ACR 2020 gout management guideline: key recommendations

Who it applies to

Adults with gout, including those with comorbid chronic kidney disease, in primary care and rheumatology settings.

Key recommendations

• Urate-lowering therapy is strongly recommended for patients with frequent flares (two or more annually), tophi, or evidence of radiographic joint damage from gout, rather than reserving it only for severe disease.
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• Allopurinol is recommended as the preferred first-line urate-lowering agent for all patients, including those with chronic kidney disease, over febuxostat and other alternatives.
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• A treat-to-target approach is favored, starting urate-lowering drugs at a low dose and titrating upward (with monitoring of serum urate) rather than using a fixed-dose strategy without titration.
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• A serum urate target below 6 mg/dL is recommended over no target or a higher target, to reduce flare frequency and tophus burden.
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• HLA-B*5801 testing is conditionally recommended before starting allopurinol in patients of Southeast Asian (e.g., Korean, Han Chinese, Thai) or African American descent, given higher risk of severe hypersensitivity reactions.
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• Routine use of anti-inflammatory prophylaxis (such as low-dose colchicine or NSAIDs) is recommended when starting urate-lowering therapy, to reduce the risk of treatment-associated flares, continued for several months.
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• For acute gout flares, colchicine, NSAIDs, and corticosteroids are all considered acceptable first-line options, with choice guided by comorbidities and patient preference rather than one agent being universally preferred.
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• Low-dose colchicine is favored over high-dose colchicine for treating flares, given similar efficacy with fewer gastrointestinal side effects.
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• Continuing urate-lowering therapy during an acute flare is recommended rather than interrupting it, since stopping treatment does not improve flare resolution and may complicate long-term management.
  conditional
• Lifestyle and dietary counseling (such as limiting alcohol and purine-rich foods) is suggested as an adjunct but is not considered a substitute for pharmacologic urate-lowering therapy in patients with indications for it.
  conditional

Practice points for students

• Allopurinol remains first-line even in CKD; dose should be started low and titrated rather than avoided or capped arbitrarily.
• Treat-to-target with serial serum urate monitoring is central to gout management, analogous to treat-to-target strategies in other chronic diseases.
• Do not stop urate-lowering therapy during an acute flare; manage the flare symptomatically while continuing the urate-lowering drug.
• Consider HLA-B*5801 screening before allopurinol in at-risk ethnic groups to reduce risk of severe hypersensitivity syndrome.
• ULT initiation in patients with tophi, radiographic damage, or frequent flares, the choice of first-line flare therapy, and the sub-6 mg/dL urate target are strong recommendations, while several other aspects of management remain conditional due to limited high-quality trial data.

Condition

Other guidelines on this topic

• Gout: diagnosis and management (NG219)NICE2022Summary
• 2018 updated European League Against Rheumatism evidence-based recommendations for the diagnosis of goutEULAR2020Official guideline
• Management of Acute and Recurrent Gout: A Clinical Practice Guideline From the American College of PhysiciansACP2017Summary

Independent educational summary written by the WhiteCoat Pro editorial team with AI assistance and checked by a second AI model. It does not reproduce the guideline text, tables or figures, and it is not affiliated with or endorsed by ACR. It is not medical advice: always read the original guideline before applying it to patients.