(1) Patient education on diet, lifestyle, treatment objectives, and management of comorbidities is a recommended core therapeutic measure in gout.
(2) Xanthine oxidase inhibitor (XOI) therapy with either allopurinol or febuxostat is recommended as the first-line pharmacologic urate-lowering therapy (ULT) approach in gout.
(3) Serum urate level should be lowered sufficiently to durably improve signs and symptoms of gout, with the target 6 mg/dl at a minimum, and often 5 mg/dl.
(4) The starting dosage of allopurinol should be no greater than 100 mg/day and less than that in moderate to severe chronic kidney disease (CKD), followed by gradual upward titration of the maintenance dose, which can exceed 300 mg daily even in patients with CKD.
(5) Prior to initiation of allopurinol, rapid polymerase chain reaction– based HLA–B*5801 screening should be considered as a risk management component in subpopulations where both the HLA–B*5801 allele frequency is elevated and the HLA–B*5801–positive subjects have a very high hazard ratio (“high risk”) for severe allopurinol hypersensitivity reaction (e.g., Koreans with stage 3 or worse CKD and all those of Han Chinese and Thai descent).
(6) Combination oral ULT with 1 XOI agent and 1 uricosuric agent is appropriate when the serum urate target has not been met by appropriate dosing of an XOI.
(7) Pegloticase is appropriate for patients with severe gout disease burden and refractoriness to, or intolerance of, appropriately dosed oral ULT options.
(8) An acute gouty arthritis attack should be treated with pharmacologic therapy, initiated within 24 hours of onset.
(9) Established pharmacologic urate-lowering therapy should be continued, without interruption, during an acute attack of gout.
(10) Nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, or oral colchicine are appropriate first-line options for treatment of acute gout, and certain combinations can be employed for severe or refractory attacks.
(11) Pharmacologic anti-inflammatory prophylaxis is recommended for all gout patients when pharmacologic urate lowering is initiated, and should be continued if there is any clinical evidence of continuing gout disease activity and/or the serum urate target has not yet been achieved.
(12) Oral colchicine is an appropriate first-line gout attack prophylaxis therapy, including with appropriate dose adjustment in chronic kidney disease and for drug interactions, unless there is a lack of tolerance or medical contraindication.
(13) Low-dose NSAID therapy is an appropriate choice for first-line gout attack prophylaxis, unless there is a lack of tolerance or medical contraindication.