I introduced the 2012 gout guidelines as a summary of the key points, with a promise to review the details.

There have been various mentions of the new guidelines around the Internet. The best I’ve seen so far is an interview with one of the gout guidelines Task Force Panel, Dr Fitzgerald.

The questions, and summary of the answers are:

1. Anybody can look up the guidelines and read them in full. What are some of the limitations of the guidelines and what did they not say?

Links to free, full versions of the guidelines are contained in my 2012 gout guidelines introduction.
Dr Fitzgerald responded that the limitations were due to the scope of the project which evaluates existing literature. If an aspect of gout has not been investigated, the panel could not evaluate it. The method excludes cost analysis. This is significant in the recommendation of febuxostat and allopurinol as first-line uric acid lowering therapies. Medically they are similar, but allopurinol is much lower cost. Dr Fitzgerald notes that the guidelines should not be prescriptive. They exist to guide the clinician, and if cost is a factor for a patient, this should be taken into account. Clinicians should supplement the guidelines with their own knowledge and recognition of patient characteristics.

A further weakness of the study is the dosage of allopurinol with kidney disease. The guidelines can specify that allopurinol should start at 100mg and increase according to blood test results, but they cannot give specific dosage guidelines, because no studies have been done.

This gives doctors “permission” to use the guidelines as a good starting point, then supplement them with good GoutPal advice where I consider the aspects of gout not covered in the ACR guidelines project.

2. We have all learned about the importance of treat to target. The guidelines give a little latitude about what the target should be [5mg/dL or 6mg/dL]. Can you give a little guidance on how to make that decision and when?

Where gout burden is high, with many tophi, an aggressive approach is warranted, as data shows that the lower the uric acid level achieved, the faster the resolution of tophi. In serious cases, 5mg/dL is an appropriate target. Where gout patients show “typical” histories, i.e. a few gout attacks in the feet with “moderate” hyperuricemia, a target of 6mg/dL may be enough.

This completely misses the point that uric acid crystals are destroying joints, irrespective of visible tophi. Therefore, my advice is to go as low as possible with maximum allopurinol (once a low dose has established safety). After several months, adjust the target to 5, allowing 6 where exceptional factors indicate. I cannot advise on how long you should maintain maximum dose, but one month for every year you have had gout seems a reasonable starting point. Visible tophi may indicate that this period should be longer. I have been on 900mg allopurinol for just over one year now. I have agreed a 12 month extension, as the large tophi near my right elbow has shrunk by around 50%, but is still persistent.

3. The guidelines mention using an HLA-B marker to test for a tendency to adverse reactions to allopurinol(Drug information on allopurinol). Can you tell us a little more about who needs that test?

A lot of data has been generated in China, Korea, and Thailand identifying HLA-B-5801 as high risk indicator for allopurinol hypersensitivity syndrome. There is no data for other genetic groups, so the advice in the guidelines had to be selective.

4. What do you think is going to be the impact on referrals to rheumatologists?

Dr Fitzgerald hopes that greater awareness will encourage gout patients to recognize that rheumatologists have new tools to treat gout. He hopes the guidelines will encorage treatment to target, and safer use of gout drugs.

Treatment to target is something I’ve been banging on about for years. Now you, as a gout patient, must take responsibility. Do you think your family doctor has read the guidelines? Do you think your family doctor has a target for your uric acid level?

I expect the answer in most case is probably not. Therefore it is up to you to insist on a uric acid lowering program that gets you safe.

If you see other interesting discussions of the gout guidelines, please share the links. What do you think of the gout guidelines?