Summary

The 2020 ACR Gout Management Guideline updates the 2012 version using GRADE methodology, providing 42 recommendations (16 strong) covering indications for urate-lowering therapy (ULT), ULT selection and titration, flare management, lifestyle, and concurrent medications. Key updates include allopurinol as preferred first-line ULT for all patients (including CKD stage ≥3), a strong endorsement of treat-to-target with serum urate <6 mg/dl, mandatory low-dose ULT initiation with concomitant anti-inflammatory prophylaxis for 3–6 months, and expanded ULT indications to include radiographic gout damage. Cost considerations and CVD safety signals with febuxostat now firmly position allopurinol over febuxostat as first-line.

Key Recommendations

Strongly initiate ULT in patients with ≥1 subcutaneous tophus, radiographic damage from gout, or ≥2 flares/year.
Conditionally recommend against ULT after a first flare unless the patient has CKD stage ≥3, serum urate >9 mg/dl, or urolithiasis.
Conditionally recommend against ULT for asymptomatic hyperuricemia (including with imaging-detected MSU deposition).
Allopurinol is the strongly preferred first-line ULT for all patients, including those with CKD stage ≥3; pegloticase is strongly recommended against as first-line.
Start allopurinol at ≤100 mg/day (lower in CKD) and febuxostat at <40 mg/day, then titrate to target; probenecid start 500 mg once–twice daily.
Strongly recommend concomitant anti-inflammatory prophylaxis (colchicine, NSAID, or low-dose prednisone/prednisolone) for at least 3–6 months when initiating ULT.
Use a treat-to-target strategy with serial serum urate measurements aiming for SU <6 mg/dl; continue ULT indefinitely.
Conditionally test HLA-B*5801 before allopurinol in patients of Southeast Asian descent (Han Chinese, Korean, Thai) or African American patients.
Switch febuxostat to alternative ULT in patients with history of CVD or new CV event while on febuxostat.
Start ULT during an active gout flare (conditionally) rather than waiting for resolution, provided anti-inflammatory therapy is given.
For flares, use oral colchicine, NSAIDs, or glucocorticoids (oral/IA/IM) as first-line over IL-1 inhibitors or ACTH; use low-dose colchicine over high-dose.
Switch hydrochlorothiazide to alternate antihypertensive and prefer losartan when feasible; do not stop low-dose aspirin and do not switch to fenofibrate for urate-lowering.
Conditionally limit alcohol, purines, and high-fructose corn syrup; recommend weight loss in overweight/obese; recommend against vitamin C supplementation.
Switch to pegloticase (strong) when XOI + uricosurics fail to achieve SU target AND patient has frequent flares (≥2/year) or nonresolving tophi; recommend against pegloticase if infrequent flares and no tophi.

Thresholds & Doses

Serum urate target: <6 mg/dl for all patients on ULT.
Frequent flares definition triggering ULT: ≥2 flares per year.
Allopurinol starting dose: ≤100 mg/day (lower, e.g., ≤50 mg/day, in CKD stage ≥3); FDA-approved maximum 800 mg/day.
Febuxostat starting dose: <40 mg/day with subsequent titration.
Probenecid starting dose: 500 mg once or twice daily, then titrate.
Anti-inflammatory prophylaxis duration with ULT initiation: ≥3–6 months, extended if flares continue.
ULT indication thresholds for first-flare patients: CKD stage ≥3, SU >9 mg/dl, or urolithiasis.
Colchicine flare dosing (FDA): 1.2 mg at onset, then 0.6 mg one hour later (low-dose regimen preferred).
HLA-B*5801 prevalence: ~7.4% in Han Chinese/Korean/Thai; 3.8% African American; 0.7% white/Hispanic; 3-fold increased AHS risk in Asian and African American allopurinol users.
ULT titration interval (carried from 2012 guideline): every 2–5 weeks with SU recheck after each titration.
BMI change association: >5% BMI increase → 60% higher recurrent flare odds; >5% BMI decrease → 40% lower odds.

Citations

Table 1 — Indications for pharmacologic ULT (tophi, radiographic damage, ≥2 flares/year, CKD/SU>9/urolithiasis exceptions).
Table 2 — Recommendations for initial ULT choice, low starting doses, and anti-inflammatory prophylaxis duration.
Table 3 — Treat-to-target SU <6 mg/dl and indefinite ULT continuation.
Table 4 — HLA-B*5801 testing, allopurinol desensitization, febuxostat CVD switching, uricosuric monitoring.
Table 5 — Switching ULT strategy including pegloticase indications.
Table 6 — Gout flare management (colchicine/NSAIDs/glucocorticoids first-line, IL-1 inhibitor second-line, ice adjuvant).
Table 7 — Lifestyle management (alcohol, purines, fructose, weight loss, vitamin C).
Table 8 — Concurrent medications (HCTZ switch, losartan preference, aspirin continuation, fenofibrate avoidance).