This protocol covers patients with frequent gout flares who have established contraindications to colchicine, to NSAIDs, and to corticosteroids (both oral and injectable), and who have no current infection. In this setting, IL-1 blockers may be considered for flare management; an active infection is a contraindication to their use.
Allopurinol — titrated with dose escalation — together with lifestyle measures (diet, alcohol reduction, regular exercise) did not achieve the serum uric acid target:
This protocol defines the next therapeutic step when those targets are not met.
When allopurinol fails to reach the serum uric acid target, the structured approach involves switching to a different urate-lowering agent or a combination strategy — the complete regimen is available in the full protocol.
Treatment goals:
DOI: 10.1136/annrheumdis-2016-209707
In patients with frequent flares and contraindications to colchicine, NSAIDs and corticosteroid (oral and injectable), IL-1 blockers should be considered for treating flares.
Current infection is a contraindication to the use of IL-1 blockers.
If the SUA target cannot be reached by an appropriate dose of allopurinol, allopurinol should be switched to febuxostat or a uricosuric, or combined with a uricosuric.
For patients on ULT, SUA level should be monitored and maintained to <6 mg/dL (360 mmol/L).
A lower SUA target (<5 mg/dL; 300 mmol/L) to facilitate faster dissolution of crystals is recommended for patients with severe gout (tophi, chronic arthropathy, frequent attacks) until total crystal dissolution and resolution of gout.
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