Timing of Initiation of Urate / Uric Acid Lowering Therapy (ULT)

Time of Initiation	Reference
Key Recommendation: When the decision is made that ULT is indicated while the patient is experiencing a gout flare, starting ULT during the gout flare over starting ULT after the gout flare has resolved is conditionally recommended.  Starting ULT during a flare has conceptual benefits, * including the time efficiency offered by initiating therapy during the concurrent flare visit rather than risking the patient not returning for ULT initiation. *input from the Patient Panel emphasized that patients are likely to be highly motivated to take ULT due to the symptoms related to the current flare.  However, concerns about starting ULT during a flare include, *potential extension or worsening of a flare * possibility of information overload for patients, which may lead to conflating flare management and long-term ULT  Two small RCTs and an observational study support the hypothesis that starting ULT during a flare does not significantly extend flare duration or severity.  Input from the Patient Panel, citing their own ability to simultaneously process information related to flare treatment and ULT initiation together, along with their preference to start on a treatment path sooner to prevent future flares, influenced the final recommendation.  As with all conditional recommendations, there may be patient factors or preferences that would reasonably support the alternative of delaying ULT initiation until the flare has resolved.	American College of Rheumatology , 2020
Key Recommendation: Commencement of ULT is best delayed until inflammation has settled as ULT is better discussed when the patient is not in pain.   Although a small RCT has shown that commencement of allopurinol during an acute attack was not associated with a significant increase in daily pain, recurrent flares or inflammatory markers, the working group thought that postponing detailed discussion of long term ULT until a time when the patient was no longer in pain would allow the information to be better absorbed. However, in patients in whom attacks are so frequent to make this difficult, the findings of this trial support initiation of ULT before inflammation has resolved.	British Society for Rheumatology , 2017
Key Recommendation : Allopurinol can be initiated during an acute flare of gout; there is little evidence supporting delaying treatment until the flare has settled.  Traditionally, initiation of urate-lowering treatment has been delayed until the pain of a flare has resolved. The rationale being that dispersion of urate crystals during the initiation phase of treatment may make the patient’s pain worse.  However, there is little evidence to support this delay and two randomised controlled trials have found no increase in pain, flares or markers of inflammation when allopurinol was initiated during a flare, compared to waiting ten days.	BPACNZ, 2018
Allopurinol should not be started until the acute attack has settled. However, if patient has been on long term allopurinol, the drug should not be stopped	CPG Malaysia Gout, 2008

 

Reference

1)      American College of Rheumatology Guideline for the Management of Gout 2020 Retrieved from https://www.rheumatology.org/Portals/0/Files/Gout-Guideline-Early-View-2020.pdf

2)      The British Society for Rheumatology Guideline for the Management of Gout 2017  Retrieved from https://academic.oup.com/rheumatology/article/56/7/e1/3855179

3)      Managing Gout, BPACNZ, 2018 Retrieved from  https://bpac.org.nz/2018/docs/gout-part1.pdf

4)      Clinical Practice Guideline Malaysia: Gout, 2008

Prepared by Nabiha @ 22.08.2020