For patients with recurrent gout attacks despite ongoing treatment, consider reviewing and optimizing urate-lowering therapy (ULT) using a treat-to-target strategy to achieve a serum urate level below 360 micromol/L (6 mg/dL), or below 300 micromol/L (5 mg/dL) if they have tophi or ongoing flares despite lower levels NICE CKS.
Start or adjust ULT at least 2-4 weeks after a gout flare has settled, and consider initiating during a flare if flares are frequent NICE CKS.
Use a low dose of ULT initially and guide dose increases with monthly serum urate levels until the target is reached NICE CKS.
Discuss with the patient the benefits and risks of continuing or initiating long-term ULT, and consider adding or optimizing prophylactic treatment to prevent flares during titration, such as colchicine, NSAIDs, or corticosteroids, especially if flares are frequent or severe NICE CKS.
Ensure management of comorbidities and lifestyle factors, including weight management, alcohol intake, and medication review, to reduce flare frequency NICE CKS.
If flares persist despite optimal ULT, consider referral to a rheumatology service for further assessment and management NICE CKS.