Gout · House

Red Flags

Acute hot swollen joint with fever or prosthesis — exclude septic arthritis (joint aspiration); empirical antibiotic until ruled out^[1]
Tophaceous deposits with skin breakdown or compressive neuropathy — surgical referral^[1]
Severe drug reaction on allopurinol — stop drug, dermatology; HLA-B*5801 association in Han Chinese, Korean, Thai, South Asian^[1]
CKD or recurrent uric acid stones with hyperuricaemia — joint nephrology and rheumatology^[1]

First-line treatment

Interventions

Acute attack — early treatment^[1]
Treat at first symptoms with low-dose colchicine, NSAID, or corticosteroid; combination therapy for severe or polyarticular attack; do not stop urate-lowering therapy during a flare
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 foods (red meat, organ meats, seafood), alcohol (especially beer), sugar-sweetened beverages; weight reduction; adequate hydration; moderate dairy and coffee may be protective
Comorbidity management^[1]
Treat hypertension preferentially with losartan; SGLT2 inhibitors lower urate; review aspirin and diuretic role; address CKD and metabolic syndrome

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Colchicine (low-dose)^[1]	Microtubule inhibitor / anti-inflammatory	Acute: 1.0 mg PO at first symptom, then 0.5 mg 1 hour later; subsequent days 0.5 mg BD until resolution. Prophylaxis: 0.5 mg PO BD for 3–6 months at start of urate-lowering therapy	—	Renal and hepatic dose adjustment; avoid with strong CYP3A4 inhibitors; 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; 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
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 recommended before initiation in South Asian populations; renal dose adjustment
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 — caution in cardiovascular disease; LFT monitoring

Colchicine (low-dose)^[1]

Microtubule inhibitor / anti-inflammatory

Adult: Acute: 1.0 mg PO at first symptom, then 0.5 mg 1 hour later; subsequent days 0.5 mg BD until resolution. Prophylaxis: 0.5 mg PO BD for 3–6 months at start of urate-lowering therapy
Paediatric: —

Renal and hepatic dose adjustment; avoid with strong CYP3A4 inhibitors; 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; 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

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 recommended before initiation in South Asian populations; renal dose adjustment

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 — caution in cardiovascular disease; LFT monitoring

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^[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 suspicionEmergency department / orthopaedics^[1]
Refractory or tophaceous gout failing oral urate-lowering therapyRheumatology^[1]
Allopurinol-induced severe cutaneous adverse reaction or drug intoleranceDermatology and rheumatology^[1]
Gout with CKD G4–G5 or recurrent uric acid kidney stonesJoint rheumatology and nephrology^[1]

Clinical summary

Diagnosis, acute attack management, and treat-to-target urate-lowering therapy for adults with gout per Indian Rheumatology Association guidance.

References

1.Indian Rheumatology Association Guidelines for Gout Management (2022) (2022)