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msk.gout-acute.core.v1PRODUCTION
msk.gout-acute.core.v1

Acute gout flare (primary-care / ED — acute monoarthritis)

rheumatologyacuteadult
Hard-required inputs
0 / 10
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Adult acute gout FLARE / acute monoarthritis at the primary-care or ED front door — triage, exclude the septic cannot-miss, abort, and ROUTE chronic urate management out (this is not the ULT engine) (ACR 2020 FitzGerald PMID 32391934; ACP 2017 Qaseem PMID 27802508)

Inputs
1
Actions
0
Advance rule
Set
Advance when

Acute-monoarthritis scope confirmed; chronic ULT recognised as out-of-scope (routed)

Patient inputs (13)

If already on allopurinol/febuxostat — CONTINUE through the flare, do NOT stop (2020 ACR strong); do NOT start ULT here — route to chronic engine (ACR 2020 FitzGerald PMID 32391934)

Podagra/monoarticular pattern + onset <24 h frames the abort window (AGREE response window) and the gout pre-test prior (ACR 2020 FitzGerald PMID 32391934; AGREE Terkeltaub PMID 20131255)

Arthrocentesis-first: cell count + differential + Gram + crystal exam is the decisive test for both septic arthritis (WBC/PMN/Gram) and gout (negatively birefringent MSU) (Margaretten JAMA 2007 PMID 17405973; ACR 2020 PMID 32391934)

Fever raises septic-arthritis suspicion — but fever sensitivity is only 57%, so absence does NOT exclude (Margaretten JAMA 2007 PMID 17405973)

Age, diabetes, RA, prior joint surgery, prosthetic joint, overlying skin infection, HIV, IVDU, immunosuppression each significantly raise septic-arthritis probability (Margaretten JAMA 2007 PMID 17405973)

eGFR (race-neutral CKD-EPI 2021) drives colchicine dose-reduction / avoidance and NSAID avoidance — abort-drug gating (NKF-ASN Delgado PMID 34563581; ACR 2020 PMID 32391934)

NSAID relatively contraindicated in HF / CVD / uncontrolled HTN — shifts abort drug to colchicine or steroid (ACR 2020 FitzGerald PMID 32391934; ACP 2017 PMID 27802508)

Active PUD / GI bleed / anticoagulation contraindicates NSAID; steroid GI-counsel; colchicine if eGFR permits (ACR 2020 FitzGerald PMID 32391934)

Strong CYP3A4 (clarithromycin, ketoconazole, ritonavir) or P-gp (cyclosporine, verapamil) inhibitors → BLOCK colchicine (fatal myotoxicity / marrow suppression, esp. with CKD) (ACR 2020 FitzGerald PMID 32391934)

Drives eGFR for colchicine/NSAID abort-drug dosing (race-neutral CKD-EPI 2021) (NKF-ASN Delgado PMID 34563581)

Prior identical self-limited podagra episodes raise the gout prior and lower first-presentation-septic prior (ACR 2020 FitzGerald PMID 32391934)

Frequently NORMAL/low in an acute flare — does NOT rule in or out gout acutely (LR ≈ 1); definitive treat-to-target SUA is a CHRONIC-engine decision (ACR 2020 FitzGerald PMID 32391934)

CRP/ESR support the inflammatory picture and trajectory; do NOT discriminate gout from septic (raised in both) (Margaretten JAMA 2007 PMID 17405973)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateningseptic_arthritis_high_probability
    Acute monoarthritis with synovial WBC >50,000/µL (LR+ 7.7, 95% CI 5.7-11.0) or >100,000 (LR+ 28.0, 12.0-66.0) or PMN ≥90% (LR+ 3.4, 2.8-4.2) or positive Gram stain — co-existence with gout possible (Margaretten JAMA 2007 PMID 17405973)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereseptic_not_excludable_immunosuppressed_or_prosthetic
    Acute monoarthritis in immunosuppressed / prosthetic-or-operated joint / partially-treated host where a "low" synovial WBC LR is DOWN-WEIGHTED (conditional dependence) and fever may be absent (sens only 57%) (Margaretten JAMA 2007 PMID 17405973)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecolchicine_fatal_interaction_or_renal_risk
    Strong CYP3A4 inhibitor (clarithromycin/ketoconazole/ritonavir) or P-gp inhibitor (cyclosporine/verapamil) or eGFR <30 / dialysis with colchicine considered (ACR 2020 FitzGerald PMID 32391934)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererefractory_flare_all_first_line_contraindicated
    Flare refractory at 48 h OR colchicine + NSAID + corticosteroid all contraindicated (frequent-flare multimorbid patient) (EULAR 2016 Richette PMID 27457514; ACR 2020 PMID 32391934)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatensaid_contraindicated_comorbidity
    CKD stage ≥3b, active PUD / GI bleed, heart failure / severe CVD, or anticoagulation with NSAID considered for the flare (ACR 2020 FitzGerald PMID 32391934; ACP 2017 Qaseem PMID 27802508)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatedo_not_start_or_stop_ult_in_flare
    Patient on ULT presenting with a flare (continue ULT), or clinician about to start ULT during the acute flare (do NOT — route to chronic engine) (ACR 2020 FitzGerald strong PMID 32391934)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

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Recommended regimen

Acute gout flare abort (≤24 h onset) — comorbidity-gated; chronic ULT routed to msk.gout-chronic.core.v1 (ACR 2020 FitzGerald; EULAR 2016 Richette; AGREE Terkeltaub)
axis: gout_acute_flare_abort_comorbidity_gated
Selected axis "Acute gout flare abort (≤24 h onset) — comorbidity-gated; chronic ULT routed to msk.gout-chronic.core.v1 (ACR 2020 FitzGerald; EULAR 2016 Richette; AGREE Terkeltaub)" by default fallback (first axis)
  • colchicine
    first line
    colchicine
    1.2 mg PO ×1, then 0.6 mg 1 h later (1.8 mg over 1 h), then 0.6 mg q12h-daily until resolution • PO • AGREE low-dose then q12h-daily (max: low-dose AGREE regimen only — never the legacy high-dose hourly-to-toxicity regimen)
    triggers: onset_<24h, eGFR_>=30, no_strong_CYP3A4_inhibitor, no_PGP_inhibitor, not_on_cyclosporine
    AGREE (Terkeltaub Arthritis Rheum 2010 PMID 20131255): low-dose 37.8% vs placebo 15.5% responders at 24 h (P=0.005); low-dose AE profile = placebo (OR 1.5, 95% CI 0.7-3.2), 0% severe diarrhoea/vomiting vs high-dose diarrhoea OR 21.3. ACR 2020 strong; low-dose strongly preferred (PMID 32391934)
    rxcui 2683
  • naproxen
    first line
    NSAID
    500 mg PO BID × 5-7 d • PO • BID
    triggers: no_CKD_stage>=3b, no_active_PUD_or_GI_bleed, no_HF_or_severe_CVD, not_anticoagulated
    ACR 2020 equal first-line; ACP 2017 strong/high-quality. Alternative indomethacin 50 mg PO TID (PMID 32391934; PMID 27802508)
    rxcui 7258
  • indomethacin
    first line
    NSAID
    50 mg PO TID × 5-7 d • PO • TID
    triggers: no_CKD_stage>=3b, no_active_PUD_or_GI_bleed, no_HF_or_severe_CVD, naproxen_alternative
    ACR 2020 equal first-line NSAID alternative for acute flare abort (PMID 32391934)
    rxcui 5781
  • prednisone
    first line
    corticosteroid
    40 mg PO daily × 5 d (or 0.5 mg/kg/d taper over 10-14 d) • PO • daily
    triggers: CKD_stage>=3b, NSAID_contraindicated, colchicine_contraindicated, polyarticular, diabetes_counsel_glucose
    ACR 2020 equal first-line; preferred when CKD/NSAID/colchicine-restricted; ACP 2017 strong. Counsel glycaemic monitoring in diabetes (PMID 32391934; PMID 27802508)
    rxcui 8640
  • methylprednisolone
    comorbidity specific
    corticosteroid
    IM 40-80 mg single dose; or IV 40-125 mg if NPO/severe • IM/IV • single
    triggers: NPO_or_cannot_tolerate_oral, severe_polyarticular, ED_setting
    ACR 2020 — parenteral steroid when oral route unavailable or severe flare (PMID 32391934; EULAR 2016 PMID 27457514)
    rxcui 6902
  • triamcinolone (intra-articular)
    comorbidity specific
    corticosteroid
    Intra-articular 20-40 mg (large joint) / 10 mg (small joint), single • intra-articular • single
    triggers: monoarticular_amenable_to_injection, systemic_steroid_undesirable, SEPTIC_ARTHRITIS_EXCLUDED_FIRST
    ACR 2020 — IA steroid equal/superior for accessible monoarticular flare; ONLY after septic arthritis excluded by synovial analysis (never inject an infected joint) (PMID 32391934; EULAR 2016 PMID 27457514)
    rxcui 10759
  • anakinra
    rescue
    IL_1_inhibitor
    100 mg SC daily × 3-5 d • SC • daily
    triggers: colchicine_AND_NSAID_AND_steroid_all_contraindicated, refractory_to_first_line, frequent_flare_multimorbid
    EULAR 2016 — IL-1 blocker when colchicine + NSAID + corticosteroids all contraindicated (PMID 27457514); ACR 2020 conditional off-label rescue (PMID 32391934)
    rxcui 72435

outpatient playbook — drug actions (5)

  1. 1. arthrocentesis (procedure)
    n/a • procedural • single
    trigger: Any acute monoarthritis — BEFORE anti-inflammatory commitment
    T_aspirate — exclude septic arthritis; identify MSU vs CPPD crystals (Margaretten JAMA 2007 PMID 17405973; ACR 2020 PMID 32391934)
  2. 2. low-dose colchicine
    1.2 mg PO ×1 then 0.6 mg 1 h later, then 0.6 mg q12h-daily • PO • until resolution
    trigger: Onset <24 h, eGFR ≥30, no strong CYP3A4/P-gp inhibitor
    AGREE low-dose (Terkeltaub PMID 20131255); ACR 2020 strong, low-dose preferred (PMID 32391934)
  3. 3. NSAID (naproxen/indomethacin)
    Naproxen 500 mg BID OR indomethacin 50 mg TID × 5-7 d • PO • BID/TID
    trigger: No CKD≥3b, no PUD/GI-bleed, no HF/severe CVD, not anticoagulated
    ACR 2020 equal first-line; ACP 2017 strong/high-quality (PMID 32391934; PMID 27802508)
  4. 4. prednisone
    40 mg PO daily × 5 d • PO • daily
    trigger: CKD≥3b / NSAID or colchicine contraindicated / polyarticular
    ACR 2020 equal first-line; counsel glucose in diabetes (PMID 32391934)
  5. 5. triamcinolone intra-articular
    20-40 mg large joint (10 mg small) • intra-articular • single
    trigger: Accessible monoarticular flare AND septic arthritis excluded by synovial analysis
    ACR 2020 — IA steroid equal/superior for monoarticular; never inject before septic excluded (PMID 32391934)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Acute hot, swollen, exquisitely painful single joint (acute monoarthritis) (ACR 2020 FitzGerald PMID 32391934; Margaretten JAMA 2007 PMID 17405973); Classic podagra — acute 1st MTP flare (ACR 2020 FitzGerald PMID 32391934); Acute monoarthritis WITH fever / systemic illness — septic-arthritis cannot-miss (Margaretten JAMA 2007 PMID 17405973).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Acute gout flare (primary-care / ED — acute monoarthritis)** (msk.gout-acute.core.v1).
Phenotype framing: Gout (MSU) vs SEPTIC ARTHRITIS (co-existence — NOT mutually exclusive) vs CPPD/pseudogout (look-alike) vs trauma/haemarthrosis vs cellulitis overlying a joint vs mono-onset psoriatic/reactive arthritis. Pivot = synovial WBC/PMN/Gram/crystal + clinical prior; crystal-positivity is conditionally INDEPENDENT of infection (Margaretten JAMA 2007 PMID 17405973; EULAR 2016 Richette PMID 27457514)
Scope: Adult acute gout FLARE / acute monoarthritis at the primary-care or ED front door — triage, exclude the septic cannot-miss, abort, and ROUTE chronic urate management out (this is not the ULT engine) (ACR 2020 FitzGerald PMID 32391934; ACP 2017 Qaseem PMID 27802508)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Acute gout flare abort (≤24 h onset) — comorbidity-gated; chronic ULT routed to msk.gout-chronic.core.v1 (ACR 2020 FitzGerald; EULAR 2016 Richette; AGREE Terkeltaub)**.
1. colchicine 1.2 mg PO ×1, then 0.6 mg 1 h later (1.8 mg over 1 h), then 0.6 mg q12h-daily until resolution PO AGREE low-dose then q12h-daily (colchicine, first line) — AGREE (Terkeltaub Arthritis Rheum 2010 PMID 20131255): low-dose 37.8% vs placebo 15.5% responders at 24 h (P=0.005); low-dose AE profile = placebo (OR 1.5, 95% CI 0.7-3.2), 0% severe diarrhoea/vomiting vs high-dose diarrhoea OR 21.3. ACR 2020 strong; low-dose strongly preferred (PMID 32391934)
2. naproxen 500 mg PO BID × 5-7 d PO BID (NSAID, first line) — ACR 2020 equal first-line; ACP 2017 strong/high-quality. Alternative indomethacin 50 mg PO TID (PMID 32391934; PMID 27802508)
3. indomethacin 50 mg PO TID × 5-7 d PO TID (NSAID, first line) — ACR 2020 equal first-line NSAID alternative for acute flare abort (PMID 32391934)
4. prednisone 40 mg PO daily × 5 d (or 0.5 mg/kg/d taper over 10-14 d) PO daily (corticosteroid, first line) — ACR 2020 equal first-line; preferred when CKD/NSAID/colchicine-restricted; ACP 2017 strong. Counsel glycaemic monitoring in diabetes (PMID 32391934; PMID 27802508)
5. methylprednisolone IM 40-80 mg single dose; or IV 40-125 mg if NPO/severe IM/IV single (corticosteroid, comorbidity specific) — ACR 2020 — parenteral steroid when oral route unavailable or severe flare (PMID 32391934; EULAR 2016 PMID 27457514)
6. triamcinolone (intra-articular) Intra-articular 20-40 mg (large joint) / 10 mg (small joint), single intra-articular single (corticosteroid, comorbidity specific) — ACR 2020 — IA steroid equal/superior for accessible monoarticular flare; ONLY after septic arthritis excluded by synovial analysis (never inject an infected joint) (PMID 32391934; EULAR 2016 PMID 27457514)
7. anakinra 100 mg SC daily × 3-5 d SC daily (IL_1_inhibitor, rescue) — EULAR 2016 — IL-1 blocker when colchicine + NSAID + corticosteroids all contraindicated (PMID 27457514); ACR 2020 conditional off-label rescue (PMID 32391934)

Setting playbook (outpatient) — Recognise acute monoarthritis, exclude the septic cannot-miss (arthrocentesis or urgent referral if unavailable), abort the flare comorbidity-gated within 24 h, and ROUTE the ULT shared decision to msk.gout-chronic.core.v1 (do NOT start ULT for a first/infrequent attack) (ACR 2020 FitzGerald PMID 32391934; ACP 2017 Qaseem PMID 27802508)
8. arthrocentesis (procedure) n/a procedural single — Any acute monoarthritis — BEFORE anti-inflammatory commitment (T_aspirate — exclude septic arthritis; identify MSU vs CPPD crystals (Margaretten JAMA 2007 PMID 17405973; ACR 2020 PMID 32391934))
9. low-dose colchicine 1.2 mg PO ×1 then 0.6 mg 1 h later, then 0.6 mg q12h-daily PO until resolution — Onset <24 h, eGFR ≥30, no strong CYP3A4/P-gp inhibitor (AGREE low-dose (Terkeltaub PMID 20131255); ACR 2020 strong, low-dose preferred (PMID 32391934))
10. NSAID (naproxen/indomethacin) Naproxen 500 mg BID OR indomethacin 50 mg TID × 5-7 d PO BID/TID — No CKD≥3b, no PUD/GI-bleed, no HF/severe CVD, not anticoagulated (ACR 2020 equal first-line; ACP 2017 strong/high-quality (PMID 32391934; PMID 27802508))
11. prednisone 40 mg PO daily × 5 d PO daily — CKD≥3b / NSAID or colchicine contraindicated / polyarticular (ACR 2020 equal first-line; counsel glucose in diabetes (PMID 32391934))
12. triamcinolone intra-articular 20-40 mg large joint (10 mg small) intra-articular single — Accessible monoarticular flare AND septic arthritis excluded by synovial analysis (ACR 2020 — IA steroid equal/superior for monoarticular; never inject before septic excluded (PMID 32391934))

Non-pharmacologic actions:
- Joint rest, ice, elevation (EULAR 2016 Nuki PMID 28430170)
- Do NOT start ULT for first/infrequent attack — defer to longitudinal shared decision (ACP 2017 Qaseem PMID 27802508)
- Continue any existing ULT through the flare (ACR 2020 strong PMID 32391934)
- Book msk.gout-chronic.core.v1 follow-up if ≥2 flares/yr, tophus, CKD≥3, urolithiasis, or on ULT (ACR 2020 PMID 32391934)

AVOID / contraindication checks:
- Colchicine block with strong CYP3A4 or PGP inhibitor or eGFR<30 or dialysis (fatal myotoxicity/marrow suppression) (ACR 2020 FitzGerald PMID 32391934)
- NSAID block if CKD stage>=3b or active PUD or GI bleed or HF or anticoagulated (ACR 2020 PMID 32391934; ACP 2017 PMID 27802508)
- Corticosteroid counsel glycaemic monitoring in diabetes (ACR 2020 PMID 32391934)
- NEVER inject intra articular steroid until septic arthritis excluded by synovial analysis (Margaretten JAMA 2007 PMID 17405973; ACR 2020 PMID 32391934)
- Do NOT start or stop ULT during flare CONTINUE if already on it (ACR 2020 strong PMID 32391934)
- Route:chronic ULT treat to target HLA B5801 febuxostat pegloticase OUT OF SCOPE route to msk.gout chronic.core.v1

Monitoring

Regimen monitoring:
- pain and inflammation trajectory 24-48h (AGREE response window PMID 20131255; ACR 2020 PMID 32391934)
- BMP pre post NSAID course if renal risk (ACR 2020 PMID 32391934)
- glucose if steroid and diabetes (ACR 2020 PMID 32391934)
- CK if colchicine plus interacting drug (ACR 2020 PMID 32391934)
- reassess for occult septic or CPPD if no improvement 48h (Margaretten JAMA 2007 PMID 17405973)

Setting (outpatient) monitoring:
- Pain/inflammation 24-48 h (AGREE window PMID 20131255)
- BMP if NSAID + renal risk; glucose if steroid + diabetes (ACR 2020 PMID 32391934)
- Return if no improvement in 48 h — reassess for occult septic / CPPD (Margaretten JAMA 2007 PMID 17405973)

Follow-up plan: Route to msk.gout-chronic.core.v1 for the longitudinal ULT shared decision (≥2 flares/yr, tophus, CKD≥3, urolithiasis, or already on ULT). Counsel: this acute engine ABORTS and REFERS — it does not manage urate. Return precautions: fever + hot joint, rapid worsening, no improvement in 48 h (ACP 2017 Qaseem PMID 27802508; ACR 2020 PMID 32391934)
- Close-out criterion: Chronic-engine handoff booked + return precautions given

Monitoring phase: Pain/inflammation trajectory 24-48 h (AGREE response window); BMP pre/post NSAID course if renal risk; glucose if steroid + diabetes; CK if colchicine + interacting drug. Failure to improve in 48 h → reassess diagnosis (occult septic / CPPD) (ACR 2020 PMID 32391934; AGREE PMID 20131255)

Disposition

Current setting: outpatient — Recognise acute monoarthritis, exclude the septic cannot-miss (arthrocentesis or urgent referral if unavailable), abort the flare comorbidity-gated within 24 h, and ROUTE the ULT shared decision to msk.gout-chronic.core.v1 (do NOT start ULT for a first/infrequent attack) (ACR 2020 FitzGerald PMID 32391934; ACP 2017 Qaseem PMID 27802508)

Disposition criteria:
- Discharge with comorbidity-gated abort regimen + msk.gout-chronic.core.v1 follow-up for ULT shared decision (ACP 2017 PMID 27802508)
- Refer/escalate if septic arthritis suspected or flare refractory (ACR 2020 PMID 32391934)

Escalation triggers (move to higher acuity):
- Synovial purulence / Gram-positive / WBC >50k band with high prior / sepsis → ED + empiric anti-staph + orthopaedics + route id.osteomyelitis-septic-arthritis.v1 (Margaretten JAMA 2007 PMID 17405973)
- Cannot perform arthrocentesis + cannot exclude septic arthritis → urgent ED referral (ACR 2020 PMID 32391934)
- Refractory flare not responding to first-line × 48 h → ED for parenteral steroid or anakinra; reassess diagnosis (EULAR 2016 PMID 27457514)

Patient Action Plan

**Acute gout flare — abort plan + when this is an emergency**
Personalised values: abort_regimen_and_dose, comorbid_CKD_CVD_PUD, on_ult_yes_no, usual_flare_joint.

**Between flares — no active joint attack** (green):
Triggers:
- No hot/swollen/painful joint right now
- Last flare fully resolved
Actions:
- If you take urate-lowering medicine (allopurinol/febuxostat), keep taking it every day — never stop it, even during a flare (ACR 2020 strong PMID 32391934)
- Keep the follow-up appointment to discuss long-term urate-lowering therapy (this is decided over time, not in the ED) (ACP 2017 PMID 27802508)
- Have your abort medicine on hand if your clinician prescribed a rescue plan

**Early flare — joint pain/warmth/swelling starting** (yellow):
Triggers:
- New hot, swollen, painful joint (often the big toe)
- Feels like your previous gout attacks
- No fever, not systemically unwell
Actions:
- Start your pre-prescribed abort regimen as early as possible (best within 24 h) (AGREE PMID 20131255; ACR 2020 PMID 32391934)
- Do NOT stop your urate-lowering medicine during the flare (ACR 2020 strong PMID 32391934)
- Rest, ice, and elevate the joint (EULAR 2016 PMID 28430170)
- Do NOT start a new urate-lowering medicine yourself during a flare
Contact provider when:
- Not improving within 48 h
- More than one joint involved
- You develop a fever (could be a joint infection — see red zone)

**Possible joint infection or severe illness — emergency** (red):
Triggers:
- Fever with a hot, swollen joint (a gout attack and a joint infection can happen together) (Margaretten JAMA 2007 PMID 17405973)
- A single joint rapidly getting worse
- Cannot move or bear weight on the joint at all
- Feeling very unwell / shivering / confused
Actions:
- Go to the emergency department now — the joint may need to be tapped (aspirated) urgently to check for infection
- Bring your full medication list including any urate-lowering and abort medicines
- Tell the ED you have gout but that this might be an infection — both can occur at once (ACR 2020 PMID 32391934)
Contact provider when:
- Always seek emergency care for fever + a hot joint, or rapid severe worsening (Margaretten JAMA 2007 PMID 17405973; ACR 2020 PMID 32391934)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Acute monoarthritis with synovial WBC >50,000/µL (LR+ 7.7, 95% CI 5.7-11.0) or >100,000 (LR+ 28.0, 12.0-66.0) or PMN ≥90% (LR+ 3.4, 2.8-4.2) or positive Gram stain — co-existence with gout possible (Margaretten JAMA 2007 PMID 17405973)
- [SEVERE] Acute monoarthritis in immunosuppressed / prosthetic-or-operated joint / partially-treated host where a "low" synovial WBC LR is DOWN-WEIGHTED (conditional dependence) and fever may be absent (sens only 57%) (Margaretten JAMA 2007 PMID 17405973)
- [SEVERE] Strong CYP3A4 inhibitor (clarithromycin/ketoconazole/ritonavir) or P-gp inhibitor (cyclosporine/verapamil) or eGFR <30 / dialysis with colchicine considered (ACR 2020 FitzGerald PMID 32391934)

Citations

- 2020 ACR Guideline for the Management of Gout (FitzGerald et al, Arthritis Care Res 2020) + 2016 EULAR updated recommendations (Richette et al) + ACP 2017 (Qaseem et al); septic-arthritis cannot-miss anchored to Margaretten JAMA Rational Clinical Examination 2007 [PMID:32391934](https://pubmed.ncbi.nlm.nih.gov/32391934/)
- Cited evidence (PMID 20131255) [PMID:20131255](https://pubmed.ncbi.nlm.nih.gov/20131255/)
- Cited evidence (PMID 17405973) [PMID:17405973](https://pubmed.ncbi.nlm.nih.gov/17405973/)
- Cited evidence (PMID 27457514) [PMID:27457514](https://pubmed.ncbi.nlm.nih.gov/27457514/)
- Cited evidence (PMID 28430170) [PMID:28430170](https://pubmed.ncbi.nlm.nih.gov/28430170/)

Last reconciled with current guidelines: 2026-05-22.
References
  • 2020 ACR Guideline for the Management of Gout (FitzGerald et al, Arthritis Care Res 2020) + 2016 EULAR updated recommendations (Richette et al) + ACP 2017 (Qaseem et al); septic-arthritis cannot-miss anchored to Margaretten JAMA Rational Clinical Examination 2007 — PMID:32391934
  • Cited evidence (PMID 20131255) — PMID:20131255
  • Cited evidence (PMID 17405973) — PMID:17405973
  • Cited evidence (PMID 27457514) — PMID:27457514
  • Cited evidence (PMID 28430170) — PMID:28430170