What are the guidelines for managing gout?

Gout Management Guidelines

Initiation of Urate-Lowering Therapy (ULT)

Start lifelong urate-lowering therapy immediately for any patient with tophaceous gout, radiographic damage from gout, or frequent flares (≥2 per year), with allopurinol as the first-line agent regardless of kidney function. 1, 2

Additional indications for ULT include: 1

• Chronic kidney disease stage ≥2
• History of urolithiasis
• Chronic tophaceous gouty arthropathy with persistent joint symptoms

First-Line ULT: Allopurinol Dosing Strategy

Allopurinol is the preferred first-line agent, including for patients with moderate-to-severe chronic kidney disease (stage ≥3). 1, 2, 3

Start low and titrate to target: 1, 3, 4

• Initial dose: ≤100 mg/day (lower in CKD)
• Titrate upward by 100 mg every 2-5 weeks based on serum urate measurements
• Maximum dose: 800 mg/day in patients with normal renal function 5, 4
• For CrCl 10-20 mL/min: maximum 200 mg/day 4
• For CrCl <10 mL/min: maximum 100 mg/day 4

Target serum urate: <6 mg/dL for all patients, maintained lifelong. 1, 2, 3 For erosive arthropathy or extensive tophaceous disease, consider a more intensive target of <5 mg/dL to accelerate crystal dissolution. 5

Mandatory Anti-Inflammatory Prophylaxis

When initiating any ULT, concomitant anti-inflammatory prophylaxis for at least 3-6 months is strongly recommended to prevent mobilization flares. 1, 2, 3

Prophylaxis options: 2, 3

• Colchicine 0.5-0.6 mg once or twice daily (preferred agent)
• Low-dose NSAIDs with gastroprotection
• Low-dose prednisone/prednisolone (5-10 mg/day)

Dose adjustment for colchicine: reduce to 0.5 mg daily or every other day if CrCl 30-50 mL/min. 2

Acute Gout Flare Management

For acute flares, start treatment immediately—within 12-24 hours of symptom onset—with oral colchicine, NSAIDs, or glucocorticoids as first-line therapy. 1, 2, 3 Speed of initiation matters more than agent selection. 3

First-Line Options (choose based on patient factors and contraindications):

Colchicine (low-dose regimen): 1, 2

• 1.2 mg immediately, followed by 0.6 mg one hour later (total 1.8 mg)
• Continue 0.6 mg once or twice daily until flare resolves
• Most effective when started within 12 hours of onset 2

NSAIDs at full anti-inflammatory doses: 1, 3

• Add proton pump inhibitor for gastroprotection if appropriate 2
• Continue until flare resolves

Glucocorticoids: 1, 3

• Oral: prednisone 30-40 mg daily for 3-5 days 1, 2, 3
• Intraarticular injection (if single accessible joint) 3
• Intramuscular or intravenous (if NPO) 1

Second-Line Options:

IL-1 inhibitors (canakinumab) are conditionally recommended only when colchicine, NSAIDs, and glucocorticoids are all contraindicated or poorly tolerated. 1 Cost and access are significant barriers. 1

Topical ice may be used as adjuvant therapy. 1

Critical Management Principles During ULT Initiation

Continue existing ULT during acute flares—never stop or start ULT during an active flare. 3, 5 Treat the flare with anti-inflammatory agents while maintaining steady-state urate lowering. 3, 5

Monitor serum urate every 2-4 weeks during dose titration until target is achieved, then every 6 months on maintenance therapy. 5

Alternative ULT Agents

If allopurinol target not achieved at maximum tolerated dose or if allopurinol is not tolerated: 5

• Febuxostat (start ≤40 mg/day, titrate to 80-120 mg/day) 1
• Uricosuric agents (probenecid, avoid in CKD or history of kidney stones) 1, 5
• Pegloticase (for refractory tophaceous gout; requires specialized monitoring) 6

Lifestyle Modifications (Conditional Recommendations)

All patients with gout should receive counseling on: 1, 2

• Weight loss if overweight/obese 1, 2
• Limit alcohol intake, especially beer and spirits 1, 2
• Avoid high-fructose corn syrup and sugar-sweetened beverages 1, 2
• Limit purine-rich foods: organ meats, shellfish, excessive red meat 1, 2
• Encourage low-fat dairy products and regular exercise 2, 5

Medication Adjustments for Comorbidities

Substitute diuretics if possible (thiazide and loop diuretics increase uric acid). 1, 5 Consider: 2, 5

• Losartan (modest uricosuric effect) for hypertension
• Calcium channel blockers for hypertension
• Fenofibrate (uricosuric properties) for hyperlipidemia

Common Pitfalls to Avoid

Never use high-dose colchicine regimens (>1.8 mg in first hour)—severe GI toxicity without added benefit. 3

Never start allopurinol at high doses—this triggers flares and reduces adherence. 3

Never forget prophylaxis when initiating ULT—this is the most common cause of treatment failure. 3

Never delay acute flare treatment beyond 24 hours—early intervention is critical for efficacy. 2

Never discontinue ULT during acute flares—maintain steady urate lowering and treat inflammation separately. 3, 5

Never treat asymptomatic hyperuricemia without gout—no evidence supports this approach. 3