Long-Term Management of Gout:
• Continue all measures (including pharmacologic ULT) needed to maintain serum
urate <6 mg/dl indefinitely. (C)
• Regularly monitor serum urate (C) and monitor for ULT side effects. (C)
• Consider referral to a specialist for (i) Unclear etiolog y of hyperuricemia; (ii)
Refractory signs or symptoms of gout; (iii) Difficulty achieving serum urate target,
particularly with renal impairment; (iv) Multiple and/or serious adverse events. (C)
Figure 1. Management of Gout (continued)
a
Examples of serum urate-elevating drugs that might be non-essential in a given patient and potentially
replaced by alternative agents that do not elevate serum urate:
• Niacin for hyperlipidemia.
• Thiazide and loop diuretics for hypertension, so long as cessation of treatment would not exacerbate
difficult-to-control hypertension cases.
• Calcineurin inhibition with cyclosporine or tacrolimus so long as other satisfactory immune
suppression agent is available.
b
Probenecid is not recommended as a first line or alternative first line ULT agent if the CrCl is <50. (C)
Figure 2. Chronic Tophaceous Gouty Arthopathy
Mild Tophaceous Burden
Stable, simple tophus
limited to 1 joint region
Moderate Tophaceous Burden
Stable, simple tophi affecting 2–4 joints
Severe Tophaceous Burden
• Lack of drainage
• Lack of aggressive
mass or connective
tissue destructive effects
• Low risk of tophus
infection
• Stable in size, or slow
growth
• Lack of severe chronic,
tophaceous joint
inflammation
• Tophi affecting more than 4 joint regions
OR
• One or more tophi demonstrating
︎✔︎ Drainage
✔ Aggressive mass or connective
tissue destructive effects
✔ High risk of infection
✔ Very rapid growth
✔ Severe, chronic tophaceous joint
inflammation
Overview of Gout
