gout: acute flare + urate-lowering therapy (ult)

Colchicine (BNF): 500 micrograms 2–4 times daily until symptoms improve. Total dose per course must not exceed 6 mg and do not repeat a course within 3 days. Adjust/avoid in renal/hepatic impairment and with strong CYP3A4/P-gp inhibitors (see BNF).

NSAID: choose based on GI/CV/renal risk and local formulary; consider gastroprotection where appropriate.

Oral corticosteroid: suitable where NSAIDs/colchicine are contraindicated or not tolerated; dose and duration should follow local protocol (and consider diabetes, infection risk, etc.).

Key safety: always consider septic arthritis if fever, systemic toxicity, immunosuppression, prosthetic joint, or atypical course.

• Treat-to-target: NICE recommends monitoring serum urate and using a dose-titration strategy to achieve the agreed target.
• Targets: aim for serum urate <360 micromol/L (6 mg/dL). Consider <300 micromol/L (5 mg/dL) for tophi, chronic gouty arthritis, or frequent flares.
• Allopurinol is first-line ULT for most people; start low and titrate. BNF lists initially 100 mg once daily, with dose adjustment guided by urate level; reduce starting dose in renal impairment.
• Flare prophylaxis when starting ULT: commonly colchicine 500 micrograms once or twice daily (or alternative) depending on patient factors and local protocols.

• Start low, go slow: allopurinol 100 mg OD (lower in CKD), then increase in 100 mg increments at intervals (often ~4 weeks) until target urate is achieved, with periodic urate checks and side effect monitoring.
• Do not stop ULT during a flare: manage the flare and continue the established ULT regimen.
• Address drivers: diuretics, obesity, alcohol (especially beer/spirits), dehydration, high purine intake, CKD; optimise BP/diabetes/lipids in parallel.