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2020 American College of Rheumatology Guideline for the Management of Gout


Arthritis Care Res (Hoboken). 2020 Jun;72(6):744-760.doi: 10.1002/acr.24180. Epub 2020 May 11.

John D FitzGerald 1Nicola Dalbeth 2Ted Mikuls 3Romina Brignardello-Petersen 4Gordon Guyatt 4Aryeh M Abeles 5Allan C Gelber 6Leslie R Harrold 7Dinesh Khanna 8Charles King 9Gerald Levy 10Caryn Libbey 11David Mount 12Michael H Pillinger 5Ann Rosenthal 13Jasvinder A Singh 14James Edward Sims 15Benjamin J Smith 16Neil S Wenger 17Sangmee Sharon Bae 17Abhijeet Danve 18Puja P Khanna 19Seoyoung C Kim 20Aleksander Lenert 21Samuel Poon 22Anila Qasim 4Shiv T Sehra 23Tarun Sudhir Kumar Sharma 24Michael Toprover 5Marat Turgunbaev 25Linan Zeng 4Mary Ann Zhang 20Amy S Turner 25Tuhina Neogi 11

Author Information

1 University of California, Los Angeles and VA Greater Los Angeles Health Care System, Los Angeles, California.

2 University of Auckland, Auckland, New Zealand.

3 University of Nebraska Medical Center and VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska.

4 McMaster University, Hamilton, Ontario, Canada.

5 New York University School of Medicine, New York City, New York.

6 Johns Hopkins University, Baltimore, Maryland.

7 University of Massachusetts Medical School, Worcester Massachusetts, and Corrona, Waltham, Massachusetts.

8 University of Michigan, Ann Arbor.

9 North Mississippi Medical Center, Tupelo.

10 Kaiser Permanente, Downey, California.

11 Boston University School of Medicine, Boston, Massachusetts.

12 VA Boston Healthcare System, Boston, Massachusetts.

13 Medical College of Wisconsin, Milwaukee.

14 University of Alabama at Birmingham and Birmingham Veterans Affairs Medical Center, Birmingham.

15 Atlanta, Georgia.

16 Florida State University College of Medicine School of Physician Assistant Practice, Tallahassee.

17 University of California, Los Angeles.

18 Yale University, New Haven, Connecticut.

19 University of Michigan, VA Ann Arbor Healthcare System, Ann Arbor.

20 Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

21 University of Kentucky, Lexington.

22 US Department of Veterans Affairs, Manchester, New Hampshire.

23 Mount Auburn Hospital, Cambridge, Massachusetts.

24 Allegheny Health Network, Pittsburgh, Pennsylvania.

25 American College of Rheumatology, Atlanta, Georgia.

Erratum in

[No authors listed]Arthritis Care Res (Hoboken). 2020 Aug;72(8):1187. doi: 10.1002/acr.24401.PMID: 32726516 No abstract available.



Objective: To provide guidance for the management of gout, including indications for and optimal use of urate-lowering therapy (ULT), treatment of gout flares, and lifestyle and other medication recommendations.

Methods: Fifty-seven population, intervention, comparator, and outcomes questions were developed, followed by a systematic literature review, including network meta-analyses with ratings of the available evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, and patient input. A group consensus process was used to compose the final recommendations and grade their strength as strong or conditional.

Results: Forty-two recommendations (including 16 strong recommendations) were generated. Strong recommendations included initiation of ULT for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares; allopurinol as the preferred first-line ULT, including for those with moderate-to-severe chronic kidney disease (CKD; stage >3); using a low starting dose of allopurinol (≤100 mg/day, and lower in CKD) or febuxostat (<40 mg/day); and a treat-to-target management strategy with ULT dose titration guided by serial serum urate (SU) measurements, with an SU target of <6 mg/dl. When initiating ULT, concomitant antiinflammatory prophylaxis therapy for a duration of at least 3-6 months was strongly recommended. For management of gout flares, colchicine, nonsteroidal antiinflammatory drugs, or glucocorticoids (oral, intraarticular, or intramuscular) were strongly recommended.

Conclusion: Using GRADE methodology and informed by a consensus process based on evidence from the current literature and patient preferences, this guideline provides direction for clinicians and patients making decisions on the management of gout.