Patient handout

Chronic gout — urate-lowering therapy (treat-to-target)

PRODUCTION

1. Your condition

This handout is for chronic gout — urate-lowering therapy (treat-to-target). Your care team identified this based on: ≥2 gout flares in the past 12 months — strong ult indication (acr 2020 fitzgerald strong; eular 2016 richette).

Other reasons your team may use this plan: one or more subcutaneous tophi — strong ult indication, sua target <5 mg/dl (acr 2020 fitzgerald strong); radiographic erosion / dect or us double-contour urate deposition (acr 2020; eular 2018 diagnostic pmid 31167758); hyperuricemia + ckd ≥3 or uric-acid urolithiasis or sua >9 mg/dl — conditional/strong ult indication (acr 2020 fitzgerald).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
discontinue/substitute urate-raising drug (thiazide/loop → losartan or amlodipine; review low-dose ASA)	—	—	—	Thiazide/loop diuretics raise SUA; losartan is uniquely uricosuric among ARBs — switch where cardiovascularly feasible (EULAR 2016 Richette PMID 27457514)
losartan	50 mg	PO	once daily	Uricosuric ARB — replaces a urate-raising diuretic while modestly lowering SUA (EULAR 2016 Richette PMID 27457514)
lifestyle: alcohol moderation, fructose/SSB reduction, weight loss, hydration	—	—	—	Adjunctive — insufficient alone to reach target but reduces required ULT dose (EULAR 2016 Richette PMID 27457514; ACR 2020 conditional)

Plan: Urate-lowering therapy — treat-to-target SUA <6 mg/dL (<5 if tophaceous/severe) (ACR 2020 FitzGerald PMID 32391934; EULAR 2016 Richette PMID 27457514)

3. Your action plan

Use these zones to know what to do based on how you feel.

GREEN — Stable — on ULT at target urate

If you have:

No flares in 6+ months (ACR 2020 FitzGerald)
SUA at target (<6, or <5 if you have/had tophi) (ACR 2020; EULAR 2016 PMID 27457514)
Taking allopurinol/febuxostat exactly as prescribed

Do this:

Take your urate-lowering medicine every day — never stop because you feel well (gout comes back) (ACR 2020 FitzGerald strong)
Keep your urate blood test every 6 months (ACR 2020 FitzGerald)
Continue flare-prevention medicine until your provider says to stop (usually ≥3–6 months after target) (ACR 2020 strong)
Limit alcohol and sugary/fructose drinks; hydrate; aim for a healthy weight (EULAR 2016 Richette PMID 27457514)
Tell any new prescriber you take gout medicine (some drugs interact — especially azathioprine)

YELLOW — Caution — flare, rising urate, or missed doses

If you have:

A new joint flare while on ULT
Urate level rising or above target on labs
Missed several ULT doses / new diuretic started

Do this:

DO NOT stop your urate-lowering medicine during a flare — keep taking it (ACR 2020 FitzGerald strong)
Use your pre-agreed flare rescue plan (managed by the acute-gout plan) — do not start/stop ULT for the flare
Restart any missed ULT doses and book a urate recheck
Call your provider if flares are becoming more frequent — your dose may need titration (ACR 2020 treat-to-target)

Call your provider if:

Two or more flares despite being on ULT
A new tophus (lump) appears or an old one grows
A new medicine was started that may raise urate (diuretic) or interact (azathioprine)

RED — Medical alert — drug reaction

If you have:

Rash, fever, facial swelling, or peeling skin after starting allopurinol (possible hypersensitivity) (ACR 2020 FitzGerald)
Severe reaction during/after a pegloticase infusion (anaphylaxis)
Dark urine + fatigue (possible haemolysis on pegloticase if G6PD-deficient)

Do this:

STOP allopurinol and seek emergency care immediately for any rash/fever/skin reaction — do NOT take it again ever (ACR 2020 FitzGerald)
Call emergency services for any severe infusion reaction
Bring your full medication list including the ULT drug and dose

Call your provider if:

Always seek emergency care for skin rash + fever on allopurinol or any severe infusion reaction (ACR 2020 FitzGerald)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Fever + rash + eosinophilia + AKI/hepatitis after starting allopurinol (DRESS/SJS-TEN spectrum) (ACR 2020 FitzGerald)(life-threatening)
HLA-B*5801 positive OR high-risk ancestry, AND CKD ≥3, AND thiazide use — compounded AHS risk (ACR 2020 FitzGerald strong)
Patient on azathioprine or 6-mercaptopurine (transplant/IBD) requiring a xanthine oxidase inhibitor — absolute interaction (ACR 2020)(life-threatening)
Persistent tophi / SUA above target despite max XOI + uricosuric and verified adherence (ACR 2020; MIRROR Botson 2022 PMID 36099211)
Pre-infusion SUA >6 mg/dL on two consecutive doses or infusion reaction — predicts anaphylaxis (FDA label; ACR 2020)(life-threatening)
G6PD deficiency in a patient otherwise eligible for pegloticase (FDA label; ACR 2020)

5. Follow-up

Lifelong ULT for established gout (ACR 2020 FitzGerald strong). CV risk modification (treat the gout, not the urate, outside gout — ALL-HEART PMID 36216006). Diet/alcohol/fructose/weight counseling (EULAR 2016 Richette PMID 27457514). Cautious dose-REDUCTION deprescribing (never abrupt stop) only after years of sustained target + no tophi + no flares, with continued surveillance. Tophus surgical referral if functional impairment

6. Sources

Guideline: 2020 ACR Guideline for the Management of Gout (FitzGerald et al, Arthritis Care Res 2020, PMID 32391934) + 2016 EULAR management recs (Richette, PMID 27457514) + 2018 EULAR diagnostic update (PMID 31167758) + ACP 2017 (PMID 27802508). EVIDENCE GAP: no EULAR 2024 full management revision located on 2026-05-16 (see research bundle §E)