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Practice Guideline
. 2012 Oct;64(10):1431-46.
doi: 10.1002/acr.21772.

2012 American College of Rheumatology guidelines for management of gout. Part 1: systematic nonpharmacologic and pharmacologic therapeutic approaches to hyperuricemia

Dinesh Khanna  1 , John D Fitzgerald, Puja P Khanna, Sangmee Bae, Manjit K Singh, Tuhina Neogi, Michael H Pillinger, Joan Merill, Susan Lee, Shraddha Prakash, Marian Kaldas, Maneesh Gogia, Fernando Perez-Ruiz, Will Taylor, Frédéric Lioté, Hyon Choi, Jasvinder A Singh, Nicola Dalbeth, Sanford Kaplan, Vandana Niyyar, Danielle Jones, Steven A Yarows, Blake Roessler, Gail Kerr, Charles King, Gerald Levy, Daniel E Furst, N Lawrence Edwards, Brian Mandell, H Ralph Schumacher, Mark Robbins, Neil Wenger, Robert Terkeltaub; American College of Rheumatology
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Practice Guideline

2012 American College of Rheumatology guidelines for management of gout. Part 1: systematic nonpharmacologic and pharmacologic therapeutic approaches to hyperuricemia

Dinesh Khanna et al. Arthritis Care Res (Hoboken). 2012 Oct.
No abstract available

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Conflict of interest statement

Author conflict of interests are provided directly from the American College of Rheumatology and detailed separately.

Figures

Figure 1
Figure 1. Fundamental Case Scenarios Evaluated by the TFP
The TFP evaluated a broad spectrum of severity of gout, with presenting clinical information comparable to that encountered in practice. Scenarios were formulated iteratively by the CEP, as described in the text, and were not intended to serve as disease classification criteria. All case scenarios assumed that the diagnosis of gout was correct, and that there was some evidence of gout disease activity. Three distinct “treatment groups” for these recommendations, each with 3 case scenarios designed to succinctly represent clinically based decision making, and totaling 9 in all, are presented in panels A-B. The “treatment group” with intermittent attacks of acute gout, but no tophi detected on physical examination, was sub-divided based on increasing yearly frequency of episodes of acute gouty arthritis of at least moderate to severe pain intensity (Case Scenarios 1–3)(panel A). Gout associated with clinically apparent high body urate burden was evaluated in case scenarios where there were one or more tophi on physical exam, and either intermittently symptomatic acute gouty arthritis (Case Scenarios 4–6)(panel A), or in panel B, chronic joint symptoms due to synovitis attributable to gout, or articular tophus or tophi, in Case Scenarios 7–9 (the domain termed chronic tophaceous gouty arthropathy (CTGA)). Severity of case scenarios in the CTGA domain was distinguished by extent and characteristics of the tophi, and chronic arthropathy, with variable inflammatory and deforming features, detected on physical examination (see accompanying Figure 2).
Figure 1
Figure 1. Fundamental Case Scenarios Evaluated by the TFP
The TFP evaluated a broad spectrum of severity of gout, with presenting clinical information comparable to that encountered in practice. Scenarios were formulated iteratively by the CEP, as described in the text, and were not intended to serve as disease classification criteria. All case scenarios assumed that the diagnosis of gout was correct, and that there was some evidence of gout disease activity. Three distinct “treatment groups” for these recommendations, each with 3 case scenarios designed to succinctly represent clinically based decision making, and totaling 9 in all, are presented in panels A-B. The “treatment group” with intermittent attacks of acute gout, but no tophi detected on physical examination, was sub-divided based on increasing yearly frequency of episodes of acute gouty arthritis of at least moderate to severe pain intensity (Case Scenarios 1–3)(panel A). Gout associated with clinically apparent high body urate burden was evaluated in case scenarios where there were one or more tophi on physical exam, and either intermittently symptomatic acute gouty arthritis (Case Scenarios 4–6)(panel A), or in panel B, chronic joint symptoms due to synovitis attributable to gout, or articular tophus or tophi, in Case Scenarios 7–9 (the domain termed chronic tophaceous gouty arthropathy (CTGA)). Severity of case scenarios in the CTGA domain was distinguished by extent and characteristics of the tophi, and chronic arthropathy, with variable inflammatory and deforming features, detected on physical examination (see accompanying Figure 2).
Figure 2
Figure 2. Detailed pictorial representations of chronic arthropathy in CTGA case scenarios presented to the TFP
A core element of our approach was to present the TFP, and the readership of the ultimate publication, with specifically detailed summaries of the CTGA case scenarios (numbers 7–9 in Figure 1), including pictorial examples, to allow focus on clinical information that prompts management decisions. The photograph on the top left was provided by Dr. Robert Terkeltaub, and the other two by Dr. Fernando Perez-Ruiz.
Figure 3
Figure 3. Baseline recommendations and overall strategic plan for patients with gout
This algorithm summarizes overall treatment strategies and flow of management decisions for gout. Certain elements, including non-pharmacologic and pharmacologic measures, the approach to refractory disease, and treatment and anti-inflammatory prophylaxis of acute gout attacks, are developed further in Tables 2–4 and Figures 4–5, and in Part II of the guidelines, as respectively referenced in the figure. Evidence Grades (A-C, as indicated) are summarized for each TFP recommendation, and the text discusses, in detail, each aspect of clinical decision making.
Figure 4
Figure 4. Specific TFP recommendations on general health, diet, lifestyle measures for gout patients
The figure presents the TFP recommendations on non-pharmacologic measures for gout patients, including a program of broad diet and lifestyle measures. The recommendations encompass measures not only for decreasing the risk and frequency of acute gout attacks and lowering serum urate, but also with a major emphasis on maintenance of ideal health, and prevention and best practice management of cardiovascular and metabolic diseases. Dietary recommendations were grouped into 3 simple qualitative categories, termed “limit”, “avoid”, or “encourage”, reflecting general lack of specific evidence from prospective, blinded, randomized clinical intervention trials linking consumed quantities of individual dietary components to changes in either serum urate or to gout signs and symptoms. Specific TFP votes on dietary components resulting in “lack of consensus” also are cited.
Figure 5
Figure 5. Case scenario-specific escalation of pharmacologic ULT in gout, including approach to refractory disease
This figure, which accompanies Table 4, presents TFP recommendations for patients with continuing gout disease activity, and focuses on escalating pharmacologic ULT measures, particularly for refractory disease. Each of the fundamental case scenarios (as numbered 1–9 above, and described in detail in Figure 1A–B) are considered. These recommendations specifically assume that for each case scenario: (i) The serum urate target needed to achieve improved gout signs and symptoms has not yet been achieved; (ii) Appropriate non-pharmacologic ULT measures have been applied; (iii) Appropriate treatment and anti-inflammatory prophylaxis are employed for attacks of acute gouty arthritis. Evidence Grades for individual TFP votes to recommend that are summarized here are presented in the text. The designation of ± for decision making in the figure indicates that the TFP recommended this measure only in clinical scenarios indicated by the symbol§.
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References

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    1. Dalbeth N, Aati O, Gao A, House M, Liu Q, Horne A, et al. Assessment of tophus size: a comparison between physical measurement methods and dual-energy computed tomography scanning. J Clin Rheumatol. 2012;18:23–7. - PubMed
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    1. Desai MA, Peterson JJ, Garner HW, Kransdorf MJ. Clinical utility of dual-energy CT for evaluation of tophaceous gout. Radiographics. 2011;31:1365–75. - PubMed

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