Gout management trips up on two recurring errors: stopping urate-lowering therapy when a flare hits, and starting it without flare cover. Both make the next months worse.
If a patient is already on allopurinol or febuxostat, continue it through an acute flare and treat the flare on top, with an NSAID, low-dose colchicine or a corticosteroid chosen by the patient's comorbidities. Stopping and restarting urate-lowering therapy only destabilises serum urate and provokes further attacks.
When starting urate-lowering therapy, treat to a target serum urate — below 6 mg/dL, or below 5 in tophaceous disease — and co-prescribe flare prophylaxis, usually low-dose colchicine, for several months while urate falls. Framed this way, the flare is a treatment opportunity rather than a reason to pause the drug that prevents it.
- Continue established urate-lowering therapy through an acute gout flare; do not stop it.
- Treat the flare with an NSAID, low-dose colchicine or a corticosteroid, chosen by comorbidity.
- When starting urate-lowering therapy, treat to a serum urate below 6 mg/dL (below 5 if tophaceous).
- Co-prescribe flare prophylaxis, usually low-dose colchicine, for several months when initiating.
Why it matters
Stopping urate-lowering therapy during flares and starting it without cover are common errors that drive recurrent attacks.
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