Practice Guidelines

Management of Gout: Update from the American College of Rheumatology


Am Fam Physician. 2021 Aug ;104(2):209-210.

Author disclosure: No relevant financial affiliations.

Key Points for Practice

• During a second gout flare-up in one year, low-dose allopurinol can be started with anti-inflammatory therapy without worsening the flare-up.

• Allopurinol is the preferred urate-lowering agent, but HLA testing should be offered to patients of Southeast Asian or African American descent before starting to identify patients at risk for an allergic reaction.

• Titrating urate-lowering therapy to reach a serum urate level of 6 mg per dL decreases flare-ups and increases treatment adherence.

• During acute flare-ups, low-dose colchicine, NSAIDs, and glucocorticoids delivered orally, intramuscularly, or intra-articularly are similarly effective.

From the AFP Editors

Although effective medications exist to prevent and treat acute flare-ups, gout remains the most common inflammatory arthritis in the United States. Urate-lowering therapy is underused despite previous recommendations from the American College of Rheumatology (ACR). The ACR published updated guidelines for gout management focused on improving prevention of flare-ups.

When to Consider Urate-Lowering Therapy

Urate-lowering therapy is recommended for patients with two or more gout flare-ups per year, tophaceous gout, or damage attributable to gout visible on radiography. Consider starting therapy for patients with a second flare-up even if not within one year. With a first gout flare-up, shared decision-making is appropriate in patients at high risk because of a serum urate level of 9 mg per dL (0.54 mmol per L) or higher, urolithiasis, or stage 3 or greater chronic kidney disease. Urate-lowering therapy has not been shown to be beneficial for patients with asymptomatic hyperuricemia.

The ACR recommends starting urate-lowering therapy during an acute flare-up instead of waiting until it resolves. Therapy started during a flare-up does not increase or prolong symptoms as long as anti-inflammatory treatments are provided. The ACR notes that patients are most motivated for treatment during an exacerbation. Anti-inflammatory medications such as colchicine or nonsteroidal anti-inflammatory drugs (NSAIDs) should be continued for three to six months after starting urate-lowering therapy.

Urate-Lowering Therapies

Allopurinol is the first-line urate-lowering therapy. Febuxostat (Uloric), the other xanthine oxidase inhibitor, is limited by increased cardiovascular and all-cause mortality seen in studies. Hypersensitivity reactions to allopurinol occur in patients with the HLA-B*5801 allele. Because this allele affects 7% of people of Southeast Asian descent and 4% of people of African American descent, HLA testing is recommended for these patients before starting allopurinol. Allopurinol desensitization can be performed after an allergic response. Urate-lowering therapies are summarized in Table 1.

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Urate-Lowering Therapies for Treatment of Gout

MedicationMechanism of actionDosageSpecial considerations

Allopurinol (first-line option for all patients)

Xanthine oxidase inhibitor

Start at ≤100 mg daily (or lower in ≥ stage 3 chronic kidney disease), dosages can be titrated to 800 mg daily

Test for HLA-B*5801 in patients of Southeast Asian or African American descent

Febuxostat (Uloric)

Xanthine oxidase inhibitor

Start at ≤40 mg daily, maximum dosage is 80 mg daily in the United States

Switch to another agent in patients with history of cardiovascular disease or new cardiovascular event



Start at 100 mg once or twice daily, can be increased to 1 g twice daily

No evidence for checking urinary uric acid

Pegloticase (Krystexxa)


8 mg intravenously every 2 weeks

Not recommended as first-line option


Urate-Lowering Therapies

Author disclosure: No relevant financial affiliations.

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Michael J. Arnold, MD, contributing editor.

A collection of Practice Guidelines published in AFP is available at



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