2020 recommendations from the French Society of Rheumatology for the management of gout: Urate-lowering therapy

•These first French recommendations aim at improving urate-lowering therapy (ULT) prescription as ULT, although being the only treatment able make gout symptoms disappear, is largely under prescribed to gout patients.•All patients with a definite diagnosis of gout should be given urate-lowering therapy.•The serum urate target should be below 300μmol/l for all gout patients.•Patient education is of outmost importance to improve long-term adherence to ULTs.•The choice of the first urate-lowering treatment relies on the assessment of the glomerular filtration rate.•ULT-induced flare prophylaxis includes low dose colchicine and progressive increase of ULT doses. To develop French Society of Rheumatology-endorsed recommendations for the management of urate-lowering therapy (ULT). Evidence-based recommendations were developed by 9 rheumatologists (academic or community-based), 3 general practitioners, 1 cardiologist, 1 nephrologist and 1 patient, using a systematic literature search, one physical meeting to draft recommendations and two Delphi rounds to finalize them. A set of 3 overarching principles and 5 recommendations was elaborated. The overarching principles emphasize the importance of patient education, especially the need for explaining the objective of lowering serum urate (SU) level to obtain crystal dissolution, clinical symptoms disappearance and avoidance of complications. ULT is indicated as soon as the diagnosis of gout is established. SU level must be decreased below 300μmol/l (50mg/l) in all gout patients or at least below 360μmol/l (60ml/l) when the 300μmol/l target cannot be reached, and must be maintained at these targets and monitored life-long. The choice of the ULT primarily relies on renal function: in patients whose estimated glomerular filtration rate (eGFR) is above 60ml/min/1.73m2, first-line ULT is allopurinol; in those with eGFR between 30 and 60ml/min/1.73m2, allopurinol use must be cautious and febuxostat can be considered as an alternative; and in those whose eGFR is below 30ml/min/1.73m2, allopurinol must be avoided and febuxostat should be preferred. Prophylaxis of ULT-induced gout flares involves progressive increase of ULT dosage and low-dose colchicine for at least 6 months. Cardiovascular risk factors and diseases, the metabolic syndrome and chronic kidney disease must be screened and managed. These recommendations aim to provide simple and clear guidance for the management of ULT in France.