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'Step Change' in Gout Guidance Regarding ULT

Manchester — Urate-lowering therapy (ULT) should follow the treat-to-target principle rather than treat-to-avoid symptoms, and the benefits of ULT should be emphasised to patients earlier in disease, according to the latest (2022) National Institute for Health and Care Excellence (NICE) guideline for the diagnosis and management of gout.

In contrast to the British Society for Rheumatology (BSR) guidelines, the 2022 NICE recommendations allow either allopurinol or febuxostat as first-line ULT. Both sets of guidelines recommend treating-to-target; however, whereas BSR recommended a target level of 300 µmol/L, NICE said that target serum urate should be 360 µmol/L. 

The NICE guidelines also highlight that interleukin-1 (IL-1) inhibitors should not be considered for flare management or prophylaxis unless colchicine, non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids are contraindicated, not tolerated, or effective. Referral to specialist rheumatology services should be made before prescribing an IL-1 inhibitor.

Using ULT From the First Flare

Kelsey Jordan, consultant in rheumatology and honorary senior lecturer at University Hospitals Sussex NHS Foundation Trust, Brighton, discussed the NICE guidelines, published in June last year, at this year's BSR conference in Manchester on Monday. 

"A key point is to discuss urate-lowering therapy using a treat-to-target approach with people who have had a first or subsequent gout flare, so we need to raise it at diagnosis of gout rather than waiting for subsequent and multiple flares," asserted Dr Jordan.

She added: "We also need to ensure patients understand ULT is continued after the target is reached. Sometimes people reach the target for their allopurinol course and stop, thinking that's it. But empowering patients to understand the need to continue treatment is really important. Gout is a lifelong, inflammatory condition and gout is the only curable form of inflammatory arthritis."  

Previous Disagreement Regarding ULT Approach

The 2022 NICE guideline provides recommendations concerning diagnosis and assessment, information and support, the management of gout flares, diet and lifestyle, long-term management of gout (including which ULT to start and when, treatment-to-target, anti-inflammatory prophylaxis, and monitoring), and referral to specialist services.

Prior to the latest NICE guideline, there was disagreement around the best approach to urate lowering therapy (ULT), with inconsistencies between the American College of Physicians (ACP) guideline and those from the American College of Rheumatology (ACR), the British Society for Rheumatology (BSR) and the European Alliance of Associations for Rheumatology (EULAR). 

In the NICE guidelines, febuxostat (Adenuric, A. Menarini Farmaceutica Internazionale SRL), as well as allopurinol, is recommended as a first-line treatment for ULT in patients without a history of major cardiovascular disease, compared with other guidelines that recommend febuxostat only as a second-line ULT. The latest update provides patients with greater access to febuxostat.

"If the patient has a history of cardiovascular disease, then use allopurinol and consider switching one drug to the other if the serum urate level is not reached on first-line treatment," explained Dr Jordan. 

NICE also recommended a target serum urate level of less than 360 µmol/L, in contrast to the BSR guidelines recommendation of a universal target serum urate level of less than 300 µmol/L. The NICE guideline also concludes that there is equivalent cost-effectiveness and clinical efficacy between febuxostat and allopurinol. 

The updated NICE guideline also provides follow-up and disease monitoring recommendations with an organised framework that emphasises the benefit of joint disease management agreed between doctor and patient. 

The 2022 NICE guideline was developed following systematic literature review considered and combined with consensus view, expert opinion (comprising an orthopaedic surgeon, a dietician, a pharmacist, two lay representatives, an independent chair and NICE methodological experts) as well as patient perspectives.

'Step-Change' in the Management of Gout

Abhishek Abhishek, MBBS, professor of rheumatology at the University of Nottingham, commented on the NICE recommendations at the conference: "These guidelines provide a step-change in the management of gout in the UK, with both febuxostat and allopurinol considered as first-line urate lowering drugs in the treatment of gout," he emphasised.

"There is also the recommendation for GPs to refer difficult-to-treat gout to rheumatology services and to consider anti-IL1 drugs for both flare management and prophylaxis under specialist guidance," he added.

Dr Luay Zebouni, MBBS, consultant rheumatologist at Epsom and St Helier University Hospitals NHS Trust, also remarked on the new guideline. "There are no trials comparing urate levels of 360 versus 300 µmol/L, but we know from real life that the lower the urate in these patients with gout then the better the outcome," he told Medscape News UK.

Presented at the British Society for Rheumatology (BSR) April 24, 2023.

Dr Jordan declares she was a contributor to the NICE gout guidelines in 2007,2017, and 2022, and a trustee director of the UK Gout Society Charity. Dr Zebouni has declared no conflicts of interest. Dr Abhishek declares institutional research grants from AstraZeneca and Oxford Immunotech, as well as personal fees from UpToDate (royalty), Springer (royalty), Cadilla Pharmaceuticals (lecture fees), NGM Bio (consulting), Limbic (consulting), and personal fees from Inflazome (consulting) unrelated to the work.