Acute monoarthritis (1st MTP), after NSAID failure
Most accurate: Joint aspirate — negatively birefringent needle crystals (uric acid normal in 25%)
Acute: Colchicine, NSAID, OR glucocorticoid — co-equal strong first-line options (ACR 2020), chosen by patient factors; low-dose colchicine preferred over high-dose
Chronic (may start during flare with cover): Allopurinol — strongly recommended first-line ULT for ALL patients including CKD ≥3 (ACR 2020) → titrate to urate <6 (colchicine prophylaxis during initiation)
Order set
- Joint aspiration + crystals
- Serum urate (after flare)
- U&E
- Exclude septic arthritis
Criteria
AdmitCannot exclude septic joint or severe polyarticular
DischargeFlare settling, urate-lowering plan with cover
Never
- Diagnose gout as gout before crystal analysis
- Stop allopurinol during a flare — never stop it; STARTING ULT during a flare is acceptable (ACR 2020, conditional) provided anti-inflammatory cover is given; low-dose start, titrate to target
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
- Fever + hot joint (exclude sepsis)
Differentials
- Septic arthritis
- Pseudogout
- Cellulitis
- Reactive arthritis
Common mistakes
- Diagnosing before aspiration
- Stopping allopurinol mid-flare
Disposition & follow-up
Treat flare; urate-lowering after settling with cover.
Discharge package
MedicationsFlare therapy; allopurinol first-line ULT with cover; pegloticase for refractory gout (frequent flares/tophi despite XOI ± uricosuric)
Follow-upRecheck urate to target
LifestyleReduce alcohol/purines, weight loss, hydration
Warning symptomsRecurrent flares, hot swollen joint with fever
💊 Treatment detail — doses & preparation
NaproxenNSAID
Dose500 mg BD with food (gout flare until settled; pain)
Preparation250/500 mg tablets; add PPI if risk factors
MonitorRenal function, GI bleeding, BP; avoid in CKD/HF
Colchicineanti-gout flare
Dose1 mg then 0.5 mg 1 h later (day 1), then 0.5 mg OD–BD until flare settles
Preparation0.5/0.6 mg tablets
MonitorGI upset (dose-limiting), avoid with clarithromycin in CKD; marrow in overdose
Prednisolonecorticosteroid
DoseGout flare: 30–35 mg OD ×~5 d (no taper needed)
Preparation5/25 mg tablets; gastro-resistant or plain with food
MonitorGlucose, BP, mood; bone protection if >3 mo (Ca²⁺/D ± bisphosphonate)
Allopurinolxanthine oxidase inhibitor
DoseStart ≤100 mg OD (lower in CKD), titrate q2–4 wk to urate <0.36 mmol/L (max 900 mg); may start during flare with anti-inflammatory cover; HLA-B*5801 testing before starting in high-risk ancestries (Southeast Asian, African American)
Preparation100/300 mg tablets; co-prescribe colchicine/NSAID cover ×3–6 mo (initiation flares)
MonitorUrate, LFTs; STOP for rash (SJS risk esp. CKD); azathioprine interaction
Febuxostatxanthine oxidase inhibitor
Dose80 mg OD, ↑120 mg if urate not at target
Preparation80/120 mg tablets
MonitorCardiovascular caution (CARES), LFTs
📖 ACR / EULAR GoutReviewed July 2026