CLINICAL PRACTICE

GUIDELINES – MANAGEMENT
OF GOUT (SECOND EDITION)

R H E U M AT O L O G Y U P D AT E 2 0 2 2 , N O V 3 - 4
• Gout — one of the oldest joint diseases; Early records of gout by the Egyptians
dated back to 2640 before common era (BCE).

• Prevalence and incidence increasing globally, especially younger age

• An increase in all-cause mortality, chronic disability, impairment of health-

related quality of life, higher usage of health care services and reduced
productivity.
WHAT’RE THE
NEW CHANGES
?
NO.1: RISK FACTORS & PREVENTIVE STRATEGIES
 FOOD AND GOUT – MYTH?
• Seafood – meta analysis showed increased risk of
hyperuricaemia & gout. Li R et al 2018, level II-2

– OR for hyperuricaemia: 1.47 (95% CI 1.16 to 1.86)

– OR for gout: 1.31 (95% CI 1.01 to 1.68)

• However, fish enriched in omega-3

polyunsaturated fatty acid (n-3 PUFA) may
override the deleterious effect of its high urine
content – prevent recurrent gout flares
Zhang MA et al 2019, level II-2

– Eg. Salmon, tuna, sardines, anchovies, mackerels,

herring, trout

• Purine-rich vegetables, soy-based food, nuts and

seeds – NOT associated with hyperuricaemia & risk
of gout. Li R et al 2018, level II-2
 DIETARY RECOMMENDATION?

• Restrict high purine food intake • Prevention:

(i.e. red meat & seafood) – Dietary Approaches to Stop
Hypertension (DASH) diet
• Moderate intake of purine rich (RECOMMENDATION 1)
vegetables
• Non pharmacological Tx:
– Limit intake of purine-rich food
especially of animal origin EXCEPT
omega-3polyunsaturated fatty acid-
rich fish (RECOMMENDATION 5)
NO.2: DIAGNOSIS OF GOUT
Definite diagnosis: demonstration of MSU crystals
in synovial fluid or tissues
 NO.2: DIAGNOSIS OF GOUT
CPG 2008 — diagnostic criteria (Benett & wood 1968) CPG 2021– classification criteria (2015 ACR/EULAR)

• Clinical diagnosis: 2/4 • Entry criterion: at least 1 episode of

synovitis or bursitis
• Definite diagnosis (sufficient criterion):
presence of MSU crystals in synovial
fluid OR tophus
NO.3: COMORBIDITIES SCREENING

• Association with comorbidities (high CV risk), cardiovascular

diseases/events, all-cause mortality
 NO.4: ASYMPTOMATIC HYPERURICAEMIA

• Subtopic 5.2 … in the vast majority • More evidence from RCTs,

of patients, routine prophylactic systematic reviews, meta analyses
treatment is not required

• Treatment maybe in:-

– Persistent high SUA
• Male: > 770 umol/L
• Female: > 600 mull/L
– Persistent elevated urinary excretion of
urate
– Tumour lysis syndrome
NO.5: TREAT TO TARGET (T2T)
Target serum urate: < 360 μmol/L
NO.6: NON PHARMACOLOGICAL TREATMENT

• Patient health education is strongly recommended

— to achieve T2T and adherence to treatment

• RCTs: involvement of primary HCP, pharmacists and

nurses
NO.7: URATE LOWERING THERAPY – INDICATIONS
NO.8: URATE LOWERING THERAPY – OPTIONS

• Allopurinol • Xanthine oxidase inhibitors (XOI):

• Probenecid – Allopurinol, febuxostat
• Uricosuric: Probenecid,
benzbromarone
• Recombinat uricases: Pegloticase

• Should only be started after acute • Can be started during gout flare
attack
• Combination therapy (XOI +
uricosuric)
NO.9: FLARE PROPHYLAXIS
• Colchicine (1-2 tablets/day)
• Until free of acute attacked for 6
months OR target SUA is achieved
for 1 month
• Alternatively, low dose NSAIDs
• Stepwise increase of ULT and/or
concomitant colchicine (1-2
tablets/day)
• 3 to 6 months – until target SUA
achieved
• Alternatively, steroid
NO.10: SPECIAL GROUP (CKD): T2T
Target serum urate: < 360 μmol/L
NO.10: SPECIAL GROUP (CKD): ULT

• Allopurinol(XOI) • Allopurinol (XOI)

– ‘Ceiling dose’ – Safe and effective; Preferred first
line
– Maximal dose: 900mg/day
– Start Low, Go Slow strategy
NO.10: SPECIAL GROUP (CKD): ULT

• Febuxostat (XOI): - • Febuxostat (XOI)

– Safe and effective
– 2nd line

• Probenecid (Uricosuric) • Uricosuric

– Contraindicated in urate – Contraindicated in urolithiasis
overproduction and – Not recommended in severe
overexcretion, urolithiasis CKD (CrCl < 30)
– Normal renal function
NO.10: SPECIAL GROUP (CKD): FLARE

• Gout flare
– Cochicine ✅
– Steroid ✅
– NSAIDs: ❌

• Flare prophylaxis
– Allopurinol ✅
– Colchicine ✅
– Steroid ✅ (not long term)
– NSAIDs: ❌
NO.11: SPECIAL GROUP ( PREGNANCY & LACTATION)

• Paucity of evidence in treatment • Colchicine, NSAIDs, steroid ✅

• Referral needed • Inadequate data: allopurinol, febuxostat,
probenecid, benzbromarone

Category C:
Use with caution if
benefits outweigh risks.

Animal studies show risk

and human studies not
available or neither animal
nor human studies done.
TAKE HOME MESSAGE

• Management of gout should be guided by the latest evidence and

availability of local resources to provide quality care to patients.

• T2T strategy is an important concept in gout management and

should be emphasised in gout management throughout all levels of
care.