Suspected or Confirmed Gout
Patient presents with acute monoarticular arthritis or known gout history
All Pathways
RheumatologyManagement
Gout Flare Management (ACR 2020)
Gout Flare Management (ACR 2020): Suspected or Confirmed Gout → Active Acute Flare? → Treat Acute Flare → ⚠️ Consider Contraindications → ULT Indication...
Pathway Overview
14 steps
Algorithm Steps
14 total
01Start 02Decision Active Acute Flare?
Is the patient experiencing an acute gout flare with joint pain, swelling, erythema?
03Action 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
04Warning ⚠️ 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
05Decision 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
06Action 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
07Action 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
08Action 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)
09Decision Refractory to Standard ULT?
Failed to achieve target despite maximal allopurinol/febuxostat?
10Outcome Gout Controlled
Serum urate at target, flare-free, tophi resolving
11Action 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
12Warning ⚠️ 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
13Warning Rheumatology Referral
Complex/refractory gout, pegloticase candidate, diagnostic uncertainty
- Path rejoins step 10Shared downstream outcome
14Action 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
- Path rejoins step 10Shared downstream outcome
- Path rejoins step 05Shared downstream outcome
Guideline Source
2020 American College of Rheumatology Guideline for the Management of Gout
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Does not address pediatric gout (rare)
- Pegloticase candidacy requires specialist assessment
- CKD dosing adjustments may require nephrology input
- Drug interactions not comprehensively addressed
- Does not cover gout in transplant recipients
Contraindicated Populations
pediatricpregnancy
Applicable Regions
USEUAU
AU: ARA endorses ACR recommendations
EU: EULAR 2016 also available - similar recommendations
US: ACR 2020 is primary guidance
Version 1Next review: 2028-01-01
Next steps
Finish the workflow by opening the most relevant calculator, then convert the session into a live account when you are ready.
Related Resources
Frequently Asked Questions
What is the Gout Flare Management (ACR 2020)?
The Gout Flare Management (ACR 2020) is a management clinical algorithm for Rheumatology. It provides a structured decision tree to guide clinical decision-making, based on 2020 American College of Rheumatology Guideline for the Management of Gout.
What guideline is the Gout Flare Management (ACR 2020) based on?
This algorithm is based on 2020 American College of Rheumatology Guideline for the Management of Gout (DOI: 10.1002/acr.24180).
What are the limitations of the Gout Flare Management (ACR 2020)?
Known limitations include: Does not address pediatric gout (rare); Pegloticase candidacy requires specialist assessment; CKD dosing adjustments may require nephrology input; Drug interactions not comprehensively addressed; Does not cover gout in transplant recipients. Individual patient factors may require deviation from these recommendations.
Get AI-Powered Analysis Alongside This Algorithm
In AttendMe.ai, the Gout Flare Management (ACR 2020) appears automatically when your clinical question matches — alongside evidence from 3M+ peer-reviewed articles.
Try AttendMe Free