comorbidities, as well as the existence of effective treatments are important, and understanding the principles of managing acute attacks and eliminating urate crystals by lifelong lowering of the serum urate (SU) below a target level are essential. Advice about lifestyle, diet, weight, and other risk factors, as well as the need to screen for and manage comorbidities are emphasized. For the treatment of flares, colchicine, nonsteroidal anti -inflammatory drugs (NSAIDs), and oral or intraarticular steroids, or a combination thereof, are recommended. In patients with frequent flares and contraindications to colchicine, NSAIDs, and corticosteroids, an interleukin -1 blocker should be considered. Urate -lowering therapy (ULT) should be discussed from the first presentation of the disease, and SU levels should be maintained at less than 6 mg/dl (360 µmol/l), or less than 5 mg/dl (300 µmol/l) in patients with severe gout. Allopurinol is recommended as first -line ULT with dose adjustment according to renal function. If the SU target cannot be achieved with allopurinol,

Joint Clinical Consensus Statement of the American College of Foot and Ankle Surgeons® and the American Association of Nurse Practitioners®: Etiology, Diagnosis, and Treatment Consensus for Gouty Arthritis of the Foot and Ankle

“…The British Society for Rheumatology recommends use of oral and/or intraarticular corticosteroid for patients who cannot tolerate NSAIDs (135). Furthermore, despite lack of evidence, the 2012 ACR Guidelines for Management of Gout and 2016 EULAR Guidelines include use of intraarticular corticosteroid injection as an option for first-line therapy (136), without an established recommended dose. Oral steroids are preferred if the gout involves more than 2 joints (127).…”

“…A serum uric acid level <6.0 mg/dL is generally recommended as an initial target in hyperuricemia therapy (92,95). sUA below this level has been associated with a reduced frequency or prevention of gout flares (92,136,137). Lower serum urate level (<5.0 mg/dL) may be needed for some patients with more severe disease (137).…”

“…According to the ACR and EULAR (92,95), patients who meet the criteria for initiation of ULT should be treated and maintained at a "target" sUA level with a xanthine oxidase inhibitor such as allopurinol or febuxostat. Allopurinol is considered the first line of treatment, and dose should be adjusted for renal function (136). Probenecid should also be considered as an alternative first-line agent when patients are intolerant to a xanthine oxidase inhibitor.…”

Inhibitors of Xanthine Oxidase: Scaffold Diversity and Structure‐Based Drug Design

“…The use of allopurinol as an inhibitor of XO was aimed at increasing the half‐life of the anti‐leukemic drug; however, it was found that the combination therapy of mercaptopurine/allopurinol did not improve the efficacy of the anti‐leukemic drug. Allopurinol was subsequently investigated for its inhibitory activity against XO and was approved by the US Food and Drug Administration (FDA) in 1966 for the treatment of gout, and is currently still the drug of first choice in the treatment of hyperuricemia as advised by the 2016 European League Against Rheumatism (EULAR) guidelines …”

Study Regarding the Serum Level of Uric Acid and the Metabolic Syndrome

“…Hyperuricemia has been defined as serum uric acid (UA) ≥ 7mg/dL in men and ≥ 6mg/dL in women according to the European League Against Rheumatism Guide (EULAR) [10].…”