ACR Updates Guideline for Gout Treatment With a Focus on ULT

The American College of Rheumatology (ACR) has updated its 2012 guideline on the treatment of gout, which includes 16 strong recommendations that focus on urate-lowering therapy (ULT).

The use of ULT among patients with gout has not increased over the past 20 years, despite recommendations from ACR and other specialty societies. Efforts to improve adherence to the treat-to-target recommendations for this therapy may have been complicated by criticism of the 2012 ACR guideline for a low quality of evidence to support the use of ULT. As clinical trials revealed further evidence about the efficacy of ULT and other treatments, the ACR guideline writing panel developed a new guideline for managing gout.

The new guideline provides 42 recommendations overall. The recommendations include, but are not limited to:

  • Initiation of ULT is strongly recommended for patients with gout who fit any of the following criteria: those with one or more subcutaneous tophi; those with evidence of radiographic damage that can be attributed to gout; or those with frequent gout fares, defined as more than 2 per year.
  • ULT is conditionally recommended for patients with gout who have had a previous flare but have had fewer than 2 flares annually.
  • ULT is conditionally recommended for patients with comorbid moderate to severe (stage 3 or higher) kidney disease, serum urate concentrations of more than 9 mg/dl, or urolithiasis.


The ACR panel gave a strong recommendation to allopurinol as the preferred first-line ULT. They also strongly recommend initiating prophylactic anti-inflammatory therapy plus ULT over not using anti-inflammatory drugs.

“Gout has been characterized as a ‘curable disease,’” the panel concluded. “As data continue to emerge supporting best practices in management, implementation of these recommendations will ideally lead to improved quality of care for patients with gout”

—Rebecca Mashaw



FitzGerald JD, Dalbeth N, Mikuls T, et al. 2020 American College of Rheumatology guideline for the management of gout. Published online May 11, 2020. Arthritis Care Res.