Table 2.
Recommendations for choice of initial urate-lowering therapy (ULT) in patients with gout*
| Recommendation | PICO question | Certainty of evidence |
|---|---|---|
| For patients starting any ULT, we strongly recommend allopurinol over all other ULT as the preferred first-line agent for all patients, including in those with CKD stage ≥3. | 10 | Moderate |
| We strongly recommend a xanthine oxidase inhibitor over probenecid for those with CKD stage ≥3. | ||
| For allopurinol and febuxostat, we strongly recommend starting at a low dose with subsequent dose titration to target over starting at a higher dose (e.g., ≤100 mg/day [and lower in patients with CKD] for allopurinol or ≤40 mg/day for febuxostat). | 7 | Moderate |
| For probenecid, we conditionally recommend starting at a low dose (500 mg once or twice daily) with dose titration over starting at a higher dose. | ||
| We strongly recommend initiating concomitant antiinflammatory prophylaxis therapy (e.g., colchicine, NSAIDs, prednisone/prednisolone) over no antiinflammatory prophylaxis. The choice of specific antiinflammatory prophylaxis should be based upon patient factors. |
9 | Moderate |
| We strongly recommend continuing prophylaxis for 3–6 months rather than <3 months, with ongoing evaluation and continued prophylaxis as needed if the patient continues to experience flares. | 9 | Moderate |
| When the decision is made that ULT is indicated while the patient is experiencing a gout flare, we conditionally recommend starting ULT during the gout flare over starting ULT after the gout flare has resolved. | 6 | Moderate |
| We strongly recommend against pegloticase as first-line therapy.. | 10 | Moderate† |
|
| ||
| Strongly recommend Conditionally recommend Strongly recommend against Conditionally recommend against | ||
*
PICO = population, intervention, comparator, outcomes; CKD = chronic kidney disease; NSAIDs = nonsteroidal antiinflammatory drugs.
†
Moderate evidence is in support of the efficacy of pegloticase, but due to cost, safety concerns, and favorable benefit-to-harm ratios of other untried treatment options, the recommendation is against using pegloticase as first-line agent.