Summary of 2012 ACR Recommendations on the Management of Gout. Does not include the approach to the diagnosis of gout.

1. GOUT 2012:
Updates to an Old Disease

2. Assumptions
“The ACR gout guidelines are designed
to emphasize safety and quality of
therapy and to reflect best practice.”
• Correct Diagnosis
• Consider Co-morbid conditions
• Evaluate for Drug interactions
Khanna D, Fitzgerald JD, Khanna PP, et al. 2012 ACR Guidelines for Management of Gout. Part 1. Arth Care
& Res 2012; 64 (10): 1431-46. Khanna D, Khanna PP, Fitzgerald JD, et al. 2012 ACR Guidelines for
Management of Gout. Part 2. Arth Care & Res 2012; 64 (10): 1447-61.

3. Levels of Evidence
A Meta-analyses
>1 Randomized Clinical Trial
B Single Randomized Clinical Trial
Non-Randomized Studies
Standards of Care
C Case Studies
Expert Consensus

4. Nomenclature (Acute)
SEVERITY (Pain VAS)
1 2 3 4 5 6 7 8 9 10
DURATION (from onset of symptoms)
0 12 24 36
FREQUENCY (No of flares/ year)
1 2 3 4 5 6 7 8 9 10

5. Nomenclature
JOINT INVOLVEMENT
• Few small joints
• 1 or 2 large joints
• Polyarthritis
• 4 or more joints
involving >1 region
• 3 large joints

6. Nomenclature (CTG)
MILD MODERATE SEVERE
Affects 1 joint Affects 2-4 joints Simple tophi in >4 joints
Stable disease Stable disease OR
Simple tophi Simple tophi >1 Unstable tophus

7. Domains in Gout Care
• Acute Gout
• Prophylaxis
• Urate Lowering Therapy
• Chronic Tophaceous Gout
Khanna D, Fitzgerald JD, Khanna PP, et al. 2012 ACR Guidelines for Management of Gout. Part 1. Arth Care
& Res 2012; 64 (10): 1431-46. Khanna D, Khanna PP, Fitzgerald JD, et al. 2012 ACR Guidelines for
Management of Gout. Part 2. Arth Care & Res 2012; 64 (10): 1447-61.

8. ACUTE GOUT
a.k.a. GOUT FLARE
Self limited attack of joint inflammation

9. Treating Acute Gout
• Treat with pharmacologic therapy (C)
• Best started within 24 hours(C)
• Do not interrupt those on established urate-
lowering therapy (C)
• Educate patient on
– Initiating treatment when w/ a flare (B)
– Effective urate lowering being “curative” (B)

10. Choosing an Anti-Inflammatory
Start
Pain VAS Yes
<7/10
MONOTHERAPY
(A)
No
CONSIDER
Start
• Patient preference
COMBINATION
• Prior response to meds
THERAPY (C)
• Associated co-morbids

11. NSAIDs in Acute Gout
• Full anti-inflammatory dose/ acute pain
– Naproxen (A)
– Indomethacin (A)
– Sulindac (B)
– Other NSAIDs (B or C)
– Etoricoxib (A)
– High dose Celecoxib (B)
• Continue until flare completely resolves (C)

12. Colchicine in Acute Gout
• Best if given <36 hours of onset
• Dosing regimen
– 1.2 mg initially then 0.6 mg after 1 hour then 0.6 mg
BID until acute gout resolves (A)
– 1.0 mg initially then 0.5 mg after 1 hour then 0.5 mg
TID until acute gout resolves (C)
• Do not give IV
• Reduce in moderate-severe CKD
• Caution with clarithromycin, erythromycin,
cyclosporin and disulfiram

13. Steroids in Acute Gout
• Oral or IA steroids if 1-2 joints involved (B)
• IA steroid dose depends on joint size (B)
• Recommended dosing
– Prednisone 0.5 mkd for 5-10 days (A)
– Prednisone 0.5 mkd for 2-5 days then taper
for 7-10 days (C)
– Triamcinolone 60 mg IM with oral steroids (C)
– No consensus for ACTH (A)

14. Combination Therapy in Acute Gout
• Colchicine with NSAIDs
• Colchicine with Steroids
• IA Steroids with Colchicine/ NSAIDs/ Oral
Steroids
• Consider topical ice application (B)

15. Treating the Patient on NPO
• IA steroids for 1-2 large joints (B)
• IV or IM Methylprednisolone (or equivalent)
0.5 – 2.0 mkd (B)
• ACTH 25-40 IU SC (A)
• No consensus on IM Ketorolac or IM
Triamcinolone (C)

16. Contraindications
CONDITION NSAIDs Colchicine Steroids
Chronic Kidney Disease St 3-5  
Peptic Ulcer Disease  
Heart Failure 
Anti-coagulants/ platelets 
Diabetes Mellitus 
Infection 
Liver Disease  

17. Continuing Acute Gout Care
INADEQUATE
RESPONSE REVIEW the diagnosis
Yes
<20% in 24H CONSIDER
or <50% after • Shift to other drug (C)
24H • Combine therapy (C)
No • Anakinra 100 mg SC for
3 days (B)
• Canakinumab 150 mg
COMPLETE SC single dose (A)
TREATMENT

18. PROPHYLAXIS
To be started in all patients in whom
Urate Lowering Therapy is indicated

19. Drugs for Prophylaxis
• First Line Drugs
– Colchicine 0.5 – 0.6 mg OD-BID (A)
– Naproxen 250 mg BID + PPI (C)
• Alternate Agents
– Prednisone <10mg/d (C)
• Lack of consensus on off-label anti-IL-1 (A)

20. Duration of Prophylaxis
Choose the greater of the following:
• 6 months duration (A)
• 3 months of achieving target BUA in patients
without tophi (B)
• 6 months of achieving target BUA AND
resolution of previously noted tophi on PE (C)

21. URATE LOWERING
THERAPY
Pharmacologic and Non-Pharmacologic

22. Diet and Lifestyle Changes
AVOID LIMIT ENCOURAGE
Organ meats (B) Seafood (B) Low fat or non-fat dairy
Drinks with fructose(C) Sweetened fruit juices (C) products (B)
Alcohol overuse (B) Sugar (C) Vegetables (C)
Alcohol during an acute Salt (C)
attack (C)

23. Evaluating Hyperuricemia (C)
• Educate the patient (B)
– Diet and lifestyle changes
– Disease, treatment and objectives
– Role of hyperuricemia and targets
• Consider eliminating non-essential meds that
increase serum uric acid (C)
• Evaluate for co-morbid conditions and
contributors to hyperuricemia (C)
• Assess gout disease burden

24. Checklist
COMORBIDS (C)
• Obesity LABORATORIES
• Alcohol intake • Urinalysis
• Metabolic Syndrome and • Renal ultrasound
components • CBC
• Kidney disease • Urine uric acid
• Lead intoxication determination (C)
• Myeloprolif/ lymphoprolif – Gout < 25 y/o
disorders – Nephrolithiases
• Psoriasis

25. Indications for ULT
• Evidence of tophus/tophi (A)
• Frequent attacks (>2/year) (A)
• History of nephrolithiases (C)
• Chronic Kidney Disease Stage 2-5 (C)

26. Target Blood Uric Acid
<6 mg/dl <5 mg/dl
For most gout scenarios For more durable
(if without visible tophi) improvement and patients
(A) with visible tophi (B)

27. Urate Lowering Therapy
• First Line Agents (A)
– Allopurinol 100-800 mg/d
– Febuxostat 40-120 mg/d
• Alternative Therapy (B)
– Probenecid (except when Cr Cl <50ml/min and history
of urolithisases)
• Can be started during an attack(!) PROVIDED
effective anti-inflammatory therapy has been
given (C)

28. Allopurinol Dosing Guide
• Starting dose <100mg/d (B)
– For CKD 4-5, starting dose is 50mg/d (B)
• Titrate up every 2-5 weeks (C)
• Dose of >300mg/d can be used provided patient
is monitored for AHS and other AE (B)
– Pruritus, Rash, Inc LFT, Eosinophilia

29. Allopurinol Dosing Guide
Maximum Recommended
Allopurinol Dose Based on Crea
Clearance
Crea Cl (ml/min) Dose
0 100 mg q 3 days
10 100 mg q 2 days
20 100 mg/day
40 150 mg/day
60 200 mg/day
80 250 mg/day
100 300 mg/day
120 350 mg/day

30. Pharmacogenetics for AHS
Patients at high risk for AHS should consider
screening for HLA-B*5801 (A)
– Korean descent with CKD 3 or worse (A)
– Han Chinese
– Thai

31. Approach to ULT
• Titrate XOI to max recommended dose (A)
• If up-titration is not tolerated or target BUA is
not achieved, consider shift to other XOI (C)
• If target BUA is not achieved, start combination
therapy by adding a uricosuric (B)
• Last option, if still unable to achieve targets on
oral ULT, is to give PEGLOTICASE (A)

32. Consider referring when…
• Unclear etiology of hyperuricemia
• Refractory gout
• Difficulty in achieving target BUA
• Multiple or serious AE from ULT

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