Table 5.

When to consider switching to a new urate-lowering therapy (ULT) strategy^*

Recommendation	PICO question	Certainty of evidence
For patients with gout taking their first XOI monotherapy at maximum-tolerated or FDA-indicated dose who are not at SU target and/or have continued frequent gout flares or nonresolving subcutaneous tophi, we conditionally recommend switching the first XOI to an alternate XOI agent over adding a uricosuric agent.	24	Very low
For patients with gout where XOI, uricosurics, and other interventions have failed to achieve SU target and who have frequent gout flares or nonresolving subcutaneous tophi, we strongly recommend switching to pegloticase over continuing current ULT.†	27	Moderate
For patients with gout for whom XOI, uricosurics, and other interventions have failed to achieve serum urate target and who have infrequent gout flares (<2 flares/year) and no tophi, we strongly recommend against switching to pegloticase over continuing current ULT.‡	27	Moderate
Strongly recommend Conditionally recommend Strongly recommend against Conditionally recommend against

^*PICO = population, intervention, comparator, outcomes; XOI = xanthine oxidase inhibitor; FDA = Food and Drug Administration.

^†There is moderate certainty of evidence about the efficacy of the benefits, harms, and high certainty about the costs of pegloticase. For patients with high disease activity, the magnitude of potential benefits outweighs the harms and costs of the drug.

^‡For patients with minimal disease activity, the smaller potential benefits do not outweigh the harms and costs of the drug.