Suspected or known gout (adult)
Acute arthritis with suspected gout, or known gout. Adults only; not for pregnancy or children.
All Pathways
RheumatologyManagement
Gout Flare Management (ACR 2020)
Gout Flare Management (ACR 2020): Suspected or known gout (adult) → Active flare now? → Flare: exclude septic arthritis first → Septic arthritis still p...
Pathway Overview
21 steps
Algorithm Steps
21 total
01Start 02Decision Active flare now?
Painful, swollen, hot joint now. Yes: flare steps first. No: go to long-term management.
- If Yes
03Warning Flare: exclude septic arthritis first
Septic arthritis can look like gout. Check before any steroid.
- Aspirate the joint (Gram stain, culture, crystals) if first episode, fever, prosthetic joint, IV drug use, immunosuppression or any doubt
- Crystals do not exclude infection: send culture if sepsis is possible
- No intra-articular steroid until sepsis is excluded
04Decision Septic arthritis still possible?
Yes: stop this pathway and manage as septic arthritis. No: treat the gout flare.
- If Yes
05Warning Possible septic arthritis: manage as sepsis
Joint aspiration and culture, blood cultures, urgent orthopaedic review. Do not give steroid. Follow the local septic arthritis pathway.
If No06Warning Sepsis excluded: check contraindications before flare drugs
Choose the flare drug by comorbidity and current medicines.
- Colchicine: avoid with strong CYP3A4 or P-gp inhibitors (clarithromycin, itraconazole, ketoconazole, ritonavir, ciclosporin); contraindicated with them if kidney or liver impairment. Verapamil or diltiazem: reduce or pause colchicine
- Colchicine: do not use in severe kidney or liver impairment, or combined kidney and liver disease (never if CrCl 10 mL/min or less), blood dyscrasia or serious GI or cardiac disease
- NSAIDs: avoid in severe CKD, with an ACE inhibitor or ARB plus a diuretic (kidney injury), peptic ulcer or GI bleeding, heart failure, or with anticoagulants
07Action Treat the flare early: colchicine, NSAID or glucocorticoid
ACR 2020 strong recommendation. Choose one by patient factors. Adults.
- Colchicine (500 microgram tablets): 1 mg, then 500 micrograms 1 hour later. Maximum 1.5 mg per course. Do not repeat within 3 days. US (0.6 mg tablets): 1.2 mg, then 0.6 mg 1 hour later
- Colchicine: stop if diarrhoea or vomiting. CrCl 50 mL/min or less: halve the dose. Older people under 50 kg: prefer another drug
- NSAID at full dose (for example naproxen or indomethacin) until the flare settles
- Prednisolone 30-35 mg orally once daily for 5 days (caution in diabetes)
- One accessible joint: intra-articular steroid. Nil by mouth: IM or IV glucocorticoid
- Add ice. All options unsuitable or failed: rheumatology advice (IL-1 inhibitor)
- Do not stop current allopurinol or low-dose aspirin during a flare
08Action Lifestyle and other medicines (all patients)
ACR 2020 conditional recommendations.
- Limit alcohol, purine-rich food and high-fructose drinks
- Weight loss if overweight
- Hydrochlorothiazide: switch to another antihypertensive if feasible; losartan preferred
- Do not stop low-dose aspirin taken for a valid reason
- Vitamin C supplements are not recommended
09Decision Indication for urate-lowering therapy (ULT)?
Strong: 1 or more tophi, gout damage on imaging, or 2 or more flares a year. Conditional: more than 1 previous flare but fewer than 2 a year; or first flare with CKD stage 3 or more, urate above 0.54 mmol/L (9 mg/dL), or kidney stones.
- If Yes
10Warning ULT indicated: allopurinol safety checks first
Check these before the first dose.
- Han Chinese, Korean or Thai descent (ACR: also African American): test HLA-B*5801 first. Positive: do not start allopurinol unless no other option
- Azathioprine or mercaptopurine: avoid allopurinol and febuxostat; if the combination is essential, specialist dose reduction and blood count monitoring
- Previous allopurinol rash or reaction: do not restart. Stop allopurinol at the first rash: hypersensitivity syndrome, DRESS and SJS/TEN can be fatal
11Action Start allopurinol at a low dose
Allopurinol is first-line for all, including CKD stage 3 or more (ACR strong). ACR: it can start during a flare (conditional); Australian PIs advise waiting until the flare settles.
- Allopurinol: start 100 mg daily or less; start lower in CKD stage 3 or more
- Febuxostat if allopurinol is not suitable: start 40 mg once daily (half an 80 mg tablet). Not recommended in established major cardiovascular disease (boxed warning). Previous allopurinol reaction: use with caution and monitor closely in the first month
- Always give flare prophylaxis with ULT (next step)
- Continue ULT long term (conditional)
12Action Flare prophylaxis for 3-6 months with ULT
ACR 2020 strong recommendation. Continue longer if flares continue.
- Colchicine 500 micrograms once or twice daily (0.5-1 mg/day); reduce in kidney impairment; not in severe kidney or liver impairment or combined kidney and liver disease; check interactions
- Or low-dose NSAID if no contraindication
- Or low-dose prednisolone if colchicine and NSAIDs are unsuitable
13Action Treat to target: serum urate below 0.36 mmol/L (6 mg/dL)
ACR 2020 strong recommendation: titrate the dose by serum urate, not a fixed dose.
- Check serum urate after each dose change; titrate over weeks to months
- Allopurinol: increase by 100 mg every 2-4 weeks until at target; smaller steps in CKD
- Doses above 300 mg daily are often needed (Australian PI maximum 900 mg daily)
- Febuxostat: 80 mg once daily if urate above target after 2-4 weeks (maximum 80 mg; 40 mg in severe kidney impairment)
- Tophi or severe gout: EULAR uses a lower target below 0.30 mmol/L (5 mg/dL)
14Decision At target and flares controlled?
Yes: continue ULT. No: check adherence and dose, then second-line options.
- If Yes
15Outcome Gout controlled: continue ULT long term
Serum urate below 0.36 mmol/L, no flares. Keep checking serum urate and kidney function.
If No16Action Not at target: check adherence, then second-line ULT
For patients not at target on a titrated xanthine oxidase inhibitor (XOI).
- Check adherence and that the XOI dose was titrated to the maximum tolerated dose
- Switch to the other XOI (conditional; preferred to adding a uricosuric)
- Or add probenecid (250 mg twice daily for 1 week, then 500 mg twice daily). Not in CKD stage 3 or more, uric acid stones, or with aspirin at any dose
- Febuxostat: not in established major cardiovascular disease. Previous allopurinol reaction: monitor closely in the first month
17Decision Still 2 or more flares a year or tophi despite oral ULT?
Yes: refer to rheumatology. No: continue best oral ULT (ACR: no pegloticase for infrequent flares without tophi).
- If Yes
18Warning Refractory gout: pegloticase is specialist only
Pegloticase is not registered in Australia. Stop oral ULT before starting. Give with weekly oral methotrexate, started at least 4 weeks before, unless contraindicated.
- Test G6PD first: contraindicated in G6PD deficiency (haemolysis, methaemoglobinaemia)
- Anaphylaxis and infusion reactions: premedicate; give only where anaphylaxis can be treated
- Check urate before each infusion; stop if above 6 mg/dL (0.36 mmol/L), especially 2 levels in a row
19Warning Rheumatology referral
Refractory or tophaceous gout, pegloticase or IL-1 inhibitor candidate, diagnostic doubt, or no suitable ULT.
If No20Outcome Infrequent flares, no tophi: continue best oral ULT
Keep titrating to target and review. Pegloticase is not recommended for this group (ACR strong).
If No21Outcome No ULT indication now: flare plan and review
Give a flare plan. Discuss ULT if another flare occurs. Start ULT if flares become frequent (2 or more a year) or tophi or joint damage appear.
If No- Path rejoins step 08Shared 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
- Adults only: not for children, pregnancy or breastfeeding
- Does not diagnose gout: confirm crystals and exclude septic arthritis
- Pegloticase is not registered in Australia; IL-1 inhibitors need rheumatology advice
- Kidney and liver dosing is summarised only: check the product information
- Does not cover gout in transplant recipients
Contraindicated Populations
pediatricpregnancybreastfeeding
Applicable Regions
USEUAU
AU: Colchicine tablets are 500 micrograms. Labs report urate in mmol/L (0.36 mmol/L = 6 mg/dL). Pegloticase is not on the ARTG.
EU: EULAR 2016: urate target below 0.36 mmol/L; below 0.30 mmol/L in severe gout.
US: ACR 2020 is primary guidance. Colchicine flare dose 1.2 mg, then 0.6 mg 1 hour later.
Version 2Next review: 2027-09-30
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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: Adults only: not for children, pregnancy or breastfeeding; Does not diagnose gout: confirm crystals and exclude septic arthritis; Pegloticase is not registered in Australia; IL-1 inhibitors need rheumatology advice; Kidney and liver dosing is summarised only: check the product information; Does not cover gout in transplant recipients. Individual patient factors may require deviation from these recommendations.
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