Gout · House

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.

References

1.American College of Rheumatology Guideline for the Management of Gout (2020); EULAR 2017 (still active); BSR 2017 (2020)