Gout Treatment Guidelines

New gout treatment guidelines support the use of urate-lowering therapy but find no place for treating patients to achieve any specific serum urate target.

As a rheumatologist and Gout patient, I strongly disagree.

But I can see where the ACP is coming from.  They take the moral high ground by basing the guidelines solely on the best evidence available, and admittedly, a treat-to-urate-level-target strategy lacks good prospective randomised controlled trials to back its efficacy.  But that is mainly because most of the drugs used (like Allopurinol) are long off-patent, giving big pharmas little incentive to spend money to conduct such trials.  Also, some of the important endpoints like kidney failure, heart attack or stroke have many confounding variables and may take a long time to emerge, therefore requiring large numbers of patients and a long trial duration to demonstrate statistical differences in outcomes; meaning more money needed, which no one is keen to sponsor.

This is an example of Evidence-Based Medicine carried to an illogical conclusion, potentially jeopardising patients’ wellbeing.

ACP Gout Guidelines Reviewed and Critiqued by Rheumatologists

The American College of Physicians (ACP) has issued a series of recommendations on the diagnosis and treatment of gout. For instance, they advocate for the use of corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), or colchicine in acute gout.

Gout Doubt: Experts Challenge New ACP Guidelines

Gout clinical guidelines from the American College of Physicians include significant breaks with widely used diagnostic and management approaches and have triggered strong push-back from gout experts.

Does more rapid crystal dissolution have any clinical relevance for gout patients?

If your aim is to melt away your iceberg of uric acid (potentially a cure) accumulated over a lifetime of indulgence, rather than mere symptomatic gouty arthritis treatment and risking longterm complications (liver, kidneys, cardiovascular), then you need to target crystal dissolution rather than pain relief.

Your treatment target then should be to lower your serum uric acid to below 5 mg/dL (300 umol/L), and keep it there for as long as you shall live (or till your entire crystal load has dissolved away).

Concerns of this treatment target are:
1) Do longterm use of ULT drugs carry side-effects?
2) Is there “too low” an SUA level which may give rise to problems, like hypotension, lack of anti-oxidant function, or loss of neuroprotection?
3) Will “too fast” crystal dissolution have any untoward effect, like more frequent gout attacks?