Clinical Commander

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rheum.gout.core.v1

Gout (acute flare → urate-lowering therapy)

rheumatologyacutechronicadultoutpatientacute
Start encounter →Print handoutPRODUCTION

Refractory tophaceous gout (pegloticase + MTX) shares this dossier as a regimen branch; consider rheum.gout-refractory.core.v1 split when phenotype-specific workflow matures. PRODUCTION blockers: RxCUI verification (npm run research:rxnav:validate); HLA-B*5801 + G6PD pre-screening rules need decision-rule wiring; no dedicated test file.

Entry points (5)

  • symptom
    Acute monoarthritis, often 1st MTP (podagra) (ACR 2020 FitzGerald; EULAR 2024)
    acute_monoarthritis_first_mtp
  • symptom
    Polyarticular flare with prior gout (ACR 2020 FitzGerald)
    acute_polyarthritis_with_history
  • lab_abnormality
    Hyperuricemia + recurrent flares / tophi / urolithiasis (ACR 2020 FitzGerald)
    sua_persistently_elevated
  • imaging
    Tophi on exam / dual-energy CT (EULAR 2024)
    tophi_on_exam_or_imaging
  • problem_list
    Established gout titration visit (ACR 2020 treat-to-target)
    gout_already_diagnosed_titration

Required inputs (13)

  • age
    demographic • used at CONTEXT
    Premenopausal women rarely affected; informs differential (EULAR 2024)
  • flare_count_last_yearrequired
    symptom • used at CONTEXT
    ULT indicated if ≥2 flares/year (ACR 2020 FitzGerald strong recommendation) or ≥1 flare with comorbid risk
  • tophus_present
    symptom • used at CONTEXT
    Strong indication for ULT regardless of flare count; SUA target <5 mg/dL (ACR 2020 FitzGerald; EULAR 2024)
  • fever_in_acute_flarerequired
    symptom • used at RED_FLAGS
    Septic arthritis differential; arthrocentesis mandatory (ACR 2020 FitzGerald; EULAR 2024)
  • ckd_stagerequired
    history • used at CONTEXT
    Allopurinol / colchicine / NSAID dosing; SE Asian / African American HLA-B*5801 testing (ACR 2020 FitzGerald strong)
  • cv_diseaserequired
    history • used at CONTEXT
    CARES (White NEJM 2018) vs FAST (Mackenzie Lancet 2020) signal informs febuxostat positioning; statin / aspirin synergy
  • urolithiasis
    history • used at CONTEXT
    Uric acid stones → ULT priority; alkalinize urine (ACR 2020 FitzGerald)
  • diureticsrequired
    medication • used at CONTEXT
    Thiazide / loop diuretics raise SUA; consider switch to losartan / amlodipine (EULAR 2024)
  • cyclosporine_or_tacrolimus
    medication • used at CONTEXT
    CNI use → secondary gout + colchicine interaction (ACR 2020 FitzGerald)
  • serum_uric_acidrequired
    lab • used at INITIAL_WORKUP
    Treat-to-target <6 (general) / <5 (tophaceous) (ACR 2020 FitzGerald; EULAR 2024); often normal during acute flare
  • creatininerequired
    lab • used at TREATMENT
    eGFR drives allopurinol starting dose, colchicine reduction, NSAID avoidance (ACR 2020 FitzGerald)
  • lft
    lab • used at INITIAL_WORKUP
    Baseline before allopurinol / febuxostat (ACR 2020 FitzGerald)
  • synovial_fluid_crystals
    lab • used at INITIAL_WORKUP
    Negatively birefringent monosodium urate crystals confirm; rule out septic arthritis (EULAR 2024; ACR 2020)

12-phase flow (12)

  1. 1FRAME
    Adult primary + secondary gout — acute flare, intercritical, chronic tophaceous, refractory (ACR 2020 FitzGerald; EULAR 2024)
    advance: scope confirmed
  2. 2ENTRY
    Recognise classic monoarticular flare; differentiate from septic arthritis / CPPD / RA (EULAR 2024)
    advance: entry trigger present
  3. 3CONTEXT
    Comorbidities (CKD, CVD, HTN, MetS, urolithiasis), medications (diuretics, CNIs, ASA low-dose), prior ULT, alcohol / fructose intake, ancestry for HLA-B*5801 (ACR 2020 FitzGerald; EULAR 2024)
    inputs: flare_count_last_year, ckd_stage, cv_disease, diuretics
    advance: risk + driver profile captured
  4. 4RED_FLAGS
    Septic arthritis — fever + joint = STAT arthrocentesis (ACR 2020 FitzGerald). Polyarticular with systemic illness — broaden DDx
    inputs: fever_in_acute_flare
    advance: septic arthritis ruled out
  5. 5INITIAL_WORKUP
    SUA, BMP, LFT, CBC, CRP; arthrocentesis if first episode / atypical / fever (EULAR 2024); consider HLA-B*5801 in SE Asian / African American (ACR 2020 FitzGerald strong)
    inputs: serum_uric_acid, creatinine, lft
    actions: panel.cbc, panel.renal, panel.synovial, panel.inflammation
    advance: workup sent; treatment started
  6. 6BRANCHING_WORKUP
    24-h urinary urate if uric acid stones / very young / dialysis-dependent ULT planning; dual-energy CT if diagnosis uncertain (EULAR 2024)
    advance: subtype-specific workup complete
  7. 7DIFFERENTIAL
    Septic arthritis, CPPD, palindromic RA, reactive arthritis, psoriatic arthritis, fracture, cellulitis (EULAR 2024)
    advance: mimics excluded
  8. 8RISK_STRATIFICATION
    Recurrent flare / tophus / CKD ≥3 / SUA >9 / urolithiasis → strong ULT indication; otherwise shared decision (ACR 2020 FitzGerald conditional)
    advance: ULT indication clear
  9. 9TREATMENT
    Acute flare ≤24h: low-dose colchicine 1.2 mg → 0.6 mg 1h later (AGREE trial; ACR 2020); NSAID (naproxen 500 BID × 5-7d) if no CKD/CVD (ACR 2020); or prednisone 40 mg/d × 5d (ACR 2020). Polyarticular: systemic steroids preferred (ACR 2020). Refractory: IL-1 inhibitor (anakinra 100 mg SC × 3-5d off-label) (ACR 2020 conditional). DO NOT start or stop ULT during flare — continue if already on (ACR 2020 strong). ULT initiation: allopurinol 100 mg/d (50 mg if CKD ≥3) → titrate q2-4 weeks to SUA <6 (or <5 tophaceous) (ACR 2020 FitzGerald; EULAR 2024). Febuxostat 40 mg → 80 mg if allopurinol intolerant or AHS history (FAST Mackenzie Lancet 2020 — non-inferior CV; CARES White NEJM 2018). Pegloticase + MTX co-therapy (MIRROR Botson J Rheumatol 2022) for refractory. Anti-inflammatory prophylaxis (colchicine 0.6 mg daily / NSAID) ≥6 months after target reached (ACR 2020 strong). Address modifiable drivers (switch HCTZ → losartan, weight loss, alcohol) (EULAR 2024)
    inputs: serum_uric_acid, creatinine
    advance: flare resolved + ULT plan in place
  10. 10DISPOSITION
    Outpatient unless septic arthritis suspected / IV needs / unable to tolerate oral therapy (ACR 2020)
    advance: level of care set
  11. 11MONITORING
    SUA q2-4 weeks during ULT titration → q6 months once at target (ACR 2020 FitzGerald; EULAR 2024). CBC, LFT, BMP per ULT chosen. Re-evaluate flare prophylaxis duration
    inputs: serum_uric_acid, creatinine
    actions: panel.renal
    advance: SUA at target sustained ≥6 months
  12. 12FOLLOWUP
    Lifelong ULT for established gout (ACR 2020 FitzGerald strong); CV risk modification; counsel on diet (alcohol, fructose, organ meats), weight, hydration (EULAR 2024); tophus-specific surgery referral if functional impairment
    advance: long-term plan + counseling complete