Red Flags
- Acute hot swollen joint with fever, prior prosthesis, or rapid worsening — exclude septic arthritis (joint aspiration with Gram stain, culture); empirical antibiotic until ruled out[1]
- Tophaceous deposits with skin breakdown, secondary infection, or compressive neuropathy — surgical / multidisciplinary referral[1]
- Tumour lysis syndrome or chronic kidney disease with hyperuricaemia — nephrology and oncology; rasburicase for prevention/treatment[1]
- Severe drug reaction on allopurinol (SCAR/SJS) — stop drug, supportive care, dermatology; HLA-B*5801 association in Han Chinese, Korean, Thai, South Asian[1]
First-line treatment
Interventions
- Acute attack — early treatment[1]Treat at first symptoms; the earlier started, the more effective; combination therapy in severe or polyarticular attack
- Treat-to-target urate-lowering therapy[1]Indications: ≥2 attacks/year, tophaceous deposits, radiographic damage, gouty nephropathy. Target serum urate <6.0 mg/dL (<5.0 in tophaceous or severe). Continue indefinitely
- Lifestyle and dietary measures[1]Reduce purine-rich red meat, organ meats, seafood, alcohol (especially beer), sugar-sweetened beverages; weight reduction; moderate dairy and coffee may protect; address sleep apnoea
- Comorbidity management[1]Treat hypertension preferentially with losartan (uricosuric), avoid thiazide and loop diuretics where possible; SGLT2 inhibitors lower urate; statins and metformin neutral; review aspirin role
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Colchicine (acute and prophylaxis)[1] | Microtubule inhibitor / anti-inflammatory | Acute: 1.2 mg PO at first symptom, then 0.6 mg 1 hour later (low-dose protocol); subsequent days 0.6 mg BD until resolution. Prophylaxis: 0.5–0.6 mg PO BD for 3–6 months at start of urate-lowering therapy | — | Renal and hepatic dose adjustment; avoid with strong CYP3A4 inhibitors (clarithromycin, ritonavir); GI side effects common |
| NSAIDs (acute)[1] | Cyclooxygenase inhibitor | Naproxen 500 mg PO BD; indomethacin 50 mg TDS; ibuprofen 800 mg TDS — until 24–48 h after attack resolves | — | First-line acute treatment in non-CKD non-cardiac patients; avoid in CKD, peptic ulcer, severe heart failure, anticoagulation; co-prescribe PPI |
| Glucocorticoid (acute)[1] | Systemic corticosteroid | Prednisolone 30–40 mg PO daily × 5 days then taper; or intra-articular methylprednisolone 40 mg in single joint | — | Useful in CKD, anticoagulation, NSAID/colchicine intolerance; intra-articular if monoarticular and septic arthritis excluded; brief course preferred |
| Allopurinol (urate-lowering)[1] | Xanthine oxidase inhibitor | Start 100 mg PO daily (50 mg if eGFR <60); titrate by 100 mg every 2–4 weeks to target serum urate <6.0; usual 300–600 mg/day, max 800 mg | 10 mg/kg/day | First-line urate-lowering; HLA-B*5801 screen in Han Chinese, Thai, Korean, South Asian; renal dose adjustment; do not stop during acute attack |
| Febuxostat (allopurinol-intolerant)[1] | Non-purine xanthine oxidase inhibitor | 40 mg PO daily start, increase to 80–120 mg if not at target | — | Allopurinol-intolerant or failure; cardiovascular event signal in CARES trial — caution in cardiovascular disease; LFT monitoring |
| Probenecid (uricosuric — selected)[1] | Uricosuric | 250 mg PO BD start, titrate to 500 mg–1 g BD | — | Add-on to xanthine oxidase inhibitor in those still above target with normal renal function and no urolithiasis history; ensure good fluid intake |
| Pegloticase (refractory tophaceous)[1] | Recombinant uricase | 8 mg IV every 2 weeks | — | Refractory tophaceous gout failing oral therapy; immunogenic — anti-drug antibodies; G6PD screen; co-prescribe immunomodulator (methotrexate) to reduce immunogenicity |
Colchicine (acute and prophylaxis)[1]
Microtubule inhibitor / anti-inflammatory
- Adult
- Acute: 1.2 mg PO at first symptom, then 0.6 mg 1 hour later (low-dose protocol); subsequent days 0.6 mg BD until resolution. Prophylaxis: 0.5–0.6 mg PO BD for 3–6 months at start of urate-lowering therapy
- Paediatric
- —
Renal and hepatic dose adjustment; avoid with strong CYP3A4 inhibitors (clarithromycin, ritonavir); GI side effects common
NSAIDs (acute)[1]
Cyclooxygenase inhibitor
- Adult
- Naproxen 500 mg PO BD; indomethacin 50 mg TDS; ibuprofen 800 mg TDS — until 24–48 h after attack resolves
- Paediatric
- —
First-line acute treatment in non-CKD non-cardiac patients; avoid in CKD, peptic ulcer, severe heart failure, anticoagulation; co-prescribe PPI
Glucocorticoid (acute)[1]
Systemic corticosteroid
- Adult
- Prednisolone 30–40 mg PO daily × 5 days then taper; or intra-articular methylprednisolone 40 mg in single joint
- Paediatric
- —
Useful in CKD, anticoagulation, NSAID/colchicine intolerance; intra-articular if monoarticular and septic arthritis excluded; brief course preferred
Allopurinol (urate-lowering)[1]
Xanthine oxidase inhibitor
- Adult
- Start 100 mg PO daily (50 mg if eGFR <60); titrate by 100 mg every 2–4 weeks to target serum urate <6.0; usual 300–600 mg/day, max 800 mg
- Paediatric
- 10 mg/kg/day
First-line urate-lowering; HLA-B*5801 screen in Han Chinese, Thai, Korean, South Asian; renal dose adjustment; do not stop during acute attack
Febuxostat (allopurinol-intolerant)[1]
Non-purine xanthine oxidase inhibitor
- Adult
- 40 mg PO daily start, increase to 80–120 mg if not at target
- Paediatric
- —
Allopurinol-intolerant or failure; cardiovascular event signal in CARES trial — caution in cardiovascular disease; LFT monitoring
Probenecid (uricosuric — selected)[1]
Uricosuric
- Adult
- 250 mg PO BD start, titrate to 500 mg–1 g BD
- Paediatric
- —
Add-on to xanthine oxidase inhibitor in those still above target with normal renal function and no urolithiasis history; ensure good fluid intake
Pegloticase (refractory tophaceous)[1]
Recombinant uricase
- Adult
- 8 mg IV every 2 weeks
- Paediatric
- —
Refractory tophaceous gout failing oral therapy; immunogenic — anti-drug antibodies; G6PD screen; co-prescribe immunomodulator (methotrexate) to reduce immunogenicity
Safety-net
- Continue urate-lowering therapy lifelong; do not stop during a flare; treating to target prevents future attacks and tophaceous damage[1]
- Any new rash within 8 weeks of starting allopurinol — stop the drug and seek same-day medical review (severe cutaneous adverse reaction)[1]
- Reduce alcohol (especially beer), sugar-sweetened drinks, and high-purine foods; weight reduction by even 5% can lower urate[1]
Referral criteria
- Septic arthritis suspicion (hot joint with fever, prosthesis, immunosuppression)Emergency department / orthopaedics[1]
- Refractory or tophaceous gout failing oral urate-lowering therapyRheumatology — pegloticase or combination therapy[1]
- Allopurinol-induced severe cutaneous adverse reaction or drug intoleranceDermatology and rheumatology; switch and avoid same agent indefinitely[1]
- Gout with CKD G4–G5 or recurrent uric acid kidney stonesRheumatology and nephrology joint[1]
Clinical summary
Diagnosis, acute attack management, and treat-to-target urate-lowering therapy for adults with gout.