Gout Management Guidelines

Acute Gout Attack Management

The American College of Rheumatology recommends corticosteroids as first-line therapy in patients without contraindications due to their safety profile and cost-effectiveness 1
The European League Against Rheumatism suggests NSAIDs at full anti-inflammatory doses are effective when started promptly 2, 3
Low-dose colchicine (1.2 mg followed by 0.6 mg one hour later) is most effective when started within 12 hours of symptom onset, according to the American College of Rheumatology 2, 3
Oral prednisone is recommended at 30-35 mg/day for 3-5 days or 0.5 mg/kg per day for 5-10 days, as suggested by the American College of Rheumatology 3, 4
NSAIDs should be avoided in patients with renal disease, heart failure, or cirrhosis, as recommended by the American College of Physicians 1

The American College of Rheumatology recommends initiating urate-lowering therapy (ULT) after multiple attacks or after development of tophi or urate nephrolithiasis 5, 6
Xanthine oxidase inhibitors (allopurinol or febuxostat) are first-line options for ULT, as suggested by the European League Against Rheumatism 5, 7
Allopurinol starting dose should be no greater than 100 mg/day (50 mg/day in stage 4 or worse CKD), according to the American College of Rheumatology 5, 6
The target serum urate level should be below 6 mg/dL (357 μmol/L), as recommended by the European League Against Rheumatism 2

Anti-inflammatory prophylaxis should be initiated with or just before starting ULT, as suggested by the American College of Rheumatology 3, 7
Low-dose colchicine (0.6 mg once or twice daily, adjusted for renal function) is recommended as first-line prophylaxis, according to the American College of Rheumatology 3, 7
Prophylaxis should be continued for the greater of six months duration or three months after achieving target serum urate for patients without tophi, as recommended by the American College of Rheumatology 3, 7

Weight loss is recommended for obese patients, as suggested by the American Heart Association 7
Avoiding alcohol (especially beer and spirits) and sugar-sweetened drinks is recommended, according to the European League Against Rheumatism 2

For polyarticular joint involvement, combination therapy may be appropriate, as recommended by the American College of Rheumatology 8
For severe/polyarticular attacks, consider combination therapy or intra-articular injections for accessible joints, according to the American College of Rheumatology 8
For mild-moderate attacks (1-2 joints), choose one of: NSAIDs, low-dose colchicine, or oral corticosteroids, as suggested by the American College of Physicians 9

Prophylaxis should be continued for the greater of six months duration or three months after achieving target serum urate for patients without tophi, as recommended by the American College of Rheumatology 8
For patients with tophi, prophylaxis should continue for six months after achieving target serum urate and resolution of tophi, according to the American College of Rheumatology 8

The American College of Rheumatology recommends initiating treatment within 24 hours with NSAIDs, low-dose colchicine, or corticosteroids as first-line monotherapy options, selecting based on comorbidities and contraindications 10
NSAIDs at full anti-inflammatory doses are appropriate first-line therapy when started promptly, but should be avoided in patients with chronic kidney disease, congestive heart failure, peptic ulcer disease, or cirrhosis 10, 11, 12
Low-dose oral colchicine is most effective when started within 12 hours of symptom onset, but can be used up to 36 hours, and the dose should be adjusted for renal impairment 10, 11
Oral corticosteroids, such as prednisone, can be used as first-line therapy, but should be avoided in patients with diabetes, active infection, or high infection risk 11, 12
Intra-articular corticosteroid injection is an option for 1-2 accessible affected joints, with the dose depending on joint size 12

The American College of Rheumatology recommends initiating ULT in patients with recurrent attacks, tophi, chronic gouty arthropathy, radiographic changes of gout, or history of nephrolithiasis, with a target serum urate level of <6 mg/dL 10
Low-dose colchicine, at 0.5-0.6 mg once or twice daily, is a first-line option for anti-inflammatory prophylaxis during ULT initiation, with adjustments for renal impairment and drug interactions 11, 12
Low-dose NSAIDs, such as naproxen, can be used as an alternative for anti-inflammatory prophylaxis, with a proton pump inhibitor if indicated 11, 12
Low-dose prednisone, at ≤10 mg/day, can be used for patients with contraindications to both colchicine and NSAIDs 11