Gout Flare Management (ACR 2020)

Algorithm Steps

1. ▶

   Start

   Suspected or Confirmed Gout

   Patient presents with acute monoarticular arthritis or known gout history

   1. ◆

      Decision

      Active Acute Flare?

      Is the patient experiencing an acute gout flare with joint pain, swelling, erythema?

      1. ●

         Action

         Treat Acute Flare

         First-line options (Strong recommendation)

         • Colchicine (LOW-DOSE preferred): 1.2mg then 0.6mg 1hr later
         • NSAIDs: Full-dose naproxen or indomethacin
         • Glucocorticoids: Oral prednisone 0.5mg/kg/day x5-7d
         • Intra-articular steroid if single joint accessible
         • Combination therapy for severe polyarticular flares
         1. ⚠

            Warning

            ⚠️ Consider Contraindications

            Modify treatment based on comorbidities

            • CKD/GI disease: Avoid NSAIDs
            • CKD: Reduce colchicine dose or avoid
            • Diabetes/infection risk: Caution with steroids
            • Drug interactions: Check statins with colchicine
            1. ◆

               Decision

               ULT Indication Present?

               Strong recommendation for ULT if ANY present:

               • Tophaceous gout
               • Radiographic damage from gout
               • Frequent flares (≥2/year)
               • CKD stage ≥3
               • Urolithiasis history
               1. ●

                  Action

                  Initiate Urate-Lowering Therapy

                  Start during or after flare resolution (Strong)

                  • Allopurinol PREFERRED first-line (even in CKD)
                  • Start LOW: ≤100mg/day (lower if eGFR <30)
                  • Febuxostat: <40mg/day start (if allopurinol contraindicated)
                  • Titrate dose based on serum urate
                  • Target: Serum urate <6 mg/dL
                  1. ●

                     Action

                     Flare Prophylaxis During ULT

                     Continue for 3-6 months minimum (Strong)

                     • Low-dose colchicine 0.6mg daily or BID
                     • OR low-dose NSAID (if tolerated)
                     • OR low-dose prednisone ≤10mg/day
                     • Longer duration if tophi present
                     • Continue until tophi resolved + flare-free
                     1. ●

                        Action

                        Treat-to-Target Strategy

                        Titrate ULT dose guided by serum urate (Strong)

                        • Check serum urate every 2-4 weeks during titration
                        • Increase allopurinol by 100mg increments
                        • Target: Serum urate <6 mg/dL
                        • Lower target (<5 mg/dL) may help dissolve tophi faster
                        • Allopurinol doses >300mg may be needed (up to 800mg)
                        1. ◆

                           Decision

                           Refractory to Standard ULT?

                           Failed to achieve target despite maximal allopurinol/febuxostat?

                           1. ✓

                              Outcome

                              Gout Controlled

                              Serum urate at target, flare-free, tophi resolving

                           2. ●

                              Action

                              Second-Line ULT Options

                              For patients not at target on xanthine oxidase inhibitors

                              • Switch XOI (allopurinol ↔ febuxostat)
                              • Add uricosuric (probenecid) if eGFR >50
                              • Combination XOI + uricosuric
                              • Consider pegloticase for severe tophaceous gout refractory to oral ULT
                              1. ⚠

                                 Warning

                                 ⚠️ Pegloticase Considerations

                                 Reserved for refractory tophaceous gout

                                 • Discontinue other ULT before starting
                                 • Risk of infusion reactions and anaphylaxis
                                 • Monitor uric acid before each infusion
                                 • Stop if serum urate >6 mg/dL (antibodies)
                                 • Consider immunomodulator co-therapy
                                 1. ⚠

                                    Warning

                                    Rheumatology Referral

                                    Complex/refractory gout, pegloticase candidate, diagnostic uncertainty

               2. ●

                  Action

                  Lifestyle Modifications

                  Conditional recommendation for all gout patients

                  • Limit alcohol (especially beer)
                  • Limit high-purine foods
                  • Limit high-fructose corn syrup
                  • Weight loss if obese
                  • Adequate hydration