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rheum.gout.core.v1PRODUCTION
rheum.gout.core.v1

Gout (acute flare → urate-lowering therapy)

rheumatologyacutechronicadult
Hard-required inputs
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Care setting:

Encounter flow

12/12 authored

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

Current phase

Frame

Detailed

Adult primary + secondary gout — acute flare, intercritical, chronic tophaceous, refractory (ACR 2020 FitzGerald; EULAR 2024)

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Actions
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Advance rule
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Advance when

scope confirmed

Patient inputs (13)

ULT indicated if ≥2 flares/year (ACR 2020 FitzGerald strong recommendation) or ≥1 flare with comorbid risk

Allopurinol / colchicine / NSAID dosing; SE Asian / African American HLA-B*5801 testing (ACR 2020 FitzGerald strong)

CARES (White NEJM 2018) vs FAST (Mackenzie Lancet 2020) signal informs febuxostat positioning; statin / aspirin synergy

Thiazide / loop diuretics raise SUA; consider switch to losartan / amlodipine (EULAR 2024)

Treat-to-target <6 (general) / <5 (tophaceous) (ACR 2020 FitzGerald; EULAR 2024); often normal during acute flare

Septic arthritis differential; arthrocentesis mandatory (ACR 2020 FitzGerald; EULAR 2024)

eGFR drives allopurinol starting dose, colchicine reduction, NSAID avoidance (ACR 2020 FitzGerald)

Premenopausal women rarely affected; informs differential (EULAR 2024)

Strong indication for ULT regardless of flare count; SUA target <5 mg/dL (ACR 2020 FitzGerald; EULAR 2024)

Uric acid stones → ULT priority; alkalinize urine (ACR 2020 FitzGerald)

CNI use → secondary gout + colchicine interaction (ACR 2020 FitzGerald)

Baseline before allopurinol / febuxostat (ACR 2020 FitzGerald)

Negatively birefringent monosodium urate crystals confirm; rule out septic arthritis (EULAR 2024; ACR 2020)

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

Severity triggers (6)

6 need judgement
  • informationallife_threateningseptic_arthritis_suspicion
    Monoarticular flare with fever, immunocompromise, or atypical features (ACR 2020 FitzGerald; EULAR 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretophaceous_or_destructive_disease
    Visible tophus, joint destruction, or recurrent flares despite ULT (ACR 2020 FitzGerald)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereallopurinol_hypersensitivity_syndrome_risk
    SE Asian or African American ancestry, CKD ≥3, or thiazide use → high AHS risk (ACR 2020 FitzGerald strong)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepegloticase_g6pd_or_mtx_compatibility
    Refractory gout with G6PD deficiency or MTX contraindication (ACR 2020 FitzGerald; MIRROR Botson 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecv_disease_with_febuxostat_question
    Established CVD considering febuxostat (CARES White NEJM 2018; FAST Mackenzie Lancet 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateurolithiasis_uric_acid
    Recurrent uric acid stones or chronic kidney disease (ACR 2020 FitzGerald)
    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 (≤24 h symptom onset)
axis: gout_acute_flare
Selected axis "Acute gout flare (≤24 h symptom onset)" by default fallback (first axis)
  • colchicine
    first line
    colchicine
    triggers: onset_<24h, no_severe_CKD, no_strong_CYP3A4_inhibitor
    1.2 mg → 0.6 mg 1h later — low-dose colchicine per AGREE trial (Terkeltaub Arthritis Rheum 2010); ACR 2020 FitzGerald strong; 0.6 mg q12h or daily until resolution
    rxcui 2683
  • naproxen
    first line
    NSAID
    triggers: no_CKD, no_PUD, no_severe_CVD
    500 mg BID × 5-7 d; alternative indomethacin 50 mg TID (ACR 2020 FitzGerald first-line)
    rxcui 7258
  • prednisone
    first line
    corticosteroid
    triggers: CKD, NSAID_contraindicated, polyarticular
    40 mg/d × 5 d or 0.5 mg/kg/d taper over 10-14 d (ACR 2020 FitzGerald first-line; EULAR 2024)
    rxcui 8640
  • anakinra
    rescue
    IL_1_inhibitor
    triggers: refractory_to_first_line, CKD_severe_NSAID_excluded_steroid_contraindicated
    100 mg SC daily × 3-5 d (off-label, ACR 2020 FitzGerald conditional; EULAR 2024)
    rxcui 72435

outpatient playbook — drug actions (8)

  1. 1. colchicine acute flare
    1.2 mg PO × 1 then 0.6 mg 1 h later, then 0.6 mg q12h-daily • PO • until resolution
    trigger: Flare onset <24 h, no severe CKD, no strong CYP3A4/PGP inhibitor
    Low-dose colchicine per AGREE trial (Terkeltaub 2010); ACR 2020 FitzGerald strong; reduce dose for CKD
  2. 2. NSAID
    Naproxen 500 mg PO BID OR indomethacin 50 mg PO TID • PO • 5-7 d
    trigger: No CKD, no PUD, no severe CVD
    ACR 2020 FitzGerald first-line acute flare
  3. 3. prednisone
    40 mg PO daily • PO • 5 d (no taper for short course) or 0.5 mg/kg taper × 10-14 d
    trigger: CKD, NSAID contraindicated, polyarticular, hospitalised
    ACR 2020 FitzGerald first-line; EULAR 2024
  4. 4. intra-articular steroid
    Methylprednisolone 40-80 mg or triamcinolone 40 mg • intra-articular • single
    trigger: Monoarticular flare amenable to injection
    ACR 2020 FitzGerald — equivalent or superior to systemic for monoarticular; EULAR 2024
  5. 5. allopurinol initiation
    Start 100 mg PO daily (50 mg if CKD ≥3); titrate q2-4 weeks by 100 mg • PO • daily
    trigger: ULT indication (≥2 flares/yr, tophus, CKD ≥3, urolithiasis, SUA >9)
    ACR 2020 FitzGerald strong first-line; EULAR 2024; treat-to-target SUA <6 or <5 tophaceous
  6. 6. flare prophylaxis
    Colchicine 0.6 mg PO daily OR low-dose NSAID • PO • daily ≥6 months after target reached
    trigger: Starting/titrating ULT
    ACR 2020 FitzGerald strong — prevents mobilisation flare; EULAR 2024
  7. 7. febuxostat alternative
    40 mg → 80 mg PO daily • PO • daily
    trigger: Allopurinol intolerant or HLA-B*5801 positive (high AHS risk)
    FAST (Mackenzie Lancet 2020) — non-inferior CV safety; ACR 2020 conditional
  8. 8. pegloticase + MTX
    Pegloticase 8 mg IV q2 weeks + MTX 15 mg PO weekly • IV + PO • q2 weeks
    trigger: Refractory tophaceous gout, failure of XOI
    MIRROR (Botson J Rheumatol 2022 PMID 36099211) — MTX co-therapy raises responder rate to 71%

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Acute monoarthritis, often 1st MTP (podagra) (ACR 2020 FitzGerald; EULAR 2024); Polyarticular flare with prior gout (ACR 2020 FitzGerald); Hyperuricemia + recurrent flares / tophi / urolithiasis (ACR 2020 FitzGerald).

Objective

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

Assessment

**Gout (acute flare → urate-lowering therapy)** (rheum.gout.core.v1).
Phenotype framing: Septic arthritis, CPPD, palindromic RA, reactive arthritis, psoriatic arthritis, fracture, cellulitis (EULAR 2024)
Scope: Adult primary + secondary gout — acute flare, intercritical, chronic tophaceous, refractory (ACR 2020 FitzGerald; EULAR 2024)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Acute gout flare (≤24 h symptom onset)**.
1. colchicine (colchicine, first line) — 1.2 mg → 0.6 mg 1h later — low-dose colchicine per AGREE trial (Terkeltaub Arthritis Rheum 2010); ACR 2020 FitzGerald strong; 0.6 mg q12h or daily until resolution
2. naproxen (NSAID, first line) — 500 mg BID × 5-7 d; alternative indomethacin 50 mg TID (ACR 2020 FitzGerald first-line)
3. prednisone (corticosteroid, first line) — 40 mg/d × 5 d or 0.5 mg/kg/d taper over 10-14 d (ACR 2020 FitzGerald first-line; EULAR 2024)
4. anakinra (IL_1_inhibitor, rescue) — 100 mg SC daily × 3-5 d (off-label, ACR 2020 FitzGerald conditional; EULAR 2024)

Setting playbook (outpatient) — Treat acute flare to resolution within 7-10 days, initiate or titrate ULT to target SUA <6 (or <5 tophaceous), address modifiable drivers (ACR 2020 FitzGerald; EULAR 2024)
5. colchicine acute flare 1.2 mg PO × 1 then 0.6 mg 1 h later, then 0.6 mg q12h-daily PO until resolution — Flare onset <24 h, no severe CKD, no strong CYP3A4/PGP inhibitor (Low-dose colchicine per AGREE trial (Terkeltaub 2010); ACR 2020 FitzGerald strong; reduce dose for CKD)
6. NSAID Naproxen 500 mg PO BID OR indomethacin 50 mg PO TID PO 5-7 d — No CKD, no PUD, no severe CVD (ACR 2020 FitzGerald first-line acute flare)
7. prednisone 40 mg PO daily PO 5 d (no taper for short course) or 0.5 mg/kg taper × 10-14 d — CKD, NSAID contraindicated, polyarticular, hospitalised (ACR 2020 FitzGerald first-line; EULAR 2024)
8. intra-articular steroid Methylprednisolone 40-80 mg or triamcinolone 40 mg intra-articular single — Monoarticular flare amenable to injection (ACR 2020 FitzGerald — equivalent or superior to systemic for monoarticular; EULAR 2024)
9. allopurinol initiation Start 100 mg PO daily (50 mg if CKD ≥3); titrate q2-4 weeks by 100 mg PO daily — ULT indication (≥2 flares/yr, tophus, CKD ≥3, urolithiasis, SUA >9) (ACR 2020 FitzGerald strong first-line; EULAR 2024; treat-to-target SUA <6 or <5 tophaceous)
10. flare prophylaxis Colchicine 0.6 mg PO daily OR low-dose NSAID PO daily ≥6 months after target reached — Starting/titrating ULT (ACR 2020 FitzGerald strong — prevents mobilisation flare; EULAR 2024)
11. febuxostat alternative 40 mg → 80 mg PO daily PO daily — Allopurinol intolerant or HLA-B*5801 positive (high AHS risk) (FAST (Mackenzie Lancet 2020) — non-inferior CV safety; ACR 2020 conditional)
12. pegloticase + MTX Pegloticase 8 mg IV q2 weeks + MTX 15 mg PO weekly IV + PO q2 weeks — Refractory tophaceous gout, failure of XOI (MIRROR (Botson J Rheumatol 2022 PMID 36099211) — MTX co-therapy raises responder rate to 71%)

Non-pharmacologic actions:
- Switch HCTZ → losartan or amlodipine when feasible (EULAR 2024)
- Alcohol moderation, fructose reduction, hydration (EULAR 2024; ACR 2020 FitzGerald)
- Weight loss if overweight (1 kg ↓ ≈ 0.1 mg/dL SUA) (EULAR 2024)
- Treat tophus surgically if functional impairment (ACR 2020 FitzGerald)
- Cardiovascular risk modification (ASCVD assessment) (EULAR 2024)

AVOID / contraindication checks:
- Colchicine block with strong CYP3A4 or PGP inhibitor (ACR 2020 FitzGerald)
- NSAID block if CKD3b or active PUD or HF (ACR 2020 FitzGerald; ACP 2017)
- Steroid counsel glucose monitoring (ACR 2020 FitzGerald)

Monitoring

Regimen monitoring:
- symptom resolution 24-48h (ACR 2020 FitzGerald)
- BMP pre post NSAID course if renal risk (ACR 2020)

Setting (outpatient) monitoring:
- SUA q2-4 weeks during ULT titration → q6 months at target (ACR 2020 FitzGerald)
- CBC, LFT, BMP q3 months first year (ACR 2020 FitzGerald)
- Symptom diary for flares (EULAR 2024)
- Continue prophylaxis ≥6 months after target reached (ACR 2020 FitzGerald strong)

Follow-up plan: 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
- Close-out criterion: long-term plan + counseling complete

Monitoring phase: 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

Disposition

Current setting: outpatient — Treat acute flare to resolution within 7-10 days, initiate or titrate ULT to target SUA <6 (or <5 tophaceous), address modifiable drivers (ACR 2020 FitzGerald; EULAR 2024)

Disposition criteria:
- Continue outpatient ULT titration; specialist referral if refractory

Escalation triggers (move to higher acuity):
- Refractory flare not responding to first-line × 24 h → ED for IM/IV steroid or anakinra (ACR 2020 FitzGerald conditional)
- Septic arthritis suspicion (fever + monoarticular) → ED arthrocentesis (ACR 2020; EULAR 2024)
- Refractory tophaceous → rheumatology + pegloticase (MIRROR Botson 2022)

Patient Action Plan

**Gout self-management + ULT plan**
Personalised values: ult_drug_and_dose, flare_rescue_plan, comorbid_CKD_CVD, sua_target.

**Stable, on ULT, at target SUA** (green):
Triggers:
- No flares in last 6+ months (ACR 2020 FitzGerald)
- SUA <6 (or <5 if tophaceous) (ACR 2020 FitzGerald; EULAR 2024)
- Taking allopurinol/febuxostat as prescribed
Actions:
- Take ULT every day — never stop because you feel well (ACR 2020 FitzGerald strong)
- Keep follow-up labs every 6 months (ACR 2020 FitzGerald)
- Hydrate, limit alcohol and high-fructose drinks (EULAR 2024)
- Discuss any new medications with your prescriber (some raise SUA) (EULAR 2024)
- Continue flare prophylaxis (colchicine 0.6 mg daily or NSAID) for at least 6 months after target (ACR 2020 FitzGerald strong)

**Early flare or rising SUA** (yellow):
Triggers:
- New joint pain / warmth / swelling
- SUA rising
- Missed ULT doses
Actions:
- DO NOT stop your ULT during a flare (ACR 2020 FitzGerald strong)
- Start your pre-prescribed flare rescue regimen immediately (colchicine 1.2 mg → 0.6 mg 1 h later, then 0.6 mg q12h; OR NSAID if no CKD; OR prednisone if you have a script) (ACR 2020 FitzGerald)
- Ice and rest the joint (EULAR 2024)
- Call your provider within 24 h if not improving
- Continue flare medication until pain fully resolved (typically 5-7 days) (ACR 2020)
Contact provider when:
- Flare not improving within 48 h
- Multiple joints involved
- Fever (ACR 2020 — rule out septic arthritis)

**Septic arthritis suspicion or severe systemic illness** (red):
Triggers:
- Fever (>38 C) with hot, swollen joint (ACR 2020 FitzGerald; EULAR 2024)
- Single joint that is rapidly worsening
- Cannot bear weight or move joint at all
- Severe systemic illness
Actions:
- Go to emergency department now
- Bring medication list including ULT and flare regimen
- Tell ED about your gout history but emphasise this might be infection (ACR 2020)
Contact provider when:
- Always seek emergency care for fever + joint or severe rapid worsening (ACR 2020; EULAR 2024)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Monoarticular flare with fever, immunocompromise, or atypical features (ACR 2020 FitzGerald; EULAR 2024)
- [SEVERE] Visible tophus, joint destruction, or recurrent flares despite ULT (ACR 2020 FitzGerald)
- [SEVERE] SE Asian or African American ancestry, CKD ≥3, or thiazide use → high AHS risk (ACR 2020 FitzGerald strong)

Citations

- 2020 ACR Guideline for Gout (FitzGerald et al, Arthritis Care Res 2020) + 2024 EULAR Updated Recommendations (Richette et al) + ACP 2017 [PMID:32391934](https://pubmed.ncbi.nlm.nih.gov/32391934/)
- Cited evidence (PMID 33181081) [PMID:33181081](https://pubmed.ncbi.nlm.nih.gov/33181081/)
- Cited evidence (PMID 36099211) [PMID:36099211](https://pubmed.ncbi.nlm.nih.gov/36099211/)
- Cited evidence (PMID 29527974) [PMID:29527974](https://pubmed.ncbi.nlm.nih.gov/29527974/)

Last reconciled with current guidelines: 2026-05-22.
References
  • 2020 ACR Guideline for Gout (FitzGerald et al, Arthritis Care Res 2020) + 2024 EULAR Updated Recommendations (Richette et al) + ACP 2017 — PMID:32391934
  • Cited evidence (PMID 33181081) — PMID:33181081
  • Cited evidence (PMID 36099211) — PMID:36099211
  • Cited evidence (PMID 29527974) — PMID:29527974