Gout management

ACR2020

Treat-to-target: serum urate goal <6 mg/dL (strong). Allopurinol is preferred first-line ULT for all, including CKD stage 3 or worse; start <=100 mg/day (lower in CKD) and titrate. Strongly start ULT for >=1 subcutaneous tophus, gout-attributable radiographic damage, or >=2 flares/year.

ACR2020

Conditionally start ULT after more than 1 prior flare when flares are infrequent (fewer than 2 per year). After a first flare, ULT is conditionally not recommended unless there is CKD stage 3 or worse, serum urate >9 mg/dL, or urolithiasis. Conditionally recommend against ULT in asymptomatic hyperuricemia. When starting ULT, give anti-inflammatory flare prophylaxis for 3 to 6 months.

ACR2020Grade Strong recommendation

Gout flares: colchicine, an NSAID, or a glucocorticoid (oral, intra-articular, or intramuscular) is first line; if using colchicine, choose low-dose over high-dose. Topical ice is a reasonable adjunct. Starting urate-lowering therapy during a flare is conditionally preferred over waiting when ULT is indicated.

ACR2020Grade Conditional recommendations

Before allopurinol, test for HLA-B*5801 in patients of Southeast Asian descent (for example Han Chinese, Korean, Thai) and African American patients; universal testing is not recommended. For all patients with gout, limit alcohol, purines, and high-fructose corn syrup; switch hydrochlorothiazide to another antihypertensive when feasible and prefer losartan; do not stop low-dose aspirin taken for a valid indication.