Gout- 2020 Treatment Guidelines for Chronic Therapy

Question 1

Do all gout patients need chronic therapy?

Answer 1

No, they can use nonpharm treatment options

Question 2

Nonpharm therapy for chronic gout

Answer 2

Limiting alcohol intake, red meats, organ meat, seafood high in purines, high fructose corn syrup

Weight loss if patient is obese/exercise

Question 3

Components of chronic gout therapy

Answer 3

UA lowering therapy and flare prophylaxis

Question 4

UA-lowering therapy can do what?

Answer 4

Initiate flares

Question 5

Prophy gout flare meds should be used with what?

Answer 5

UA lowering therapy

Question 6

Chronic gout therapy should not be what?

Answer 6

Stopped during a flare

Question 7

Indications for chronic gout treatment

Answer 7

≥1 SQ tophi, radiographic evidence of damage attributable to gout; OR frequent flares (≥2/year)

Question 8

When to CONSIDER chronic gout treatment

Answer 8

History of >1 attack, but <2 attacks/year

Those with first gout flare with the following characteristics:
CKD Stage ≥3
UA concentration >9 mg/dl
Urolithiasis

Question 9

If it’s decided that a patient needs ULT during a flare, when should it be started?

Answer 9

During the flare

Question 10

SUA goal

Answer 10

<6mg/dl

Question 11

What agent is recommended first line over all others?

Answer 11

Allopurinol

Question 12

UA level monitoring

Answer 12

Monitor q2-5wks with increased ULT intensity until the goal is reached

Question 13

How long should therapy be continued for when it meets the goal?

Answer 13

Indefinitely

Question 14

When to switch to pegloticase in chronic gout treatment

Answer 14

When XOI treatment, probenecid, and other interventions failed to achieve goal UA level and patients continue to have at least 2 flares/year OR non-resolving tophi

Question 15

When should gout flare prophy be started?

Answer 15

Prophy with anti-inflammatory meds should be initiated when ULT is initiated (AKA initiate both at the same time)

Question 16

What agents do you use for gout prophy?

Answer 16

The same ones as you do for a flare, but at different doses

Question 17

Prophy dose of colchicine

Answer 17

0.6mg PO QD-BID

Question 18

Prophy dose of NSAIDs

Answer 18

Example is 250mg naproxen, add on a PPI when indicated

(any low dose NSAID will work)

Question 19

Prophy dose of steroids

Answer 19

Low dose prednisolone or prednisone <=10mg/day

Question 20

First-line options for gout prophy treatment

Answer 20

Colchicine and low-dose NSAIDs

Question 21

When to use low dose steroids for prophy

Answer 21

If BOTH colchicine and low dose NSAIDs are CI’ed, not tolerated, or ineffective

Question 22

How long should prophy gout treatment be continued for?

Answer 22

3-6 months based on resolution of symptoms and tophi absence with ongoing evaluation and continued prophy if flares continue

Question 23

If a patient is on gout prophy and they have a flare in the last 3 months with palpable tophi present, what do you do?

Answer 23

Continue prophy treatment

Question 24

If a patient is on gout prophy and there’s no signs and symptoms, what do you do?

Answer 24

Continue treatment for at least 6 months OR 3 months after achieving target SUA goal appropriate for the patient and no tophi on PE OR 6 months after achieving target SUA goal with one or more tophi present on PE

Question 25

Medication management: what to do if the patient is taking HCTZ

Answer 25

Switch to losartan

Question 26

Medication management: stopping low-dose ASA

Answer 26

Don’t do it

Question 27

Medication management: adding fenofibrate or switching cholesterol medications to fenofibrate

Answer 27

Don’t do it

Question 28

Non-pharm therapy: what should you not add to the patient’s regimen?

Answer 28

Vitamin C