Urate-lowering therapy and gout prevention — Rapid

Synopsis

Use shared decisions and a treat-to-target strategy to dissolve monosodium-urate crystals, prevent flares and tophi, titrate allopurinol or febuxostat safely and sustain monitoring across renal, cardiovascular and reproductive contexts.

Urate-lowering therapy is crystal-dissolving treatment, not an analgesic. Benefits require a serum-urate target, gradual titration, flare prophylaxis and continuation after the patient feels well.
Offer treat-to-target ULT for multiple or troublesome flares, CKD stages 3–5, diuretic therapy, tophi or chronic gouty arthritis; discuss it after a first or later flare in other patients.
NICE usually starts ULT two to four weeks after a flare has settled; frequent flares can justify starting during an attack while adequate anti-inflammatory treatment and prophylaxis continue.
Aim below 360 micromol/L. Consider below 300 micromol/L for tophi, chronic gouty arthritis or persistent frequent flares despite remaining below 360.
NICE accepts allopurinol or febuxostat as first-line in most adults after comorbidity and preference review, but allopurinol is specifically first-line when major cardiovascular disease is present.
Start low and measure serum urate monthly while increasing treatment. Allopurinol 300 mg is not a universal ceiling; many adults need careful higher licensed doses to reach target.
Start allopurinol commonly at 100 mg once daily and lower in important renal impairment; increase according to urate and tolerance rather than estimating the final dose from eGFR alone.

Key red flags

Rash, mucosal pain, blistering, facial swelling, fever or systemic illness after allopurinol requires immediate permanent cessation pending urgent assessment.

Severe diarrhoea, vomiting, proximal weakness, paraesthesia, bruising or infection during colchicine prophylaxis can signal accumulation, neuromyopathy or marrow toxicity.

Chest pain, new focal neurological symptoms or decompensated heart failure during febuxostat treatment requires urgent cardiovascular assessment and medicine review.

Abrupt oliguria, tumour-lysis physiology or uric-acid obstruction needs acute renal and oncology management rather than routine outpatient dose titration.

Pregnancy, conception planning or breastfeeding requires early specialist review because febuxostat should not be used and allopurinol or prophylaxis needs individual benefit-risk assessment.

A hot prosthetic or systemically unwell joint remains a septic-arthritis question even when serum urate is above target and flares are expected during titration.

Allopurinol hypersensitivity

Investigation priorities

First-line baseline urate and safety bloodsFirst stepFirst line

Confirm the treatment baseline and identify prescribing constraints.

Management branches

First-line eligibilityOffer or discuss lifelong crystal dissolution

Gout is confirmed and the acute attack has been reviewed.

Offer ULT for troublesome recurrence, CKD stages 3–5, diuretic therapy, tophi or chronic gouty arthritis and discuss it with other patients after any flare.
Explain targets, early mobilisation flares, prophylaxis, likely lifelong duration and why symptom freedom alone is not crystal clearance.
Obtain baseline urate, renal, hepatic and blood safety data and plan the start usually two to four weeks after the flare settles.

First-line selectionChoose allopurinol or febuxostat safely

The patient elects to begin treat-to-target urate-lowering therapy.

Use allopurinol first when major cardiovascular disease is present; otherwise discuss either option using comorbidity, interaction and preference.
Start allopurinol 100 mg daily, lower when severe renal impairment warrants, or febuxostat 80 mg daily and arrange monthly urate review.
Offer colchicine prophylaxis while target is approached and supply a separate written plan for treating breakthrough flares without stopping ULT.

Key medicines

AllopurinolStart 100 mg orally once daily after food in most adults; consider 50 mg once daily in advanced renal impairment. Increase commonly by 100 mg every 2 to 4 weeks against monthly serum urate, up to the licensed maximum 900 mg daily when necessary and tolerated.Stop immediately for any rash and never rechallenge after DRESS, SJS or TEN. Consider HLA-B*58:01 testing in high-prevalence ancestry, especially with CKD. Review renal and liver function, ACE inhibitor or diuretic context, warfarin and the dangerous azathioprine or mercaptopurine interaction. Use in pregnancy only when no safer alternative and disease itself carries risk.

FebuxostatGive 80 mg orally once daily with or without food; if serum urate remains above 357 micromol/L after 2 to 4 weeks, consider increasing to 120 mg once daily.Use cautiously in previous myocardial infarction, stroke, unstable angina or other major cardiovascular disease and monitor regularly. Check liver function and rash; avoid azathioprine or mercaptopurine unless a specialist manages the major interaction. Do not use in pregnancy or breastfeeding and avoid severe hepatic impairment.

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