HPE Grunenthal handbook - Page 6

guidelines Current management guidelines This article summarises the core components of the guidelines on gout management and highlights their differences when relevant Alexandre Dumusc MD Alexander So MD Rheumatology Department, Lausanne University Hospital, Lausanne, Switzerland Clinical guidelines are meant to help clinicians in their decision-making process in the choice of available treatments. Several guidelines on treating patients with gout are currently available. They are in general developed by experts, with or without the help of general physicians and patients, and should be based on the best available evidence at the time of preparation of the guideline. The American College of Rheumatology (ACR) issued guidelines in 2012 1,2 and the European League Against Rheumatism (EULAR) issued recommendations in 2016. 3 A group of international experts published treat-to-target (T2T) recommendations highlighting the use of several targets including serum urate level in gout management. 4 The American College of Physicians (ACP) issued practical guidelines in 2017 that have generated a certain amount of controversy. 5 National guidelines were published by the British Society for Rheumatology (BSR) in 2017. 6 Management of acute attacks of gout A gout flare should be treated promptly with anti- inflammatory drugs. Ideally, patients should be educated to self-medicate as soon as they notice symptoms of a flare. The affected joint should be rested and elevated. The use of topical ice could reduce pain. During an acute attack of gout, urate- lowering therapies (ULT) should not be discontinued; thus patients should be educated accordingly as this fact could seem counter-intuitive. Non-steroidal anti-inflammatory drugs (NSAIDs), colchicine and corticosteroids (intra-articular injection or systemic) are effective to treat acute gout. Interleukin-1 (IL-1) blockers are sometimes used for selected patients. 7 Guidelines are in agreement that the choice of treatment depends on comorbidities, contraindications (especially renal impairment), previous experience, time of initiation after flare onset, number/type of joint involved and patient preferences. If these drugs are insufficient, they can be combined, especially for a polyarticular attack or when multiples large joints are involved. NSAIDs should be used at full dose with gastric protection. There is some minor discordance about the use of colchicine between guidelines. A starting dose of 1mg (EULAR) or 1.2mg (ACR) followed 1 hour later with 0.5mg (EULAR) or 0.6mg (ACR), or 0.5mg 2–4-times a day (BSR) is proposed. 1,3,6 NSAIDs and colchicine should be avoided in patients with severe renal insufficiency. Colchicine should be prescribed with caution in patients treated with strong P-glycoprotein and/or CYP3A4 inhibitors, such as cyclosporine or clarithromycin. Oral corticosteroids, 30–35mg/day (EULAR), 6 | 2018 | hospitalpharmacyeurope.com 0.5mg/kg/day (ACR) for 3–5 days (EULAR) or 5–10 days (ACR) are an option when colchicine and NSAIDs are contraindicated or not tolerated. 1,3 ACR also suggests an alternative corticosteroid regimen of 2–5 days at full dose followed by 7–10 days with a tapered dose. Joint aspiration with corticosteroid injections is also highly effective, and might be treatment of choice when a single large joint is involved. IL-1 inhibitors (anakinra, canakinumab) may be considered in case of frequent flares and contraindications to colchicine, NSAIDs and corticosteroids. 7 Prophylaxis of gout flares when initiating ULT is generally recommended and should be explained and discussed with the patient. All guidelines recommend a prophylaxis of six months’ duration after starting ULT or three to six months after reaching serum urate level target (ACR). ACR suggests continuing prophylaxis if there are ongoing symptoms of gout. 1 The drug of choice for prophylaxis is colchicine. The recommended dose for colchicine is 0.5–1 mg/day (0.6–1.2mg/ day; ACR), which should be reduced in case of renal impairment. 1 BSR suggests a colchicine dose of 0.5mg/day for glomerular filtration rate (GFR) of 30–60ml/min and 0.5mg every two or three days for GFR 10–30ml/min. Colchicine should be avoided when GFR is <10ml/min (BSR). 8 Low-dose NSAIDs (with gastroprotection) might be considered when colchicine is not tolerated or contraindicated (EULAR, ACR, BSR). Use of low-dose prednisone (≤10mg/day) is suggested by ACR for prophylaxis when both NSAIDs and colchicine are ineffective, not tolerated or contraindicated. Management of ULT ULT should be considered in every patient having a definite diagnosis of gout. Patients should be fully involved in the decision-making process of starting ULT. The importance of a regular intake of the treatment should be emphasised to optimise long- term adherence to ULT. ULT is indicated in all patients with tophi, chronic gouty arthritis, urate arthropathy, past urolithiasis, recurrent flares or impaired renal function. Primary gout starting at young age (<40 years) is also an indication for ULT. Guidelines differ substantially in defining the number of gout flares needed to start ULT. Ideally, ULT should be initiated when the gout flare has settled. Most guidelines agree that treatment should aim to reduce serum urate levels (sUA) to a defined target. sUA should be measured on a regular basis and ULT adjusted accordingly. A sUA target of