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Gout Management - 2012 ACR Guidelines

Recommendations for Hyperuricemia and Acute Gouty Arthritis


Updated June 27, 2014

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Gout is one of the most common rheumatic diseases in the U.S., affecting about 8.3 million adults. Over the past few decades, the prevalence of gout has increased. The increased prevalence of gout has been linked to the increased prevalence of comorbidities associated with hyperuricemia, such as hypertension, obesity, metabolic syndrome, type 2 diabetes, and chronic kidney disease. Other factors that increase gout prevalence include diet and side effects of certain drugs used to treat cardiovascular disease.

Researchers associated with the American College of Rheumatology were assigned the task of developing recommendations for gout management. They developed a two-part set of guidelines which serves to educate patients about preventing gout attacks and provides doctors and patients with information about long-term gout management.

Part 1 - Nonpharmacologic and Pharmacologic Therapeutic Approaches to Hyperuricemia

Baseline Recommendations for Patients Diagnosed With Gout

  • Patients should be educated on dietary choices that affect gout and on lifestyle choices.
  • Secondary causes of hyperuricemia should be considered (the aforementioned comorbidities).
  • Elimination of non-essential prescription medications that promote hyperuricemia should be considered.
  • Patients should be evaluated for gout symptom severity (tophi, synovitis, number of gout attacks).

Recommendations for Urate-Lowering Medications

  • Urate-lowering medications (allopurinol or probenecid) are appropriate for any patient diagnosed with gouty arthritis who has tophus (tophi) evident by physical examination or imaging studies.
  • Urate-lowering medications are also appropriate for patients who have frequent gout attacks, defined as two or more per year.
  • Urate-lowering medications are recommended for patients with gout and chronic kidney disease (stage 2 or worse) or for patients with past urolithiasis (urinary stones).
  • The minimum target for treatment with urate-lowering medications is a serum uric acid level of less than 6 mg/dl. To sufficiently reduce gout signs and symptoms, it may be necessary to go lower, to a 5 mg/dl urate level.
  • For urate-lowering therapy, either allopurinol or Uloric (febuxostat) (both xanthine oxidase inhibitors) is considered the first-line agent.
  • If a gout attack is already underway, urate-lowering medications may be started, provided that effective anti-inflammatory therapy has already been started.
  • The allopurinol starting dose should be no more than 100 mg/day for gout patients, and 50 mg/day for gout patients with stage 4 or worse chronic kidney disease. The dose can be bumped up every 2-5 weeks until the target serum urate level is achieved.
  • Probenecid is the first choice when uricosuric drugs are used (drugs that lower uric acid levels in the body by increasing the elimination of uric acid by the kidneys). In individual cases, certain kidney tests (such as urine uric acid, creatinine clearance, and a history of urolithiasis) may be used to determine if probenecid is an appropriate choice.
  • A xanthine oxidase inhibitor (allopurinol or Febuxostat, for example) and a uricosuric agent (e.g., probenecid) may be combined when target urate levels are not achieved with just one of the drugs.

A Closer Look at Dietary Recommendations

The researchers divided their dietary recommendations into three categories: Avoid, Limit, and Encourage. None of the recommendations were based on multiple randomized clinical trials or meta-analysis. The recommendations came from either a single randomized clinical trial, non-randomized trials, or the consensus of the experts. Interestingly, the researchers were unable to reach consensus on cherries, nuts, or legumes.

AVOID: organ meats high in purines; soda, other beverages, or foods that are sweetened with high fructose corn syrup; alcohol overuse (more than 2 servings per day for male and 1 serving per day for female gout patients; any alcohol during periods of frequent gout attacks or with advanced gout.

LIMIT: serving sizes of beef, lamb, and pork, seafood with high purine content (such as sardines and shellfish); servings of naturally sweet fruit juices; table sugar, sweetened beverages, and dessert; table salt; alcohol (especially beer, but also wine and spirits).

ENCOURAGE (but not to excess): low-fat and non-fat dairy products; vegetables.

Part 2 - Therapy and Anti-inflammatory Prophylaxis of Acute Gouty Arthritis

Researchers provided the following guidance for dealing with acute gouty arthritis attacks:

  • Within 24 hours of onset of an acute gouty arthritis attack, pharmacologic therapy should be started.
  • Urate-lowering pharmacologic therapy should continue during an acute gout attack.
  • NSAIDs (nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, or oral colchichine are appropriate first line agents for treating acute gout. Combinations of these drug classes can be used when the gout attack is severe or when monotherapy (treatment with one class of drug) is insufficient. One exception is the combination of systemic corticosteroids and NSAIDs, which was not recommended due to concerns over unacceptable risk of gastrointestinal side effects.
  • Topical ice is appropriate, as needed, for acute gout.
  • To prevent gout attacks, oral colchicine or a low-dose NSAID is appropriate when initiating urate-lowering therapy. If NSAIDs or colchicine are contraindicated or not well-tolerated, low dose prednisone or prednisolone is an option.


2012 American College of Rheumatology Guidelines for Management of Gout. Part 1: Systematic Nonpharmacologic and Pharmacologic Therapeutic Approaches to Hyperuricemia. Khanna D. et al. Arthritis Care and Research. Volume 64 No. 10. October 2012.

2012 American College of Rheumatology Guidelines for Management of Gout. Part 2: Therapy and Antiinflammatory Prophylaxis of Acute Gouty Arthritis. Khanna D. et al. Arthritis Care and Research. Volume 64 No. 10. October 2012.

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