New Gout Guidelines

New Guidelines for Treating and Preventing Gout

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Gout is one of the most common forms of inflammatory arthritis, affecting nearly 4% of adult Americans. Newly approved guidelines that educate patients in effective methods to prevent gout attacks and provide primary care providers with recommended therapies for long-term management of this painful disease were recently published in Arthritis Care & Research.[1][2]

Clinician-diagnosed gout has risen over the past 20 years and now affects 8.3 million people in the U.S.[1] Medical evidence suggests that the increased prevalence of elevated uric acid levels and gout may be attributed to such factors as hypertension, obesity, metabolic syndrome, type 2 diabetes, and extensive treatment with thiazide and loop diuretics for cardiovascular disease.

A writing team reviewed medical literature from the 1950s to the present. A task force panel including seven rheumatologists, two primary care physicians, a nephrologist, and a patient representative then ranked and voted upon recommendations to create the two-part ACR gout guidelines.

Part I of the guidelines focuses on the systematic nonpharmacologic and pharmacologic therapeutic approaches to hyperuricemia. Part I guidelines include:

  • Educating patients on diet, lifestyle choices, treatment objectives, and management of concomitant diseases.
  • Treating patients with a xanthine oxidase inhibitor (XOI), such as allopurinol (Zyloprim), as first-line pharmacologic urate-lowering therapy (ULT) approach.
  • Reducing urate levels to less than 6 mg/dL.
  • Maintain the initial dose of allopurinol to less than 100 mg/day, and less for patients with chronic kidney disease. Maintenance dose can exceed 300 mg even in those with chronic kidney disease.
  • Consideration of HLA-B*5801 pre-screening of patients at particularly high risk for severe adverse reaction to allopurinol (e.g., Koreans with stage 3 or worse kidney disease, and all those of Han Chinese and Thai descent).
  • Prescribing combination therapy, with one XOI and one uriocosuric agent, when target urate levels are not achieved; pegloticase in patients with severe gout disease who do not respond to standard, appropriately dosed ULT therapy.

Part II guidelines cover therapy and prophylactic anti-inflammatory treatment for acute gouty arthritis. Part II guidelines recommend that physicians:

  • Initiate pharmacologic therapy within 24 hours of gout attack.
  • Continue uninterrupted ULT therapy during acute gout flares.
  • Use non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, or oral colchicine as first-line treatment for acute gout, and combinations of these medications for severe or unresponsive cases.
  • Unless otherwise contradicted, use oral colchicine or low-dose NSAIDs as the first-line therapy options to prevent gout attacks when initiating ULT.



  1. Khanna D, FitzGerald JD, Khanna PP, et al. 2012 American College of Rheumatology Guidelines for Management of Gout Part I: Systematic Non-pharmacologic and Pharmacologic Therapeutic Approaches to Hyperuricemia. Arthritis Care Res (Hoboken). 2012 Oct;64(10):1431-46.
  2. Khanna D, Khanna P, Fitzgerald JD, et al. 2012 American College of Rheumatology Guidelines for Management of Gout Part II: Therapy and Anti-inflammatory Prophylaxis of Acute Gouty Arthritis. Arthritis Care Res (Hoboken). 2012 Oct;64(10):1447-61.