Untitled

Management of Gout (Second Edition)
Published by:
Malaysian Health Technology Assessment Section (MaHTAS)

Medical Development Division, Ministry of Health Malaysia
Level 4, Block E1, Precinct 1
Federal Government Administrative Centre
62590 Putrajaya, Malaysia
Copyright
The copyright owner of this publication is MaHTAS. Content may be

reproduced in any number of copies and in any format or medium
provided that a copyright acknowledgement to MaHTAS is included and
the content is not changed, not sold, nor used to promote or endorse
any product or service, and not used in an inappropriate or misleading
context.
e-ISBN: 978-967-2887-28-7
Available on the following websites:

http://www.moh.gov.my
http://www.acadmed.org.my
https://msr.my/
Also available as an app for Android and IOS platforms: MyMaHTAS
STATEMENT OF INTENT
This clinical practice guideline (CPG) is meant to be a guide for

clinical practice, based on the best available evidence at the time of
development. The guideline should not override the responsibility of the
practitioners to make decisions appropriate to the circumstances of the
individual patient. This should be done in consultation with the patients
and their families or guardians, taking into account the management
options available locally.
UPDATING THE CPG
These guidelines were issued in 2021 and will be reviewed in a minimum

period of four years (2025) or sooner if there is a need to do so. When it
is due for updating, the Chairperson of the CPG or National Advisor of
the related specialty will be informed about it. A discussion will be done
on the need for a revision including the scope of the revised CPG. A
multidisciplinary team will be formed and the latest systematic review
methodology used by MaHTAS will be employed. Every care is taken
to ensure that this publication is correct in every detail at the time of
publication. However, in the event of errors or omissions, corrections
will be published in the web version of this document, which is the
definitive version at all times. This version can be found on the websites
mentioned above.
TABLE OF CONTENTS
No. Title Page

Levels of Evidence and Formulation of Recommendation i
Key Recommendations ii
Guidelines Development and Objectives v
Development Group viii
Review Committee ix
External Reviewers x
Algorithm on Management of Gout xi

1. INTRODUCTION 1

2. DEFINITION AND EPIDEMIOLOGY 3
2.1 Definition 3
2.2 Epidemiology 4

3. RISK FACTORS AND PREVENTIVE STRATEGIES 5
3.1 Risk Factors 5
3.2 Preventive Strategies 8

4. NATURAL HISTORY 9

5. CLINICAL PRESENTATION 10
5.1 Gout Flare 10
5.2 Intercritical Gout 10
5.3 Chronic Gouty Arthritis 10

6. COMORBIDITIES 12

7. DIAGNOSIS 14
7.1 Demonstration of Monosodium Urate Crystals in 14
Synovial Fluid or Tophus Aspirate
7.2 Clinical Manifestations 14
7.3 Laboratory Investigations 15
7.4 Imaging Modalities 15
7.5 Classification Criteria 17

8. BASELINE INVESTIGATIONS 20

9. DIFFERENTIAL DIAGNOSES 21

10. ASYMPTOMATIC HYPERURICAEMIA 22

11. TREAT-TO-TARGET 25
TABLE OF CONTENTS
No. Title Page

12. TREATMENT 27
12.1 Non-pharmacological Treatment 27
a. Health education 27
b. Lifestyle modifications 27
c. Concomitant medications 29
d. Topical ice 30
12.2 Pharmacological Treatment 30

a. Urate-lowering therapy 30
b. Gout flare 35
c. Flare prophylaxis 37
d. Special groups 38
i. Gout in chronic kidney disease 38
ii. Gout in pregnancy and lactation 39

13. DISCONTINUATION OF URATE-LOWERING THERAPY 40

14. ADJUNCTIVE TREATMENT 41

15. MONITORING AND FOLLOW-UP 43
15.1 Clinical Outcomes 43
15.2 Treat-To-Target Strategy 43
15.3 Drug-Related Adverse Events 43

16. REFERRAL 45
16.1 Referral criteria for rheumatology care 45
16.2 Referral criteria for orthopaedic/surgical care 45

17. IMPLEMENTING THE GUIDELINES 47
17.1 Facilitating and Limiting Factors 47
17.2 Potential Resource Implications 47
17.3 Clinical Audit Indicators 48

REFERENCES 49
Appendix 1 Example of Search Strategy 55
Appendix 2 Clinical Questions 57
Appendix 3 A. Alcohol Serving Size 58
B. DASH Diet Recommendations 58
C. Dietary Recommendations for Gout 60
Appendix 4 Application of Ice Pack 62
TABLE OF CONTENTS
No. Title Page

Appendix 5 Pharmacological Treatment for Gout 63
A. Urate-Lowering Therapy in Gout 63
B. Treatment of Flare and Flare Prophylaxis in 68
Gout
C. Treatment of Gout in Pregnancy and 73
Lactation

List of Abbreviations 76
Acknowledgement 78
Disclosure Statement 78
Source of Funding 78
LEVELS OF EVIDENCE
Level Study design
I Evidence from at least one properly randomised controlled trial
II-1 Evidence obtained from well-designed controlled trials without

randomisation
II-2 Evidence obtained from well-designed cohort or case-control

analytic studies, preferably from more than one centre or
group
II-3 vidence from multiple time series with or without intervention;

E
dramatic results in uncontrolled experiments (such as the
results of the introduction of penicillin treatment in the 1940s)
could also be regarded as this type of evidence
III Opinions of respected authorities based on clinical experience;

descriptive studies and case reports; or reports of expert
committees
SOURCE: US / CANADIAN PREVENTIVE SERVICES TASK FORCE 2001
FORMULATION OF RECOMMENDATION
In line with new development in CPG methodology, the CPG Unit of

MaHTAS is in the process of adapting Grading Recommendations,
Assessment, Development and Evaluation (GRADE) in its
work process. The quality of each retrieved evidence and its effect
size are carefully assessed/reviewed by the CPG Development
Group. In formulating the recommendations, overall balances of the
following aspects are considered in determining the strength of the
recommendations:-
• overall quality of evidence
• balance of benefits versus harm
• values and preferences
• resource implications
• equity, feasibility and acceptability
i
KEY RECOMMENDATIONS
The following recommendations were highlighted by the CPG

Development Group as the key clinical recommendations that should
be prioritised for implementation.
Risk Factors and Preventive Strategies
• To prevent gout:
 a healthy lifestyle should be advocated, which includes
- maintenance of a healthy body weight
- avoidance of alcohol
- adherence to Dietary Approaches to Stop Hypertension
(DASH) diet which
 discourages purine-rich red meat, fructose-rich foods, full-fat
dairy products and saturated fats

 encourages vegetables, fruits, whole grains, fat-free or low-
fat dairy products, fish, poultry, beans, nuts and vegetable oil
 diuretics should be avoided if possible, or replaced by an
alternative drug when used as an antihypertensive agent
Diagnosis
• Demonstration of monosodium urate (MSU) crystals in synovial

fluid or tophus aspirate under polarised light microscopy should be
performed to confirm the diagnosis of gout.
 If confirmation of presence of MSU crystals is not possible, the
diagnosis may be made based on typical clinical manifestations.
 Musculoskeletal ultrasonography may assist in the diagnosis of
gout with atypical presentations.
Treat-To-Target
• Treat-to-target strategy aiming for serum urate of <360 μmol/L should

be applied in the treatment of all gout patients.
ii
Treatment
• Patients with gout should be treated with urate-lowering therapy

when indicated.
 Allopurinol is the first-line therapy. It should be started at low dose
and increased gradually.
 When allopurinol is contraindicated or not tolerated, febuxostat or
uricosuric agents may be considered.
• Gout flare should be treated promptly and adequately.
• In gout flare, the following monotherapy may be used:
 colchicine
 nonsteroidal anti-inflammatory drugs/cyclooxygenase-2 inhibitors
 corticosteroids
• Combination of the above may be used in gout flare if response to
monotherapy is insufficient.
Monitoring and Follow-up
• Monitoring of patients with gout should include:

 clinical outcomes
 drug-related adverse events; notably allopurinol-induced severe
cutaneous adverse reaction
 blood investigations for adverse effects of drugs
 serum urate and comorbidity screening
Referral
• Referral of gout patients to a rheumatologist may be considered for

the following:
 diagnostic indications
- unclear diagnosis with atypical clinical presentations including
suspected gout in
 women with onset before menopause
 men with early onset at age <30 years without predisposing
risk factors for gout

 therapeutic indications
- refractory to conventional therapy despite drug adherence
 gout flare that fails to resolve despite treatment as
recommended by the CPG

 recurrent flares although SU target of <360 µmol/L is
achieved
 failure to achieve SU target of <360 μmol/L after a trial of at
least three months of allopurinol at a maximally tolerated dose
iii
 tophaceous gout with progressive joint damage, active

symptoms or growing tophi despite medical treatment
- complicated gout with destructive joint changes
- hypersensitivity or intolerance to allopurinol
 special group indication
- gout in pregnancy
• Surgical management of tophi may be considered when there is:
 uncontrolled infection
 entrapment neuropathy
 risk of permanent joint damage
• Gout with urolithiasis should be assessed by a urologist.
iv
GUIDELINES DEVELOPMENT AND OBJECTIVES
Guidelines Development
The members of the Development Group (DG) for this CPG were from
the Ministry of Health (MoH), Ministry of Education and private sector.
There was active involvement of a multidisciplinary Review Committee
(RC) during the process of the CPG development.
A systematic literature search was carried out using the following

electronic databases/platforms: mainly Medline via Ovid and Cochrane
Database of Systemic Reviews and others e.g. Pubmed and Guidelines
International Network. Refer to Appendix 1 for Example of Search
Strategy. The inclusion criterion was all adults with gout. The search
was limited to literature published in the last 13 years, on humans and
in English. In addition, the reference lists of all retrieved literature and
guidelines were searched and experts in the field contacted to identify
relevant studies. All searches were conducted from 12 November
2019 to 30 June 2021. Literature search was repeated for all clinical
questions at the end of the CPG development process allowing any
relevant papers published before 30 June 2021 to be included. Future
CPG updates will consider evidence published after this cut-off date.
The details of the search strategy can be obtained upon request from
the CPG Secretariat.
References were also made to other guidelines as listed below:

• 2020 American College of Rheumatology (ACR) Guideline for the
Management of Gout
• 2016 updated European League Against Rheumatism (EULAR)
evidence-based recommendations for the management of gout
• The British Society for Rheumatology (BSR) Guideline for the
Management of Gout (2017)
• 2018 updated EULAR evidence-based recommendations for the
diagnosis of gout
• 2012 ACR Guidelines for Management of Gout. Part 1: Systematic
Nonpharmacologic and Pharmacologic Therapeutic Approaches
to Hyperuricemia
The CPGs were evaluated using the Appraisal of Guidelines for
Research and Evaluation (AGREE) II prior to being used as references.
A total of 13 main clinical questions were developed under different

sections. Members of the DG were assigned individual questions within
these sections. Refer to Appendix 2 for Clinical Questions. The DG
members met 19 times throughout the development of these guidelines.
All literature retrieved was appraised by at least two DG members using
Critical Appraisal Skill Programme checklist, presented in evidence
tables and further discussed in each DG meeting. All statements and
v
recommendations formulated after that were agreed upon by both the

DG and RC. Where evidence was insufficient, the recommendations
were made by consensus of the DG and RC. Any differences in opinion
were resolved consensually. The CPG was based largely on the
findings of systematic reviews, meta-analyses and clinical trials, with
local practices taken into consideration.
Literature used in these guidelines were graded using the US/Canadian

Preventive Services Task Force Level of Evidence (2001) while the
grading of recommendation was done using the principles of GRADE
(refer to page i). The writing of the CPG follows strictly the requirements
of AGREE II.
On completion, the draft of the CPG was reviewed by external

reviewers. It was also posted on the MoH Malaysia official website for
feedback from any interested parties. The draft was finally presented to
the Technical Advisory Committee for CPG and, the Health Technology
Assessment (HTA) and CPG Council, MoH Malaysia, for review and
approval. Details on the CPG development by MaHTAS can be obtained
from Manual on Development and Implementation of Evidence-based
Clinical Practice Guidelines published in 2015 (available at http://www.
moh.gov.my/moh/resources/CPG_MANUAL_MAHTAS.pdf?mid=634)
OBJECTIVES
Objectives of the CPG are to provide evidence-based recommendations

on management of gout in the following aspects:
• diagnosis
• prevention
• treatment
• monitoring and referral
CLINICAL QUESTIONS
Refer to Appendix 2.
TARGET POPULATION
Inclusion Criterion
• Adults with gout
vi
TARGET GROUP/USER
This document is intended to guide health care providers and relevant

stakeholders in primary and secondary/tertiary care in the management
of gout including:
• doctors
• allied health professionals
• trainees and medical students
• policymakers
• patients and their advocates
• professional societies
HEALTHCARE SETTINGS
Primary, secondary and tertiary care
vii
DEVELOPMENT GROUP
Chairperson
Dr. Loh Yet Lin

Consultant Physician & Rheumatologist (retired)
Hospital Tuanku Ja’afar Seremban,
Negeri Sembilan
Members (in alphabetical order)

Ms. Ani Norita Muhamad Samudi Dr. Mohd Aminuddin Mohd Yusof
Clinical Dietitian Head of CPG Unit & Public Health
Hospital Kuala Lumpur, Kuala Lumpur Physician
Malaysian Health Technology
Assessment Section, Ministry of Health,
Putrajaya
Dr. Asmah Mohd Dr. Norliza Zainudin

Consultant Physician & Rheumatologist Physician & Rheumatologist
Hospital Tuanku Ja’afar Seremban, Hospital Selayang, Selangor
Negeri Sembilan
Dr. Chong Hwee Cheng Dr. Rizawati Ramli

Consultant Physician & Rheumatologist Family Medicine Specialist
Hospital Melaka, Melaka Pusat Perubatan Universiti Malaya,
Kuala Lumpur
Ms. Chu Ai Reen Dr. Ruhaila Abdul Rahim

Occupational Therapist Consultant Physician & Rheumatologist
Hospital Tuanku Ja’afar Seremban, KPJ Bandar Maharani Specialist
Negeri Sembilan Hospital, Johor
Dr. Ding Hui Jen Ms. Siti Mariam Mohtar

Physician & Rheumatologist Principal Assistant Director
Hospital Kuala Lumpur, Kuala Lumpur Malaysian Health Technology
Assessment Section, Ministry of Health,
Putrajaya
Dr. Fauzi Azizan Abdul Aziz Ms. Siti Rabi’atul Adawiyah Nasri
Head of Department & Consultant Pharmacist
Physician Hospital Tuanku Ja’afar Seremban,
Hospital Tuanku Ampuan Najihah, Negeri Sembilan
Negeri Sembilan
Dr. Kan Sow Lai Associate Professor Dr. Syahrul

Head of Department, Physician & Sazliyana Shaharir
Rheumatologist Consultant Physician & Rheumatologist
Hospital Bukit Mertajam, Pulau Pinang Pusat Perubatan Universiti Kebangsaan
Malaysia, Kuala Lumpur
Dr. Mohamed Hasan Ahmad
Family Medicine Specialist
Klinik Kesihatan Kerteh, Terengganu
viii
REVIEW COMMITTEE
The CPG draft was reviewed by a panel of experts from both public
and private sectors. They were asked to comment primarily on the
comprehensiveness and accuracy of the interpretation of evidence
supporting the recommendations in the CPG.
Chairperson
Dr. Mollyza Mohd Zain

National Head of Rheumatology Services,
Senior Consultant Physician & Rheumatologist
Hospital Selayang, Selangor
Members (in alphabetical order)

Mr. Ang Yu Joe Dato’ Dr. Mohd Idham Hassan
Pharmacist Consultant Orthopaedic Surgeon
Hospital Selayang, Selangor Ara Damansara Medical Centre,
Kuala Lumpur
Dr. Chin Pek Woon Professor Dr. Mohd Shahrir Mohamed Said
Head of Department & Senior Senior Consultant Physician &
Consultant Physician Rheumatologist
Hospital Enche’ Besar Hajjah Khalsom, Pusat Perubatan Universiti Kebangsaan
Johor Malaysia, Kuala Lumpur
Dr. Chow Sook Khuan Ms. Nik Mahani Nik Mahmood

Consultant Physician & Rheumatologist State Dietitian & Head of Department
Sunway Medical Centre, Selangor Hospital Pakar Sultanah Fatimah, Johor
Dato’ Dr. Gun Suk Chyn Dr. Nik Mazlina Mohammad

Senior Consultant Physician & Consultant Family Medicine Specialist
Rheumatologist Klinik Kesihatan Kelana Jaya, Selangor
Negeri Sembilan
Dr. Izzuna Mudla Mohamed Ghazali Dr. Ong Swee Gaik

Deputy Director & Public Health Physician Senior Consultant Physician &
Malaysian Health Technology Rheumatologist
Assessment Section, Ministry of Health, Hospital Kuala Lumpur, Kuala Lumpur
Putrajaya
Dr. Lily Mushahar Professor Dr. Sargunan Sockalingam

Head of Department, Consultant Senior Consultant Physician &
Physician & Nephrologist Rheumatologist
Hospital Tuanku Ja’afar Seremban, Pusat Perubatan Universiti Malaya,
Negeri Sembilan Kuala Lumpur
Dr. Mohamad Saprin Dr. Ummu Kalsum Mustapha

Director of Perak Customs Department Family Medicine Specialist
Patient Advocate Klinik Kesihatan Sungai Chua, Selangor
ix
EXTERNAL REVIEWERS (in alphabetical order)
The following external reviewers provided feedback on the draft:
Associate Professor Dr. A T M Tanveer Hasan

Head of Department of Rheumatology
Enam Medical College & Hospital, Dhaka, Bangladesh

Datin Dr. Asmahan Mohd Ismail
Consultant Physician & Rheumatologist
Hospital Raja Perempuan Zainab II, Kelantan
Dr. Bernard Thong

Divisional Chairman (Medicine) & Senior Consultant Rheumatologist
Tan Tok Seng Hospital, Singapore
Dr. Lee Tiong Chan

Senior Lecturer & Senior Consultant General Physician
Jeffrey Cheah School of Medicine and Health Sciences
Monash University Malaysia, Johor
Professor Dr. Lisa Stamp

Consultant Rheumatologist
University of Otago, Dunedin, New Zealand
Dr. Noor Hasliza Hassan

Family Medicine Specialist
Klinik Kesihatan Sungai Pelek, Selangor
Dr. Nor Sa’adah Abdul Kadir

General Practitioner
Poliklinik An-Nur Desa Pinggiran Putra, Selangor
Dr. Salmi Abdul Razak

Pharmacist
Negeri Sembilan
Dr. Sunita Bavanandan

Head of Department & Consultant Nephrologist
Hospital Kuala Lumpur, Kuala Lumpur
Dr. Yeap Swan Sim

Consultant Physician & Rheumatologist
Subang Jaya Medical Centre, Selangor
Associate Professor Dr. Zulfitri ‘Azuan Mat

Senior Lecturer & Dietitian
Universiti Putra Malaysia, Selangor
x
ALGORITHM ON MANAGEMENT OF GOUT
Acute monoarthritis/oligoarthritis
CKD: chronic kidney disease Clinical features of gout • Normal SU during gout flare does not exclude the
COX-2 inhibitors: cyclooxygenase-2 inhibitors 1. Involvement of the first metatarsophalangeal joint, ankle or midfoot diagnosis of gout.
MTP: metatarsophalangeal 2. Redness, extreme pain and loss of function in the affected joint • Repeat SU ≥2 weeks after resolution of flare if highly
NSAIDs: nonsteroidal anti-inflammatory drugs 3. Time to maximal pain <24 hours and complete resolution of symptoms within 14 days suspicious of gout.
SU: serum urate 4. Recurrence of typical attacks increase the likelihood of diagnosis
ULT: urate-lowering therapy 5. Clinical evidence of tophus (present in chronic gouty arthritis)
No Yes
Other causes of acute monoarthritis/oligoarthritis - manage accordingly Diagnosis of gout
*ULT is indicated if: Investigations Treatment of gout flare

• recurrent gout flares (≥2 flares in 12 months) OR • Baseline SU, other blood/urine/imaging study
• presence of tophi OR as indicated Non-pharmacological Pharmacological
xi
• presence of radiographic damage due to gout • Screening of associated comorbidities • Topical ice during gout flare • Colchicine, OR
ULT is conditionally recommended if: • Health education • NSAIDs/COX-2
• previously had >1 flare but infrequent (<2 flares/year) • Lifestyle modification inhibitors OR
• first gout flare if: • Avoidance of medications • Corticosteroids OR
 concomitant CKD stage ≥3 OR that increase risk of gout, if feasible • Combination of the above
 SU >540 µmol/L OR
 presence of urolithiasis
• Allopurinol as first-line ULT

• Start allopurinol at low dose and uptitrate slowly especially in patients with CKD Yes No
• Monitor for drug-related adverse events Indication for
• Treat-to-target (T2T) strategy: aim for SU <360 µmol/L ULT*
• Do not stop ULT during attack
• Initiate flare prophylactic treatment (at least 3 - 6 months)
• Monitor for associated comorbidities Continue to monitor
for possible indications
in future
If unable to tolerate allopurinol/failure to achieve SU target despite dose escalation and good compliance to treatment, consider:
• switching to febuxostat or uricosuric agent
• addition of uricosuric agent

1. INTRODUCTION
The early records of gout by the Egyptians dated back to 2640 before
common era (BCE). The disease was also described by Hippocrates
in the fifth BCE.1 Despite being one of the oldest joint diseases, its
prevalence and incidence seem to be increasing globally.2 Gout is
associated with an increase in all-cause mortality, chronic disability,
impairment of health-related quality of life, higher usage of health care
services and reduced productivity.3 In many countries, the outcomes
of the disease are far from favourable due to suboptimal management.
Commonly, only a third to half of patients with gout receive urate-
lowering therapy (ULT) and fewer than a half of them adhere to
treatment.2 A study in a rheumatology centre in Malaysia reported that
only 34.9% of its patients achieved the recommended serum urate
(SU) target. Nonadherence was the main reason for failure to attain
the target.4
The first edition of this CPG was published in 2008 by the Malaysian
Society of Rheumatology. Since then, there have been advances in
the understanding of the risk factors, diagnostic techniques, treatment
strategy and options, and comorbidities of the disease. The employment
of the treat-to-target (T2T) concept represents an important milestone in
gout management. By bringing SU to <360 µmol/L, crystals are dissolved
and this suggests that gout is potentially a ‘curable’ disease. However,
ULT which is the cornerstone of therapy needs to be maintained long-
term to prevent new crystal formation. The reversibility of the process
is a unique feature of gout, in contrast with other rheumatic conditions.
Nevertheless, if joint destruction has set in, damage is permanent.
Of equal significance is the evolving science regarding risk factors

e.g. obesity and high-fructose corn syrup. Obesity is thought to be
a contributing factor in the rising prevalence and incidence of gout.2
High-fructose corn syrup increases risk of incident gout. On the other
hand, plant-derived high purine diet does not.5 Non-invasive imaging
modalities e.g. ultrasound and dual-energy computed tomography
(DECT) have improved the diagnostic armamentarium of gout. There
is new development on the use of allopurinol. The recommendation is
to ‘start low, go slow’ when initiating and titrating it to achieve target,
especially in patients with gout and chronic kidney disease (CKD).
The discovery of febuxostat, which is a non-purine xanthine oxidase
inhibitor (XOI) widens the choice of ULT for prescribers. Combination
therapy further expands treatment options. Last but not least, the role
of education for health care professionals and patients is important too.
Without proper knowledge and understanding, all the above progress
will not be implemented successfully. Misconceptions and lack of
knowledge of the disease among both parties are barriers to effective
management of the disease.6 Therefore an updated version of the CPG
is timely.
1
This CPG aims to provide current concepts on the prevention, diagnosis

and treatment of gout as simplified in Algorithm on Management of
Gout in the preceding page. Recommendations will be based on the
latest scientific evidence and availability of resources locally. It is hoped
that this CPG will facilitate optimal management of gout in Malaysia. It
is time to approach this ancient disease with a panoramic view and aim
for SU <360 µmol/L.
2
2. DEFINITION AND EPIDEMIOLOGY
2.1 Definition
Gout is a disease caused by monosodium urate (MSU) crystal

deposition with any of the following clinical presentations (current or
prior): gout flare, chronic gouty arthritis, or subcutaneous tophus. The
label ‘gout’ should be reserved only for clinically evident disease.7
Gout is a consequence of persistent hyperuricaemia.
• Not all individuals with hyperuricaemia develop MSU crystal

deposition8 or gout.9 – 11, level II-2
Although gout is predominantly a musculoskeletal condition with acute

and chronic arthritis, as well as bursitis, it can also have extra-articular
involvement e.g. chronic nephropathy and urolithiasis.
Gout, Hyperuricemia and Crystal-Associated Disease Network (G-CAN)

has published a consensus on the labels and definitions of the basic
elements of gout as shown below:12, level III
No. Consensus Label Consensus Definition

1. MSU crystals The pathogenic crystals in gout (chemical formula:
C5H4N4NaO3)
2. Urate The circulating form of the final enzymatic product
generated by xanthine oxidase in purine metabolism
in humans (chemical formula: C5H3N4O3-)
3. Hyeruric(a)emia Elevated blood urate concentration over the saturation
threshold
4. Gout flare A clinically evident episode of acute inflammation
induced by MSU crystals
5. Intercritical gout The asymptomatic period after or between gout flares,
despite the persistence of MSU crystals
6. Chronic gouty arthritis Persistent joint inflammation induced by MSU crystals
6a. G-CAN The label ‘chronic gout’ should be avoided
recommendation
7. Tophus An ordered structure of MSU crystals and the
associated host tissue response
8. Subcutaneous tophus A tophus that is detectable by physical examination
9. Imaging evidence of MSU Findings that are highly suggestive of MSU crystals on
crystal deposition an imaging test
10. Gouty bone erosion Evidence of a cortical break in bone suggestive of gout
(overhanging edge with sclerotic margin)
11. Podagra A gout flare at the first metatarsophalangeal (MTP)
joint
Source: Bursill D, Taylor WJ, Terkeltaub R, et al. Gout, hyperuricemia, and Crystal-
Associated disease network consensus statement regarding labels and
definitions for disease elements in gout. Arthritis Care Res. 2019;71(3):427-
434.
3
2.2 Epidemiology
Globally, gout ranges from 0.1% to 6.8% in prevalence and 0.58 to 2.89
per 1,000 person-years in incidence.2 Gout is traditionally a disease of
middle-aged and older men. Its occurrence is unusual before the age of
45 years in men13 or among premenopausal women.14 The prevalence
and incidence of gout increase with age, a pattern seen over the entire
lifespan in men and after menopause in women.2
There are no local population-based epidemiologic studies on gout.

However, hospital-based studies from a few tertiary centres in Malaysia
reported a peak age of gout onset ranging from 30 to 60 years. Patients
were predominantly males. They were multi-ethnic in origin and
ethnicity distribution was dependent on the region where the studies
were conducted. Majority of the patients were Malays in all but one
study which showed a preponderance towards the Ibans.4; 15 - 18
4
3. RISK FACTORS AND PREVENTIVE STRATEGIES
The risk factors for development of gout can be categorised as

modifiable and non-modifiable (refer to Table 1 on Risk factors for
gout). Prolonged hyperuricaemia is the major risk factor for developing
gout.
3.1 Risk Factors
The table below shows the list of risk factors for gout.
Table 1. Risk factors for gout
Modifiable risk factors
Factors that increase risk Factors that reduce risk

• Obesity/overweight • Diet
• Diet o Dairy products
o Alcohol • Medications
o High-fructose corn syrup o Losartan
- Sugar-sweetened soft drinks/ o Calcium channel blockers
beverages
o Red meat
o Seafood [except n-3 polyunsaturated
fatty acid (PUFA)-rich fish]
• Medications*
o Diuretics
o Non-losartan angiotensin II receptor
blockers
o Angiotensin-converting enzyme
(ACE) inhibitors
o β-blockers
o Cyclosporine
• Others
o CKD
o Hypertension
o Psoriasis
o Haematological malignancies
Non-modifiable risk factors

• Increasing age
• Male gender
• Menopause
• Ethnicity
• Genetic
o Single nucleotide polymorphism - ABCG2 gene
o Enzymatic defect in purine metabolism - hypoxanthine-guanine phosphoribosyl
transferase deficiency
*The above list is not exhaustive and the decision to discontinue a medication should
be made based on consideration of its benefits weighed against risks in gout patients.
5
a. Obesity/Overweight
Excess weight is a major risk factor for developing gout. Men with
obesity may not benefit from other lifestyle modifications unless weight
loss is addressed.19, level II-2
Individuals with body mass index (BMI) ≥30 kg/m2 were more likely to
develop gout compared with those having BMI <30 kg/m2 (RR=2.24,
95% CI 1.76 to 2.86).20, level II-2
In various populations:21, level II-2

• 5-unit increment in BMI increased the risk of gout with RR of 1.55
(95 % CI 1.44 to 1.66)
• when compared with BMI of 20, higher BMI increased the risk of
developing gout:
 BMI 25 (RR=1.78, 95% CI 1.47 to 2.15)
 BMI 30 (RR=2.67, 95% CI 2.16 to 3.30)
 BMI 35 (RR=3.62, 95% CI 2.95 to 4.46)
 BMI 40 (RR=4.64, 95% CI 3.49 to 6.18)
b. Dietary intake
• Alcohol
High alcohol consumption increased the risk of hyperuricaemia
(OR=2.06, 95% CI 1.60 to 2.67) and gout (OR=2.58, 95% CI 1.81 to
3.66) compared with no alcohol consumption.5, level II-2
• Food
A meta-analysis showed that certain foods increased the risk of
developing hyperuricaemia and gout when highest quintile intake was
compared with lowest quintile intake as shown below:5, level II-2
Type of foods OR for hyperuricaemia OR for gout
Red meat 1.24 (95% CI 1.04 to 1.48) 1.29 (95% CI 1.16 to 1.44)
Seafood 1.47 (95% CI 1.16 to 1.86) 1.31 (95% CI 1.01 to 1.68)
Fructose 1.85 (95% CI 1.66 to 2.07) 2.14 (95% CI 1.65 to 2.78)
The beneficial effect of n-3 PUFA derived from fatty fish may override
the potential deleterious effect of its high purine content.22, level II-2
Two other meta-analyses involving the same cohort studies reported by

Li R et al. showed:
 high fructose consumption was associated with an increased risk
of gout with RR of 1.62 (95% CI 1.28 to 2.03)23, level II-2
 high intake of sugar-sweetened beverages and high intake of fruit
juices particularly orange juice, increased the risk of developing
gout with RR of 2.08 (95% CI 1.40 to 3.08) and 1.77 (95% CI
1.20 to 2.61) respectively; however, there was no significant
association between fruit intake and gout24, level II-2
6
The sweetener in both cohort studies referred to high-fructose corn

syrup.
In the same meta-analysis, purine-rich vegetables or soy-based food

did not increase the risk of incident gout. Dairy products were shown to
lower the risk of developing hyperuricaemia (OR=0.50 95% CI 0.37 to
0.66) and/or gout (OR=0.56, 95% CI 0.44 to 0.70).5, level II-2
c. Medications (Antihypertensives)
In hypertensive patients, the following medications increased the risk of
incident gout:25, level II-2
• diuretics with RR of 2.36 (95% CI 2.21 to 2.52)
• non-losartan angiotensin II receptor blockers with RR of 1.29
(95% CI 1.16 to 1.43)
• ACE inhibitors with RR of 1.24 (95% CI 1.17 to 1.32)
• β-blockers with RR of 1.48 (95% CI 1.40 to 1.57)
On the other hand, losartan and calcium channel blockers reduced the
risk with RR of 0.81 (95% CI 0.70 to 0.94) and 0.87 (95% CI 0.82 to
0.93) respectively.
A recent meta-analysis also supported diuretics as a risk factor for

incident gout (RR=2.39, 95% CI 1.57 to 3.65).20, level II-2 As for effects of
different classes of diuretics, a case-controlled study showed current
use of loop diuretics, thiazide diuretics and thiazide-like diuretics but
not potassium-sparing diuretics increased the risk of incident gout
compared with past use of the medications with OR of 2.64 (95% CI
2.47 to 2.83), 1.70 (95% CI 1.62 to 1.79), 2.30 (95% CI 1.95 to 2.70)
and 1.06 (95% CI 0.91 to 1.23) respectively.26, level II-2
d. Supplements
Vitamin C may reduce SU levels and lower the risk of gout development.
• In a study which involved various populations (postmenopausal and
diabetic women, athletes, non-smoker adults, healthy male smokers
etc.) with baseline SU concentrations ranging from 2.9 to 7.0 mg/dL
(174 to 420 µmol/L), intake of vitamin C with median dosage of 500
mg/day reduced level of SU compared with control group (MD= -0.35
mg/dL (-21 µmol/L), 95% CI -0.66 to -0.03).27, level I
• Total intake of vitamin C at different doses among male health care
professionals reduced the risk of incident gout compared with men
with intake <250 mg/day:28, level II-2
 intake of 500 to 999 mg/day (RR=0.83, 95% CI 0.71 to 0.97)
 intake of 1000 to 1499 mg/day (RR=0.66, 95% CI 0.52 to 0.86)
 intake of 1500 mg/day or greater (RR=0.55, 95% CI 0.38 to 0.80)
However, more evidence is warranted to conclude that vitamin C
confers protection from gout.
7
3.2 Preventive Strategies
A large cohort study on males and predominantly white subjects with

population attributable risks (PAR) as the main outcome, showed that
with more preventive strategies instituted, more incident gout cases
could be prevented:19, level II-2
• two factors in low-risk category
 BMI <25 kg/m2, no alcohol intake with PAR of 43% (95% CI 32 to 54)
 BMI <25 kg/m2, highest quintile of Dietary Approaches to Stop
Hypertension (DASH) diet score with PAR of 33% (95% CI 15 to 47)
• three factors in low-risk category (BMI <25 kg/m2, no alcohol intake,
highest quintile of DASH diet score) with PAR of 69% (95% CI 47 to
82)
• four factors in low-risk category (BMI <25 kg/m2, highest quintile of
DASH diet score, no alcohol intake, no diuretic use) with PAR of 77%
(95% CI 56 to 88)
Recommendation 1
• To prevent gout:
 a healthy lifestyle should be advocated, which includes
- maintenance of a healthy body weight
- avoidance of alcohol
- adherence to Dietary Approaches to Stop Hypertension
(DASH) diet which
 discourages purine-rich red meat, fructose-rich foods, full-
fat dairy products and saturated fats

 encourages vegetables, fruits, whole grains, fat-free or low-
fat dairy products, fish, poultry, beans, nuts and vegetable

oil
 diuretics should be avoided if possible, or replaced by an
alternative drug when used as an antihypertensive agent
• High-fructose corn syrup increases the risk of incident gout (check

food label for content).
Refer to Appendix 3 on Alcohol Serving Size, DASH Diet

Recommendations and Dietary Recommendations for Gout.
8
4. NATURAL HISTORY
The natural history of untreated gout evolves through the following

phases (refer to Figure 1):
i. asymptomatic hyperuricaemia (hyperuricaemia without gout)
ii. asymptomatic MSU crystal deposition (MSU crystal deposition
without gout)
iii. recurrent gout flares with intercritical gout
iv. gout with chronic gouty arthritis/tophaceous gout/erosive gout
If untreated, gout may progress to a stage with joint damage and tophi.
Gout typically presents for the first time with acute monoarthritis (first
gout flare) of the first MTP joint (podagra), midfoot or ankle, and less
commonly with oligoarthritis. The first gout flare is preceded by a period
of asymptomatic hyperuricaemia and MSU crystal deposition. It is self-
limiting and lasts about 1 - 2 weeks. This acute episode is followed by
complete resolution of symptoms and signs of joint inflammation, which
then enters a quiet interval called intercritical gout. If hyperuricaemia
persists, the result is recurrent flares. Their occurrences gradually
become more frequent and prolonged with multiple joint involvement
(polyarticular gout), including those of the upper limbs. If hyperuricaemia
remains uncontrolled, chronic gouty arthritis with or without tophi
formation can ensue later, on an average of 10 years after initial
symptom onset.
It is important to note that not all individuals with hyperuricaemia

develop asymptomatic MSU crystal deposition or gout. It has yet to
be elucidated that asymptomatic MSU crystal deposition will eventually
lead to gout in all subjects.
Episodes of gout flare Chronic gouty arthritis; increasing
with intercritical gout in frequency of gout flares with
between chronic joint pain
Joint Deformity
Pain
Tophi
deposition and
joint deformity
Asymptomatic Asymptomatic Gout
hyperuricaemia MSU crystal
deposition
Time
Figure 1. Natural history of gout
9
5. CLINICAL PRESENTATION
• The three classic clinical stages in gout are:

 Gout flare
 Intercritical gout
 Chronic gouty arthritis
5.1 Gout Flare

• Defined as a clinically evident episode of acute inflammation induced
by MSU crystals12, level III
• Presents with symptoms of acute arthritis with joint pain, swelling,
warmth, redness and movement difficulty
• Occurs abruptly with joint pain peaking in intensity within 24 hours
• Can be preceded by prodromal symptoms of tingling, mild discomfort
or itching in the hours leading up to an attack
• Is excruciatingly painful and usually measures >7 on a 0 - 10 Visual
Analogue Scale (VAS); the pain is throbbing or burning in nature with
extreme joint tenderness
• Commonest affected site is the first MTP joint; the midfoot and ankle
are also commonly involved
• Usually occurs at night, with the patient’s sleep interrupted due to
severe joint pain
• Precipitants include acute medical or surgical illness, dehydration,
alcohol and purine-rich food from animal sources
• Other than arthritis, bursitis and tendinitis, systemic features e.g.
fever can be present
• Gout flare
 Presents with symptoms of acute arthritis with joint pain, swelling,
warmth, redness and movement difficulty
 Occurs abruptly with joint pain peaking in intensity within 24 hours
and resolves spontaneously within 1 - 2 weeks
 Commonest affected site is the first MTP joint; the midfoot and
ankle are also commonly involved joints
5.2 Intercritical Gout

• Defined as asymptomatic period after or between gout flares, despite
the persistence of MSU crystals12, level III
5.3 Chronic Gouty Arthritis

• Defined as persistent joint inflammation induced by MSU
crystals12, level III
• Characterised by chronic arthritis, with or without tophi, chronic joint
pain, functional disability, structural joint destruction, deformity and
repeated flares
10
Physical examination during a flare may show presence of the following:

• swelling, redness, warmth, profound tenderness with markedly
reduced movement of the affected joint
• desquamation of overlying skin in superficial joints as flare resolves
• swelling, redness, warmth and tenderness of periarticular structures
due to involvement of bursa or tendon
• fever
In chronic gouty arthritis, the following signs may be present:
• joint deformity e.g. fixed flexion deformity
• subcutaneous tophi (refer to Figure 2 below)
 appear as white or yellow, non-tender firm nodules which can be
tender if inflamed
 common sites are first MTP joint, Achilles tendon, peroneal tendon,
helix of the ear, olecranon bursa and finger pad
 may be infected with signs of inflammation
 may ulcerate or discharge white chalky or toothpaste-like
substance
Figure 2a Figure 2b
Photos of tophi at antihelix of right ear (Figure 2a) and

left lateral malleolus (Figure 2b) as indicated by arrows.
11
6. COMORBIDITIES
Comorbidities are common in people with gout which may complicate

the disease management and outcomes.
A large cohort study which determined the risk of comorbidities in

patients with gout compared with those without gout found:29, level II-2
• At the time of gout diagnosis
 gout was associated with higher risk of at least one comorbidity listed
in the Charlson index (32.25% vs 27.97%; p<0.001)
 all cardiovascular (CV) and genitourinary diseases were associated
with a higher risk of incident gout, the highest risk being for renal
diseases (OR=5.96, 95% CI 5.09 to 6.98) and congestive heart
disease (OR=4.37, 95% CI 4.01 to 4.76) which were diagnosed in
the 10-year period before gout was diagnosed
• During follow-up after gout diagnosis
 median time to first comorbidity in the Charlson index was 43 months
(95% CI 41 to 45) in gout and 111 months (95% CI 108 to 115) in
those without gout (p<0.001)
 gout patients with a Charlson score of zero at diagnosis had higher
risk of having a Charlson index ≥1 compared with those without gout
with a HR of 1.41 (95% CI 1.34 to 1.48)
 risk of developing incident comorbidities was higher in patients with
gout in the following diseases:
- congestive heart failure (HR=1.81, 95% CI 1.65 to 1.98)
- myocardial infarction (HR=1.16, 95% CI 1.05 to 1.28)
- hypertension (HR=1.51, 95% CI 1.43 to 1.58)
- hyperlipidaemia (HR=1.40, 95% CI 1.31 to 1.50)
- renal diseases (HR=3.18, 95% CI 2.88 to 3.50)
- urolithiasis (HR=1.26, 95% CI 1.02 to 1.55)
- chronic obstructive pulmonary disease (COPD) (HR= 1.10, 95%
CI 1.02 to 1.18)
- diabetes mellitus (HR=1.65, 95% CI 1.54 to 1.77)
- hypothyroidism (HR=1.46, 95% CI 1.32 to 1.61)
- liver disease (HR=1.97, 95% CI 1.61 to 2.41)
- anaemia (HR=1.58, 95% CI 1.49 to 1.68)
• Gout was also associated with an increase in all-cause mortality
(HR=1.13, 95% CI 1.08 to 1.18)
In a meta-analysis of 17 epidemiologic studies, gout was associated

with both CKD (OR=2.41, 95% CI 1.86 to 3.11) and self-reported lifetime
nephrolithiasis (OR=1.77, 95% CI 1.43 to 2.19).30, level II-2
A large population-based study demonstrated that patients with gout

had an increased risk of venous thrombo-embolism (VTE), deep vein
thrombosis (DVT) and pulmonary embolism (PE) both before and after
gout diagnosis compared with the general population. The HR for VTE,
12
DVT and PE were 1.22 (95% CI 1.13 to 1.32), 1.28 (95% CI 1.17 to
1.41) and 1.16 (95% CI 1.05 to 1.29) respectively. Furthermore, the
risk increased gradually and peaked in the year prior to diagnosis and
subsequently declined progressively.31, level II-2
The risk of developing comorbidities was compared between patients

with controlled [SU <360 µmol/L (<6.0 mg/dL)] and uncontrolled [SU
≥480 µmol/L (≥8.0 mg/dL)] gout in a large cross-sectional study. Those
with uncontrolled gout were more likely to have diabetes mellitus (OR=
1.20, 95% CI 1.06 to 1.34), CKD (OR=2.04, 95% CI 1.80 to 2.30) and
congestive heart failure (OR=2.65, 95% CI 2.32 to 3.01).32, level III
• A few large, prospective studies have shown that gout is an

independent risk factor for mortality due to coronary heart disease
(CHD)33 - 35, level II-2 and kidney disease.35, level II-2 Therefore, screening
of CHD and its risk factors e.g. hypertension, diabetes mellitus,
hyperlipidaemia and renal disease including urolithiasis should be
done routinely.
• More evidence is warranted before recommending routine screening
of diseases e.g. COPD, hypothyroidism, liver disease, anaemia and
VTE.
• Patients with uncontrolled gout have a higher association with
diabetes mellitus, CKD and congestive heart failure compared with
well-controlled gout.
Recommendation 2
• Screening for comorbidities associated with gout e.g. hypertension,
diabetes mellitus, hyperlipidaemia, coronary heart disease and renal
disease including urolithiasis should be done upon diagnosis and
during follow-up.
13
7. DIAGNOSIS
Demonstration of MSU crystals in synovial fluid (SF) or tophus aspirate

confirms the diagnosis of gout. If confirmation is not possible, diagnosis
of gout can be made through the evaluation of clinical manifestations,
laboratory investigations and imaging modalities.
7.1 Demonstration of Monosodium Urate Crystals in Synovial

Fluid or Tophus Aspirate
Demonstration of MSU (negative birefringent) crystals in SF or tophus

aspirate is the gold standard for the diagnosis of gout (Figure 3). It
has 100% specificity. Polarised light microscopy is the standard method
for detecting MSU crystals. Low-quality evidence suggested that MSU
crystals remained stable in SF stored at room temperature for 24 - 48
hours and should be refrigerated (at 4ºCelcius) if analysis was to be
delayed.36, level III
Figure 3. Photos of needle-shaped MSU crystals in SF viewed

through A) dark-field microscopy B) polarised light microscopy
7.2 Clinical Manifestations
A systematic review of moderate-quality papers showed that presence

of tophus and response to colchicine had high specificity of 1.00
(95% CI 0.97 to 1.00) and 0.85 (95% CI 0.55 to 0.98) respectively
when compared with MSU crystal demonstration in the diagnosis of
gout.37, level III
Clinical features of gout are described in Chapter 4 on Natural History

and Chapter 5 on Clinical Presentation.
14
7.3 Laboratory Investigations
Epidemiological studies have shown that not all hyperuricaemic

subjects develop gout as discussed below.
The risks of both gout incidence in gout-free individuals and recurrence

of flares in individuals with preexisting gout increase with higher SU
levels at baseline.38, level II-2
In a meta-analysis of four cohort studies with a mean follow-up of 11.2

years, higher SU levels at baseline were associated with an increased
risk of developing gout (dose-dependent) compared with baseline SU
<6 mg/dL (360 µmol/L):9, level II-2
• 6.0 - 6.9 mg/dL (360 - 414 µmol/L) with HR of 2.69 (95% CI 2.03
to 3.57)
• 7.0 - 7.9 mg/dL (420 - 474 µmol/L) with HR of 6.64 (95% CI 5.04
to 8.77)
• 8.0 - 8.9 mg/dL (480 - 534 µmol/L) with HR of 14.92 (95% CI
11.06 to 20.13)
• 9.0 - 9.9 mg/dL (540 - 594 µmol/L) with HR of 29.66 (95% CI
20.79 to 42.31)
• ≥10 mg/dL (≥600 µmol/L) with HR of 63.96 (95% CI 42.54 to
96.16)
• Diagnosis of gout should not be made based on hyperuricaemia

alone.
• The cut-off SU level to diagnose hyperuricaemia based on urate
saturation threshold is a SU concentration of >6.8 mg/dL (408
µmol/L) at physiological pH and body temperature.39
• A normal or low SU during flare does not exclude gout, as the level
may not be elevated during a flare. If clinical suspicion of gout is high,
SU may be repeated two weeks or more after complete resolution of
flare.
7.4 Imaging Modalities

a. Plain radiography
Changes in plain radiograph take several years to develop. Thus,
utility of plain radiograph is limited in early gout but may be helpful in
supporting the diagnosis in later stages.
Typical radiographic features of established gout include (refer to

Figure 4):
• bone erosions with overhanging edges and a sclerotic rim (A)
• bone proliferation (B)
• joint space narrowing (C)
• soft tissue masses (tophi), which can be calcified (D)
15
Figure 4a. AP radiograph Figure 4b. AP radiograph

of left foot of both hands
AP = anteroposterior
b. Ultrasonography
Musculoskeletal ultrasonography is useful in assisting the diagnosis
of gout especially when the presentation is atypical and microscopic
demonstration of MSU crystals is not feasible. Evidence supporting its
diagnostic utility is described as follows:
• In a systematic review, ultrasound findings of double contour
sign (DCS), tophi, punctiform deposits in synovial membrane and
hyperechoic spots in SF showed good specificity ranging from 0.65
to 1.00 for diagnosis of gout with MSU identification as the reference
standard.37, level III
• A meta-analysis of three diagnostic studies on ultrasound in joint/
location-based evaluations for the diagnosis of gout gave a sensitivity
of 0.71 (95% CI 0.64 to 0.78), specificity of 0.62 (95% CI 0.56 to
0.67) and AUC of 0.8549 for DCS.40, level III
The DCS is indicated by arrow heads as shown in Figures 5a and 5b.
Figure 5a.
Longitudinal
ultrasound scan of
left first MTP joint
Figure 5b.
Suprapatellar
transverse
ultrasound scan of
right knee joint
16
c. Dual-energy Computed Tomography

A good meta-analysis of seven studies showed that DECT had a high
sensitivity of 88% (95% CI 84 to 90), specificity of 90% (95% CI 85
to 93) and AUC of 0.9565 as a tool for the diagnosis of gout.41, level III
However, this imaging modality is not utilised as a diagnostic tool for
gout as it is not widely available in Malaysia.
7.5 Classification Criteria
ACR-EULAR 2015 Gout Classification Criteria was originally developed

for the purpose of research. It incorporates clinical, laboratory and
radiology features/modalities in diagnosing gout. A person with a
score ≥8 can be classified as having gout with a sensitivity of 92% and
specificity of 89%. The criteria can also be used for gout classification
based on only clinical features and SU level. In this setting, it has
a sensitivity of 85% and specificity of 78%. Although regarded as
classification criteria, it can also be applied in daily clinical practice for
the diagnosis of gout. Refer to Table 2 below for the classification. An
electronic calculator is now available at:
http://goutclassificationcalculator.auckland.ac.nz
https://www.mdcalc.com/acr-eular-gout-classification-criteria
17
Table 2. The ACR/EULAR gout classification criteria

Categories Score
Step 1: Entry criterion (only apply criteria At least 1 episode of swelling, pain, or
below to those meeting this entry criterion) tenderness in a peripheral joint or bursa
Step 2: Sufficient criterion (if met, can classify Presence of MSU crystals in a symptomatic
as gout without applying criteria below) joint or bursa (i.e., in synovial fluid) or tophus
Step 3: Criteria (to be used if sufficient

criterion not met)
Clinical
Pattern of joint/bursa involvement during Ankle or midfoot (as part of 1
symptomatic episode(s) ever* monoarticular or oligoarticular episode
without involvement of the first
metatarsophalangeal joint)
Involvement of the first 2

metatarsophalangeal joint (as part of
monoarticular or oligoarticular episode)
Characteristics of symptomatic episode(s) ever

• Erythema overlying affected joint (patient- One characteristic 1
reported or physician-observed) Two characteristics 2
• Can’t bear touch or pressure to affected Three characteristics 3
joint
• Great difficulty with walking or inability to
use affected joint
Time course of episode(s) ever One typical episode 1

Presence (ever) of ≥2, irrespective of Recurrent typical episodes 2
anti-inflammatory treatment:
• Time to maximal pain <24 hours
• Resolution of symptoms in ≤14 days
• Complete resolution (to baseline level)
between symptomatic episodes
Clinical evidence of tophus Present 4

Draining or chalk-like subcutaneous nodule
under transparent skin, often with overlying
vascularity, located in typical locations: joints,
ears, olecranon bursae, finger pads, tendons
(e.g. Achilles)
Laboratory
Serum urate: Measured by uricase method. <4 mg/dL (<0.24 mmol/L)** -4
Ideally should be scored at a time when the 6 - <8 mg/dL (0.36 - <0.48 mmol/L) 2
patient was not receiving ULT and it was >4 8 - <10 mg/dL (0.48 - <0.60 mmol/L) 3
weeks from the start of an episode (i.e. during ≥ 10 mg/dL (≥0.60 mmol/L) 4
intercritical period); if practicable, retest under
those conditions.
The highest value irrespective of timing
should be scored.
Synovial fluid analysis of a symptomatic (ever) MSU negative -2
joint or bursa (should be assessed by a
trained observer)***
Imaging$
Imaging evidence of urate deposition in
symptomatic (ever) joint or bursa:
Ultrasound evidence of double contour sign# Present (either modality) 4
or
DECT demonstrating urate deposition¥
Imaging evidence of gout-related joint damage:
Conventional radiography of the hands Present 4
and/or feet demonstrates at least 1 erosion€
18
*Symptomatic episodes are periods of symptoms that include any swelling, pain, and/
or tenderness in a peripheral joint or bursa.
**If serum urate level is <4 mg/dL (<0.24 mmol/L), subtract 4 points; if serum urate
level is ≥4 -<6 mg/dL (≥0.24 -<0.36 mmol/L), score this item as 0.
***If polarising microscopy of synovial fluid from a symptomatic (ever) joint or bursa
by a trained examiner fails to show monosodium urate monohydrate (MSU) crystals,
subtract 2 points. If synovial fluid was not assessed, score this item as 0.
$
If imaging is not available, score these items as 0.
#
Hyperechoic irregular enhancement over the surface of the hyaline cartilage that
is independent of the insonation angle of the ultrasound beam (note: false-positive
double contour sign [artifact] may appear at the cartilage surface but should disappear
with a change in the insonation angle of the probe).
¥
Presence of colour-coded urate at articular or periarticular sites. Images should
be acquired using a dual-energy computed tomography (DECT) scanner, with data
acquired at 80 kV and 140 kV and analysed using gout-specific software with a
2-material decomposition algorithm that colour-codes urate. A positive scan is defined
as the presence of colour-coded urate at articular or periarticular sites. Nailbed,
submillimeter, skin, motion, beam hardening, and vascular artifacts should not be
interpreted as DECT evidence of urate deposition.
€
Erosion is defined as a cortical break with sclerotic margin and overhanging edge,
excluding distal interphalangeal joints and gull wing appearance.
Reference: Neogi T, Jansen TL, Dalbeth N, et al. 2015 Gout Classification Criteria: an
American College of Rheumatology/European League Against Rheumatism
collaborative initiative. Arthritis Rheumatol. 2015;67(10):2557-2568.
In conclusion, diagnosis of gout should ideally be confirmed by

the presence of MSU crystals. However, if demonstration of MSU
crystals is not possible, gout can be diagnosed based on typical
clinical manifestations. This is supported by the presence of
hyperuricaemia. Plain radiography is helpful only in later part of the
disease. Musculoskeletal ultrasonography maybe useful in atypical
presentations.
Recommendation 3
• Demonstration of monosodium urate (MSU) crystals in synovial
fluid or tophus aspirate under polarised light microscopy should be
performed to confirm the diagnosis of gout.
 If confirmation of the presence of MSU crystals is not possible, the
diagnosis may be made based on typical clinical manifestations.
 Musculoskeletal ultrasonography may assist in the diagnosis of
gout with atypical presentations.
19
8. BASELINE INVESTIGATIONS
Baseline investigations are performed to support the diagnosis of

gout and identify comorbidities associated with gout and those that
may influence treatment decisions. Refer to Table 3 on Baseline
investigations in gout.
Table 3. Baseline investigations in gout
Investigations Rationale
Full blood count (FBC) To exclude infection or lymphoproliferative/

myeloproliferative disorders
Renal profile (RP) To exclude renal disease leading to hyperuricaemia, renal

disease secondary to chronic nephropathy, urolithiasis
Liver function test (LFT) Baseline prior to commencement of treatment
SU Presence of hyperuricaemia is supportive of gout
Fasting blood sugar (FBS) To detect the presence of diabetes/insulin resistance

Fasting serum lipid (FSL) To detect hyperlipidaemia
Full and microscopic Presence of blood and/or protein may suggest renal
examination of urine disorders
(Urine FEME)
Plain radiography of To detect abnormalities caused by gout
affected joint(s)
Ultrasound of the kidneys, To detect urolithiasis or renal parenchymal disease
ureters and bladder
(USG KUB)
Electrocardiogram (ECG) To detect CHD
20
9. DIFFERENTIAL DIAGNOSES
Gout usually presents with acute monoarthritis and less commonly

with oligoarthritis. A diagnosis of gout can be reasonably made in a
hyperuricaemic patient who presents with acute monoarthritis of the first
MTP joint. However, other causes of acute monoarthritis/oligoarthritis
should be considered before making a diagnosis of gout.
The main differential diagnoses of gout and their supportive features

are:
i. septic arthritis (key differential diagnosis)
• commonly involves knee joint (other sites are hip, shoulder, ankle,
wrist)
• acutely painful/tender, hot, swollen, erythematous and immobile
joint
• presence of systemic features e.g. fever, ill or septic-looking
• risk factors e.g. concomitant bacteraemia, recent intra-articular
injection
• leukocytosis and raised C-reactive protein
ii. acute calcium pyrophosphate crystal arthritis
• age >60 years old
• involvement of a degenerative joint
• radiography of affected joint may show presence of
chondrocalcinosis
iii. psoriatic arthritis
• presence of psoriasis, nail dystrophy (e.g. pitting, onycholysis or
crumbling)
iv. reactive arthritis
• recent genitourinary or gastrointestinal (GI) infection
• presence of urethral discharge or ulcer, rash on soles, conjunctivitis
21
10. ASYMPTOMATIC HYPERURICAEMIA
Treatment of asymptomatic hyperuricaemia with ULT to prevent gout

has been a much debated topic for decades. There is also emerging
interest in the role of ULT in preventing progression of disease in CKD
or CV events.
a. Urate-lowering therapy for gout prevention in asymptomatic

hyperuricaemia
A cohort study showed that not all patients with hyperuricaemia will
develop gout. Only 22% of patients with SU >9.0 mg/dL (540 µmol/L)
will do so in five years.11, level II-2 Two more recent studies showed similar
results with the following findings:
• the absolute risks of developing incident gout over 30 years with
SU >405 µmol/L at baseline, were 13.3% (95% CI 12.2 to 14.8) in
men and 17.7% (95% CI 12.4 to 24.6) in women, respectively9, level II-2
• 15-year cumulative incidence of gout ranged from 1.12%
(95% CI 0.90 to 1.35) for baseline SU <6 mg/dL (360 µmol/L)
to 48.57% (95% CI 30.50 to 66.64) for baseline SU ≥10 mg/dL
(600 µmol/L)10, level II-2
In an RCT on patients with CKD stage 3 and asymptomatic

hyperuricaemia, the incidence of gouty arthritis was lower in febuxostat
compared with placebo (p=0.007). However, the incidence rates of
gouty arthritis in both groups were low (0.91% and 5.86% for febuxostat
and placebo respectively).42, level I Therefore, the benefit of starting ULT
may not outweigh the potential adverse events (AE) of treatment as the
vast majority of these patients will not develop gout.
b. Urate-lowering therapy for renoprotective effect in

asymptomatic hyperuricaemia
Hyperuricaemia is associated with progression of CKD. However, direct
causality between them is not well established as it is unclear whether
high SU is a cause of kidney disease or just a common co-occurrence.
In a meta-analysis of five RCTs comparing allopurinol with controls

(placebo or colchicine) in a heterogenous population of CKD patients
(hyperuricaemic and non-hyperuricaemic), there was no significant
difference in the change of glomerular filtration rate (GFR) from baseline
between the two groups. However, meta-analysis of three other RCTs
with serum creatinine as study end point showed that change in serum
creatinine concentration from baseline was in favour of allopurinol (MD=
-0.4 mg/dL, 95% CI -0.8 to -0.0). The quality of the primary papers
included was moderate.43, level I
An RCT involving type 1 diabetic patients with kidney disease (mean

SU of 360 µmol/L) also revealed no significant difference in the decline
22
of iohexol-based GFR between the allopurinol and placebo groups after

three years of treatment.44, level I The quality of the RCT was moderate.
In one RCT among CKD stage 3 patients and asymptomatic

hyperuricaemia (SU levels ≥420 µmol/L), there was no significant
difference in the mean estimated glomerular filtration rate (eGFR) slope
between febuxostat and placebo groups.42, level I Another RCT showed
similar results between febuxostat and non-febuxostat (allopurinol or
placebo) groups in elderly patients (≥65 years old) with asymptomatic
hyperuricaemia (SU levels ≥420 µmol/L) and ≥1 risks of CV/cerebral/
renal disease.45, level I The quality of both RCTs was moderate.
A non-randomised controlled trial comparing febuxostat and allopurinol

in patients with CKD stages 3-5 with asymptomatic hyperuricaemia
(SU levels ≥420 µmol/L) showed a decrease in eGFR in allopurinol
group among patients with CKD stage 3, 4, and 5 (p<0.05) compared
with febuxostat. In the febuxostat group, there was an increase in
eGFR in CKD stage 3 only and decrease in eGFR in CKD stage 4
and 5. The differences between the febuxostat and allopurinol groups
were significant in CKD stage 3 and 4 but nonsignificant in CKD
stage 5.46, level II-1
In terms of safety, the above meta-analysis showed no significant

difference in the incidence of skin rash between allopurinol and placebo
groups.43, level I There was also no significant difference in serious
adverse events (SAEs) between allopurinol and placebo groups in the
RCT involving type 1 diabetic patients with kidney disease. However,
there were numerically more fatal SAEs in the allopurinol arm.44, level I
There was no significant difference in AEs between febuxostat and
placebo42, level I or febuxostat and allopurinol.46, level II-1
c. Urate-lowering therapy for cardioprotective effect in

asymptomatic hyperuricaemia
Epidemiological studies have shown strong associations between
SU levels with CV disease. However, it remains unclear whether
hyperuricaemia directly or indirectly increases the risk of CV disease,
as these associations are confounded by other risk factors e.g. obesity
and hypertension.
An RCT compared febuxostat and non-febuxostat (allopurinol or

placebo) treatments in elderly patients (≥65 years old) with asymptomatic
hyperuricaemia (SU levels ≥420 µmol/L) and ≥1 risks of CV/cerebral/
renal disease. It showed that the primary composite event rate (CV,
cerebral or renal events and all deaths) was lower in the febuxostat
group at 36 months (HR=0.750, 95% CI 0.592 to 0.950).45, level I
23
In a Cochrane systematic review of three RCTs on ULTs in patients

with hypertension or prehypertension plus hyperuricaemia, there was
insufficient evidence on the effect of ULTs in reducing blood pressure
(BP). Analysis showed no significant difference in 24-hour ambulatory
systolic or diastolic BP between those who received ULT and placebo.
However, subgroup analysis demonstrated that ULTs reduced clinic-
measured systolic BP (MD= -8.43 mmHg, 95% CI -15.24 to -1.62) but
not diastolic BP among adolescents.47, level I
A recent meta-analysis comparing ULTs with placebo in adult heart

failure patients showed that ULTs did not improve left ventricular ejection
fraction, 6-minute walk test, brain natriuretic peptide/N-terminal-pro-
brain natriuretic peptide (BNP/NT-pro-BNP), all-cause mortality and CV
death among the patients. The quality of the primary papers included
was high to moderate.48, level I
In terms of safety, no AEs were reported. The occurrence of malignant

tumours was similar in the febuxostat and non-febuxostat groups.45, level I
There were also inconclusive results regarding the occurrence of AEs
when comparing between those who received ULTs and placebo.47, level I
• There is insufficient evidence from current studies to recommend

ULT in asymptomatic hyperuricaemia to prevent gout, disease
progression in CKD or CV events.
24
11. TREAT-TO-TARGET
Achieving SU target over time leads to suppression of gout flares as

well as reduction of tophi size and number.
In a two-year RCT on T2T strategy aiming for SU <360 μmol/L in gout

patients, community-based nurse-led care involving a T2T strategy
was better in achieving SU target concentration compared with general
practitioner-led usual care (RR=3.18, 95% CI 2.42 to 4.18). It also
improved patient-centred outcomes:49, level I
• ≥2 flares (RR=0.33, 95% CI 0.19 to 0.57)
• ≥4 flares (RR=0.09, 95% CI 0.02 to 0.36)
• presence of tophi (RR=0.21, 95% CI 0.08 to 0.52)
Post hoc analysis comparing patients with and without renal impairment
in the nurse-led group showed no difference in proportion of ULT use,
achievement in SU of <360 μmol/L or <300 μmol/L, and AEs.
In another RCT on gout patients, comparing allopurinol dose escalation

using T2T strategy aiming for SU <6 mg/dL (360 μmol/L) and control
[Creatinine clearance (CrCl)-based allopurinol dose], the final SU
reduction was greater in the dose escalation group at 12 months
(MD=1.2 mg/dL (72 μmol/L), 95% CI 0.67 to 1.5). However, there were
no significant differences in proportion of patients having any gout
flare and change in tophus size in both groups. There were also no
significant differences in renal function changes and SAEs.50, level I
A large cohort study on Korean adults showed that the lowest and
highest SU categories were associated with an increased all-cause
mortality when compared with the reference category [6.5 -7.4 mg/
dL (390 - 444 μmol/L) in men; 3.5 - 4.4 mg/dL (210 - 264 μmol/L) in
women]:51, level II-2
• Lowest SU category vs reference category
 <3.5 mg/dL (210 μmol/L) for men with HR of 1.58 (95% CI 1.18
to 2.10)
 <2.5 mg/dL (150 μmol/L) for women with HR of 1.80 (95% CI
1.10 to 2.93)
• Highest SU category vs reference category
 ≥9.5 mg/dL (570 μmol/L) for men with HR of 2.39 (95% CI 1.57
to 3.66)
 ≥8.5 mg/dL (510 μmol/L) for women with HR of 3.77 (95% CI
1.17 to 12.17)
ACR, EULAR and BSR recommend to achieve and maintain an SU

target of <6 mg/dL (360 μmol/L) for all gout patients receiving ULT.3; 52 - 53
The CPG DG recommends that the same SU target of <6 mg/dL (360
μmol/L) is used for all Malaysian gout patients receiving ULT as well.
25
• A lower SU target of <5 mg/dL (300 μmol/L) for faster dissolution of

crystals is recommended in severe gout (tophi, chronic arthropathy,
frequent flares). However, some studies have suggested that
urate might be protective against various neurodegenerative
diseases, therefore prolonged SU <3 mg/dL (180 μmol/L) is not
recommended.53
Recommendation 4
• Treat-to-target strategy aiming for serum urate of <360 μmol/L
should be applied in the treatment of all gout patients.
26
12. TREATMENT
Treatment of gout flare serves to provide rapid and effective pain relief
enabling a return to previous activities. Long-term management is aimed
at achieving a sustained reduction in SU level and consequent reduction
in gout flares. There are various treatment modalities which include
non-pharmacological, pharmacological and surgical approaches.
12.1 Non-pharmacological Treatment
The following are non-pharmacological treatments that have been

proven to reduce recurrent gout flares or improve other outcomes.
a. Health education
Patient education is important to achieve SU target and treatment
adherence among gout patients.
A systematic review of five RCTs and three cohort studies looked into
the effectiveness of educational/behavioural interventions in gout.
The interventions were delivered either by primary care providers,
pharmacists or nurses. Quantitative analysis of four RCTs showed that
educational/behavioural interventions were more effective than usual
care in achieving SU <6 mg/dL (360 µmol/L) among gout patients
(OR=4.86, 95% CI 1.48 to 15.97). Qualitative analysis of all five RCTs
showed that there were also improvements in other outcomes e.g.
adherence to allopurinol, a decrease of at least 2 mg/dL (120 µmol/L)
in SU, achievement of SU <5 mg/dL (300 µmol/L), reduction in the
number of tophi at two years etc. These findings were also supported
by the three cohort studies included in the review. GRADE assessment
of the evidence showed a rating of low to moderate quality.54, level I
Health education is strongly recommended as part of gout management.

It consists of education on:3, 52 - 53
• pathophysiology of gout
• recognition of gout flare
• existence of effective treatments
• prompt treatment of gout flare and its principles
• compliance to ULT including T2T strategy
• continuance of ULT during flare
• healthy lifestyle
• associated comorbidities
b. Lifestyle modifications
• Weight management
A systematic review of low to moderate quality studies showed that
compared with not losing weight after medium/long-term follow-up,
weight loss (3 - 34 kg) in overweight/obese gout patients was associated
with:55, level II-2
27
 decreased SU (range from -168 to 30 µmol/L)

 achievement of SU target (<360 μmol/L) in 0% to 60% of patients
 fewer gout flares (75% of the included studies showed beneficial
effects on gout flares)
• Dietary purine
In a case-crossover study on purine-rich food intake in patients with
gout, the following findings were noted:56, level II-2
 total purine intake in the highest quintile (median=3.48 g) over a
2-day period increased the risk of recurrent gout flares by almost
five times compared with the lowest quintile (median=0.85 g)
(OR=4.76, 95% CI 3.37 to 6.74); with a significant trend of higher
risk in increasing quintile
 animal purine sources - the highest quintile of total purine intake
increased risk of recurrent flares compared with the lowest quintile
(OR=2.41, 95% CI 1.72 to 3.36)
 plant purine sources - the difference in recurrent gout flares was
not statistically significant between the highest and lowest total
purine intake
 impact from animal purine sources was substantially greater than
that from plant purine sources
• Alcohol consumption
A case-crossover study confirmed that episodic alcohol consumption,
regardless of type of alcoholic beverage (wine, beer or liquor), was
associated with an increased risk of recurrent gout flares.57, level II-2
 Risk of recurrent gout flares increased significantly with >2
servings of alcoholic beverages compared with no alcohol
consumption in the prior 24 hours (OR=1.51, 95% CI 1.09 to
2.09); a significant dose-response relationship between amount
of alcohol consumption and risk of recurrent gout flares was noted
(p<0.001 for trend).
*One typical drink contains approximately 15 grammes of alcohol.
• Omega-3 polyunsaturated fatty acids

Omega-3 PUFAs (n-3 PUFAs) have been shown to have anti-
inflammatory effects through rapid and selective inhibition of the NLRP3
inflammasome.58 - 61 Examples of dietary n-3 PUFA-rich fish (fatty fish)
are anchovies, mackerel, salmon, sardines, trout and herring while n-3
PUFA-rich supplements are fish oil and cod liver oil. A case-crossover
study on gout patients showed that:22, level II-2
 dietary n-3 PUFA-rich fish consumption of ≥2 servings in the prior
48 hours was associated with lower risk of recurrent gout flares
compared with no fatty fish consumption (OR=0.74, 95% CI 0.54
to 0.99)
 n-3 PUFA-rich supplements were not associated with reduction in
recurrent gout flares
28
• Cherry
Cherry products contain high levels of anthocyanins62 - 64 that possess
anti-inflammatory and antioxidant properties.63; 65 - 66 A case-crossover
study on gout showed that compared with no intake in the preceding 48
hours, the risk of gout flares was decreased by:67, level II-2
 35% with cherries only intake (OR=0.65, 95% CI 0.50 to 0.85)
 45% with cherry extract only intake (OR=0.55, 95% CI 0.30 to
0.98)
 37% with cherries and cherry extract intake (OR=0.63, 95% CI
0.49 to 0.82)
When cherry intake was combined with allopurinol, risk of gout flares
was 75% lower than periods without either exposure (OR=0.25, 95%
CI 0.15 to 0.42).
However, more evidence is needed on the effect of cherry on gout.
• High-fructose corn syrup

ACR recommends to limit high-fructose corn syrup intake for patients
with gout, regardless of disease activity.52
• Others
Gout patients are advised to stay well-hydrated, exercise and cease
smoking.68
c. Concomitant medications
Medications that increase risk of gout should be discontinued or replaced
with alternatives if possible. The decision to discontinue a medication
should be made based on consideration of its benefits weighed against
risks in patients. Refer to Table 1 on Risk factors for gout.
• Low-dose aspirin
A case-crossover study on gout showed that compared with no aspirin
use, the risk of gout flares increased by 81% (OR=1.81, 95% CI 1.30 to
2.51) for ≤325 mg/day of aspirin use on two consecutive days. The risk
of gout flare was higher with lower doses (OR=1.91 for ≤100 mg, 95%
CI 1.32 to 2.85). Concomitant use of allopurinol nullified the detrimental
effect of aspirin on gout flares (OR=0.89, 95% CI 0.55 to 1.44).69, level II-2
The CPG DG recommends that aspirin if taken for appropriate

indications should not be discontinued in gout patients as there are
limited alternatives. Patients’ SU should be monitored and ULT dose
adjusted to achieve target as this may help to avoid flares.
29
Recommendation 5
• To improve outcomes in the management of gout:
 health education and behavioural intervention should be offered
 the following lifestyle modifications should be encouraged:
- reduce weight in those who are obese/overweight
- limit intake of purine-rich food especially of animal origin except
omega-3 polyunsaturated fatty acid-rich fish
- limit intake of all types of alcohol (beer, wine and liquor)
- limit intake of high-fructose corn syrup
d. Topical ice
A gout flare can cause extreme pain, which affects a patient’s ability to
focus on work or perform other daily activities.
A Cochrane systematic review of one small RCT with high risk of bias
studied the effectiveness of ice packs in reducing gout pain among
patients treated with colchicine and prednisolone. Ice packs reduced
pain compared with control (MD= -3.33 cm on VAS, 95% CI -5.84 to
-0.82). Although ice packs reduced swelling, difference between the
groups was not significant.70, level I
During gout flare, the affected joints should be rested, elevated and
exposed in a cool environment.3 Ice packs can be used as adjuvant
treatment.3; 52
• Ice packs should always be applied over a cloth and not directly onto
the skin of the affected joint (refer to Appendix 4).
Recommendation 6
• Ice packs may be used during gout flare.
12.2 Pharmacological Treatment

a. Urate-lowering therapy
The mainstay of gout treatment is ULT. Several types of ULT are now
available e.g. xanthine oxidase inhibitors (allopurinol and febuxostat),
uricosuric agents (benzbromarone and probenecid) and recombinant
uricases (pegloticase).
• Indications for urate-lowering therapy
• Established indications to initiate ULT for gout patients are:3; 52 - 53

 recurrent gout flares (≥2 flares in 12 months) OR
 presence of ≥1 tophi OR
 presence of radiographic damage attributable to gout
30
In addition, ACR conditionally recommends ULT initiation for gout

patients with their first gout flare based on the following indications:52
 moderate to severe CKD (stage ≥3) OR
 SU concentration >9 mg/dL (540 µmol/L) OR
 urolithiasis
ACR also conditionally recommends initiating ULT for gout patients who
previously experienced >1 flare but have infrequent flares (<2/year).52
For dosing of medications used in gout treatment, refer to Appendix 5

on Pharmacological Treatment for Gout.
• Allopurinol
A Cochrane systematic review studied the effectiveness of allopurinol
and other modalities of gout treatment in achieving SU target and
showed:71, level I
 more patients on allopurinol achieved SU target compared with
placebo in two RCTs [RR of 49.11 (95% CI 3.15 to 765.58) and
49.25 (95% CI 6.95 to 349.02) respectively]
 no difference in proportion of patients who achieved the SU target
between allopurinol and benzbromarone
 allopurinol 100 - 300 mg daily had fewer patients achieving SU
target compared with febuxostat 80 mg (RR=0.55, 95% CI 0.48
to 0.63), 120 mg (RR=0.48, 95% CI 0.42 to 0.54) and 240 mg
(RR=0.42, 95% CI 0.36 to 0.49) daily but showed no difference
with febuxostat 40 mg daily
The quality of the included papers was low to moderate. It has to be
noted that in the RCTs comparing efficacy of allopurinol and febuxostat
in lowering SU, allopurinol dose was not optimised and the highest
dose used was only 300 mg daily.
Traditionally, it was recommended that ULT is initiated after resolution

of gout flare. A meta-analysis of three RCTs showed that initiation of
allopurinol during a flare did not significantly increase pain severity
compared with placebo. The duration of flare also did not significantly
differ between the two groups. The primary papers included were of
moderate to high quality.72, level I ACR conditionally recommends that
ULT can be initiated during gout flare.52 Although sample sizes of the
included studies in the above meta-analysis were small, the CPG DG
opines that ULT can be initiated during a flare as long as the flare is
being appropriately managed.
Allopurinol has been associated with several AEs. Most are mild GI
events. The most serious AE is severe cutaneous adverse reaction
(SCAR) which can be fatal.73, level II-2 Reported risk factors for
Allopurinol Hypersensitivity Syndrome (AHS) include the starting
dose of allopurinol, presence of renal impairment and genetic allele
HLA-B*58:01.73, level II-2; 74, level I
31
A case-control study demonstrated a relationship between allopurinol

starting dose and AHS. The median time from starting allopurinol to
developing AHS was 30 days (range 1 - 1080 days) and 90% of AHS
cases occurred within the first 180 days. There was a strong dose-
response relationship between the starting dose of allopurinol (adjusted
for eGFR) and risk of AHS (p=0.001). AHS cases:
 had higher starting dose of allopurinol (p<0.001)
 were more likely to have a higher allopurinol starting dose than
CrCl-based dose (OR=16.7, 95% CI 5.7 to 47.6)
Based on an ROC analysis, an allopurinol starting dose of 1.5 mg/unit
eGFR minimised risk of AHS.73, level II-2 Therefore, start allopurinol at low
dose, 50 or 100 mg (refer to Appendix 5) and increase dose slowly
every four weeks (“start low, go slow”).
Two systematic reviews on gout showed no significant difference in any

AEs between allopurinol (up to 300 mg daily) and:
 placebo71, level I
 febuxostat (40 and 240 mg daily)71, level I; 75, level I
However, allopurinol had more AEs compared with febuxostat 80 mg
(RR=1.06, 95% CI 1.01 to 1.12) and 120 mg (RR=1.12, 95% CI 1.05
to 1.20).71, level I
In the Cochrane systematic review, there was also no significant

difference in AEs between allopurinol (100 - 600 mg daily),
benzbromarone (up to 200 mg daily) and probenecid (2 g daily).71, level I
Quality of the primary papers in both reviews ranged from low to
high.71, level I; 75, level I
HLA-B*58:01 is an allele carried mostly by the Han Chinese, Korean

and Thai people. It is strongly associated with SCAR (OR=44.0, 95%
CI 21.5 to 90.3). The gene dosage effect of HLA-B*58:01 influences
the development of allopurinol-induced cutaneous adverse drug
reactions:74, level I
 heterozygous (OR=15.25, 95% CI 8.40 to 27.70)
 homozygous (OR=72.45, 95% CI 14.70 to 356.70)
Both HLA-B*58:01 and renal impairment increase the risk of allopurinol-
induced cutaneous adverse drug reactions. The odds of SCAR in:74, level I
 heterozygous allele and normal renal function (OR=15.25, 95%
CI 8.40 to 27.70)
 homozygous allele and severe renal impairment (OR=1269.45,
95% CI 192.30 to 15,260.10)
On another note, a study showed that HLA-B*58:01 genetic testing

before allopurinol initiation was unlikely to be a cost-effective
intervention in Malaysia.76, level I Therefore, the CPG DG opines that
routine screening of HLA-B*58:01 prior to commencement of allopurinol
is not recommended.
32
• Febuxostat
Febuxostat is a potent non-purine selective XOI. A Cochrane systematic
review of four RCTs with the following comparisons showed:77, level I
 febuxostat vs placebo
- febuxostat was more likely to achieve SU levels <6.0 mg/dL
(360 µmol/L)
 40 mg at 4 weeks (RR=40.1, 95% CI 2.5 to 639.1)
 80 mg at 4 - 28 weeks (RR=68.9, 95% CI 13.8 to 343.9)
 120 mg at 4 - 28 weeks (RR=80.7, 95% CI 16.0 to 405.5)
 240 mg at 28 weeks (RR=93.04, 95% CI 13.23 to 654.45)
 febuxostat vs allopurinol (200 - 300 mg)

- febuxostat 40 mg showed no significant difference in achieving
SU <6.0 mg/dL (360 µmol/L)
- febuxostat 80 mg, 120 mg and 240 mg were more likely to
achieve SU levels <6.0 mg/dL (360 µmol/L) at:
 24 - 52 weeks (RR=1.80, 95% CI 1.55 to 2.09)
 28 - 52 weeks (RR=2.16, 95% CI 1.91 to 2.45)
 28 weeks (RR=2.30, 95% CI 1.94 to 2.73)
In terms of safety, there was no significant difference in any AE (liver

function test abnormalities, skin reactions, CV events, hypertension
and diarrhoea) between febuxostat of any dose and placebo. In another
comparison, febuxostat had lower total AEs than allopurinol:
 80 mg with RR of 0.93 (95% CI 0.87 to 0.99)
 120 mg with RR of 0.90 (95% CI 0.84 to 0.96)
There was no significant difference in any AEs between febuxostat 40
mg or 240 mg and allopurinol 200 - 300 mg. Risk of bias of the included
primary papers ranged from low to high.
Two post-marketing studies looked into the CV safety of febuxostat.

To fulfill the requirements of the United States (US) Food and Drug
Administration (FDA), a large RCT [Cardiovascular Safety of Febuxostat
and Allopurinol in Patients with Gout and Cardiovascular Morbidities
(CARES)] on gout patients with pre-existing CV disease was conducted.
Febuxostat was found to be noninferior to allopurinol in the overall rates
of major CV events (p=0.002 for noninferiority). However, HR for deaths
from any cause or CV events was 1.22 (95% CI 1.01 to 1.47) and 1.34
(95% CI 1.03 to 1.73) respectively.78, level I Nonetheless, this study has
its limitations which include a high dropout rate in both the febuxostat
and allopurinol groups.
In a large open-label RCT [The Febuxostat versus Allopurinol

Streamlined Trial (FAST)] on gout patients with at least one CV risk
factor commissioned by the European Medicines Agency, febuxostat
was noninferior to allopurinol with regard to the occurrence of major CV
outcomes (primary outcome of hospitalisation for nonfatal myocardial
infarction or biomarker-positive acute coronary syndrome, non fatal
stroke, or death due to a CV event) with HR of 0.85 (95% CI 0.70 to
33
1.03). In this trial, febuxostat was not associated with increased risk of
death or serious AEs.79, level I
Following the CARES trial, febuxostat has since carried a black box
warning issued by FDA regarding the increased rate of CV death in
gout patients with established CV disease.
Approximately one-quarter of patients with gout have CKD stage 3 and

above.30, level II-2 Thus, there is a need for effective and safe ULT for
them. In an RCT of patients with renal function ranging from normal
to severely impaired (eGFR 15 - 29 ml/min), febuxostat (40 mg and
80 mg, either extended release or immediate release) was more
effective than placebo in achieving an SU level of <5.0 mg/dL (300
µmol/L) and <6.0 mg/dL (360 µmol/L) at month three (p<0.001 for all
comparisons vs placebo). There were similar proportions of patients
who experienced ≥1 gout flares across the treatment groups. The rates
of treatment-emergent AEs (TEAEs) were low and evenly distributed
between treatment arms. However, the overall incidence of TEAEs was
higher in the severe renal impairment subgroup compared with the
other subgroups.80, level I
• Uricosuric agents
In a Cochrane systematic review on uricosuric agents in chronic gout,
the following results were demonstrated:81, level I
 comparison between benzbromarone and allopurinol showed no
significant difference in SU target achievement and AEs
 benzbromarone was more effective than probenecid in SU target
achievement after two months (RR=1.43, 95% CI 1.02 to 2.00:
NNTB=5) but not in frequency of gout flares
 benzbromarone also caused less AEs compared with probenecid
(risk difference= -0.27, 95% CI -0.42 to -0.11)
• Combination therapy
Uricosuric agents can be used in combination with XOI in gout
patients who do not achieve SU target with optimal doses of XOI
monotherapy.3; 53; 68
• Pegloticase
Two RCTs on patients with severe gout, allopurinol intolerance or
refractoriness, and SU concentration ≥8.0 mg/dL (480 µmol/L) showed
significantly higher proportion of responders [plasma UA <6.0 mg/
dL (360 µmol/L) for ≥80% of the time at three and six months] in
patients on pegloticase compared with placebo. However, there were
more SAEs in the pegloticase group. Gout flare and infusion-related
reactions were the two commonest AEs.82, level I ACR recommends
pegloticase in chronic gouty arthritis patients for whom treatment with
XOI, uricosurics and other interventions have failed to achieve SU
target and who continue to have frequent gout flares (≥2 flares/year)
34
or have non-resolving subcutaneous tophi.52 However, its use is limited

because of its cost.
• Health care professionals should be aware of the potential severe

AEs of allopurinol especially SCAR and its risk factors:
 starting dose of allopurinol
 presence of renal impairment
 presence of genetic allele HLA-B*58:01
• Initiation dose of allopurinol should be based on eGFR. Refer to
Appendix 5.
• Routine screening of HLA-B*58:01 prior to commencement of
allopurinol is not recommended locally.
• Febuxostat can be used in patients with renal impairment (eGFR
15 - 89 ml/min). However, uricosuric agents are contraindicated in
patients with urolithiasis3 and not recommended in severe renal
impairment.
Recommendation 7
• Patients with gout should be treated with urate-lowering therapy
when indicated.
 Allopurinol is the first-line therapy. It should be started at low dose
and increased gradually.
 When allopurinol is contraindicated or not tolerated, febuxostat or
uricosuric agents may be considered.
b. Gout flare
Gout flare is an extremely painful condition and can be very disabling. It
needs to be treated promptly and adequately. The mainstay of treatment
is pain relief.
• Colchicine
In a Cochrane systematic review of two RCTs, low dose (1.2 mg stat
and 0.6 mg one hour later; total 1.8 mg over one hour) and high dose
(1.2 mg stat, then 0.6 mg hourly for six hours; total 4.8 mg over six
hours) colchicine were more effective than placebo in achieving ≥50%
decrease in pain from baseline:83, level I
 low dose colchicine vs placebo at:
- 24 hours (RR=2.74, 95% CI 1.05 to 7.13)
- 32 to 36 hours (RR=2.43, 95% CI 1.05 to 5.64; NNTB=5, 95%
CI 2 to 20)
 high dose colchicine vs placebo at:
- 24 hours (RR=2.88, 95% CI 1.28 to 6.48)
- 32 to 36 hours (RR=2.16, 95% CI 1.28 to 3.65; NNTB=4, 95%
CI 3 to 12)
Both colchicine doses showed no significant difference for the same
outcome up to 36 hours.
35
There was no significant difference in GI AEs e.g. diarrhoea, vomiting or

nausea between low dose colchicine and placebo. However, high dose
colchicine caused more GI AEs than:83, level I
 placebo (RR=3.81, 95% CI 2.28 to 6.38; NNTH=2, 95% CI 2 to 5)
 low dose (RR=3.00, 95% CI 1.98 to 4.54; NNTH=2, 95% CI 2 to 3)
The primary papers were of low quality. In view of fewer side effects,
the CPG DG opines that low dose colchicine is the preferred choice.
• Nonsteroidal anti-inflammatory drugs/cyclooxygenase-2 inhibitors

A Cochrane systematic review compared the efficacy and safety
of various nonsteroidal anti-inflammatory drugs (NSAIDs)/
cyclooxygenase-2 (COX-2) inhibitors. There were no significant
differences in effectiveness based on different outcomes between
indomethacin and COX-2 inhibitors. In terms of safety, indomethacin
had more total AEs (RR=1.56, 95% CI 1.30 to 1.86) including GI AEs
(RR=2.35, 95% CI 1.59 to 3.48). However, there was no significant
difference in serious AEs. In one of the RCTs in the review, high dose
celecoxib (800 mg stat, 400 mg 12 hours later, then 400 mg BD for
seven days) showed no significant difference in patients’ assessment
of pain intensity compared with indomethacin 50 mg TDS. Celecoxib
had significantly less AEs compared with indomethacin. Quality of the
primary papers was low to moderate.84, level I
A meta-analysis comparing etoricoxib (120 mg OD) and NSAIDs

[indomethacin (50 mg TDS)/diclofenac (75 mg OD)] showed etoricoxib
had better pain relief based on VAS (MD= -0.46, 95% CI -0.51 to -0.41)
but non-significantly when measured with the 0 - 4 point Likert scale.
Etoricoxib also had fewer drug-related AEs (RR=0.64, 95% CI 0.50 to
0.81) with no significant difference in SAEs.85, level I The included primary
papers were of moderate quality.
• Corticosteroids
In a Cochrane systematic review, one RCT showed no difference in
resolution of pain using VAS between prednisolone (30 mg OD for 5
days) and intramuscular (IM) diclofenac (75 mg) plus indomethacin (50
mg TDS for two days, then 25 mg TDS for three days) at two weeks.
However, there were significantly more AEs in the diclofenac plus
indomethacin-treated patients. Quality of the RCT was moderate.86, level I
Two other systematic reviews showed no significant difference in

pain scores and mean pain reduction84, level I between corticosteroids
and NSAIDs. There was also no significant difference in total AEs.
The primary papers in these two reviews were of low to moderate
quality.84, level I; 87, level I
There is no direct evidence from randomised trials on the use of intra-

articular corticosteroids in gout. Evidence extrapolated from studies on
36
osteoarthritis and rheumatoid arthritis suggests it may be a safe and

effective option in gout flare.
• Interleukin-1 inhibitor
A systematic review comparing interleukin-1 (IL-1) inhibitors with
corticosteroids showed canakinumab had better effectiveness than IM
triamcinolone acetonide 40 mg at 72 hours in:88, level I
 pain reduction (MD= -10.6, 95% CI -15.2 to -5.9)
 complete absence of swelling (RR=1.39, 95% CI 1.11 to 1.74;
NNTB=9)
 Patient Global Assessment (PGA) (RR=1.37, 95% CI 1.16 to
1.61)
However, canakinumab had more frequent AEs:
 at least 1 AE (RR=1.2, 95% CI 1.1 to 1.4; NNTH=10)
 at least 1 SAE (RR=2.3, 95% CI 1.0 to 5.2)
Canakinumab is not readily accessible in Malaysia due to its cost.
In patients with gout flare where response to monotherapy is insufficient,

combinations of treatment can be used3 depending on the severity of
flares.53
Recommendation 8
• Gout flare should be treated promptly and adequately.
• In gout flare, the following monotherapy may be used*:
 colchicine
 nonsteroidal anti-inflammatory drugs/cyclooxygenase-2 inhibitors
 corticosteroids
• Combination of the above may be used in gout flare if response to
monotherapy is insufficient.
*The choice of drug will be guided by patient’s comorbidities. Refer to

Appendix 5 on Pharmacological Treatment for Gout with regard to
dosage and mode of administration.
c. Flare prophylaxis
Initiation of ULT leads to dissolution of MSU deposits which causes
dispersion of crystals resulting in increased gout flares. Therefore,
administrating a concomitant anti-inflammatory agent is necessary in
gout to reduce flares and encourage treatment adherence.
A systematic review on gout flare prophylaxis showed that the use of

colchicine or canakinumab after starting ULT (allopurinol or probenecid)
reduced both gout flares and their severity.89, level I
• Two RCTs with mixed risk of bias showed that colchicine given for at
least three months significantly reduced gout flares compared with
placebo. In one of the two RCTs, severity of the flares based on VAS
was also significantly lower.
37
• In another RCT with low risk of bias, a single dose of canakinumab

(50 mg - 300 mg) or 4 x 4 weekly doses (50 mg, 50 mg, 25 mg, 25
mg) provided significant prophylaxis against flares compared with
daily colchicine 0.5 mg.
In the fourth RCT with high risk of bias, colchicine 1 mg/day given for
7 - 9 months and 10 - 12 months were more effective than that given for
3 - 6 months. However, there was no significant difference between the
groups who received colchicine for a longer duration. In terms of AEs,
there were no significant differences between the groups in the three
out of four RCTs included in the review.89, level I
An alternative method to reduce gout flare is a stepwise dose increase

of ULT. In an RCT, stepwise dose increase of febuxostat, and fixed-
dose febuxostat with low dose colchicine prophylaxis given for three
months, significantly reduced gout flares compared with fixed-dose
febuxostat alone. However, there was no difference in gout flares
between the stepwise dose increase of febuxostat and low dose
colchicine prophylaxis groups. There were no differences in AEs
identified between the three groups.90, level I
In a cross-sectional study on chronic gouty arthritis, colchicine (mean

dose of 0.5 mg OD) or corticosteroids (prednisolone equivalent, mean
dose of 7.5 mg OD) prophylaxis given for six months reduced the
frequency and severity of gout flares during initiation of febuxostat.
However, colchicine was superior to corticosteroids in flare prophylaxis.
Both prophylactic agents were well tolerated.91, level III
CPG DG opines that stepwise dose increase of ULT and/or concomitant

colchicine should be the preferred method for gout flare prophylaxis.
Corticosteroid is less favoured as prolonged usage is usually associated
with corticosteroid-related adverse events. Canakinumab is least
preferred due to its cost.
Recommendation 9
• Prophylaxis for gout flares should be used for at least three to six
months when initiating urate-lowering therapy.
 The preferred choices are stepwise dose increase of urate-
lowering therapy and/or concomitant colchicine.
d. Special groups
i. Gout in chronic kidney disease
• Urate-lowering therapy
T2T strategy should be applied in the treatment of all gout patients
including those with CKD.49 - 50, level I; 92, level I
38
Allopurinol is effective and safe in gout patients with CKD.49 - 50, level I; 92, level I
It is the preferred first-line ULT in gout patients with moderate to severe
CKD (stage ≥3).52 Initiation dose is lower than that used in patients with
normal renal function.73, level II-2 Dose escalation is more gradual.
Febuxostat is also effective and safe in gout patients with CKD (eGFR
15 - 89 ml/min).80, level I It is the second-line ULT in moderate to severe
CKD.52 The dose for febuxostat does not need to be adjusted in mild-
to-moderate CKD (CrCl of 30 - 89 ml/min) but is limited to 40 mg OD in
severe CKD (CrCl of 15 - 29 ml/min).93 - 94, level III
Uricosurics are contraindicated in gout patients with urolithiasis3 and

not recommended in severe renal impairment.
• Gout flare
Colchicine should be avoided in severe CKD as its safety in this group
has not been established.53 NSAIDs should also be avoided in CKD
due to its potential nephrotoxic effect.95 Corticosteroids may be used in
gout flares with severe CKD.3
Topical ice therapy is safe during gout flare in patients with concomitant
CKD.
• Flare prophylaxis
Stepwise dose escalation of ULT reduces incidence of gout flares
including those with CKD.49, level I
Colchicine at a reduced dose is a recommended prophylaxis treatment

in gout patients with CKD.53 Long-term use of corticosteroid for flare
prophylaxis is not advisable due to its adverse effects. Avoid NSAIDs in
CKD due to its potential nephrotoxic effect.95
• The presence of CKD in gout patients requires a lower starting dose

of allopurinol and slower escalation of the dose.
• The maximum dose of allopurinol in gout patients with CKD should
be determined by its tolerability and not by renal function. The
maximum approved dose of allopurinol is 900 mg daily.96
Recommendation 10
• Treat-to-target strategy should also be applied in the treatment of
gout patients with concomitant chronic kidney disease.
ii. Gout in pregnancy and lactation

There is paucity of evidence in the treatment of gout in pregnancy and
lactation. The discussion in this section is based on the recommendations
39
in the ACR guidelines. Some of the recommendations put forward are

extrapolated from evidence not directly on gout.
Colchicine may be used in pregnancy and breastfeeding for the

treatment of rheumatological conditions including gout. NSAIDs should
be avoided in the third trimester while non-selective NSAIDs are preferred
over COX-2 specific inhibitors in the first two trimesters of pregnancy.
However, NSAIDs may be used in breastfeeding. Corticosteroids may
be used with caution in pregnancy and breastfeeding. Non-fluorinated
corticosteroids (prednisone, prednisolone) are preferred over fluorinated
corticosteroids (dexamethasone, betamethasone) as the former do not
cross the placenta at low to moderate doses unlike the latter.110
In addition, FDA recommends to avoid NSAIDs in pregnancy at 20

weeks or beyond as they can cause rare but serious kidney injury to
the unborn baby.97
There is inadequate data on the use of allopurinol, febuxostat,

probenecid and benzbromarone in pregnancy. Topical ice is safe for
gout flare in pregnant patients.
• There is paucity of evidence in the treatment of gout in pregnancy.

 Medications are used only when benefits clearly outweigh the
risks.
13. DISCONTINUATION OF URATE-LOWERING THERAPY
A systematic review of five observational studies on discontinuation of

ULT in adults with gout, showed that recurrence of arthritis was high
ranging from 36.4 to 81.0%. The mean time to relapse varied from 15.8
to 56.0 months with earliest relapses occurring at four months.98, level II-2
One of the cohort studies included in the systematic review showed that
higher SU levels during ULT treatment (HR=1.57, 95% CI 1.18 to 2.08)
and at follow-up after ULT discontinuation (HR=2.29, 95% CI 1.91 to
2.74) were independently associated with gout recurrence.
• ULT should be continued long-term in gout patients to prevent

recurrence of gout.
40
14. ADJUNCTIVE TREATMENT
There are multiple adjunctive treatments that have been used in gout to
augment the effect of ULT. They are discussed below.
• Vitamin C
Vitamin C has been believed to have urate lowering effect. In a small
RCT of eight weeks duration, modest dosage of vitamin C 500 mg/day
was not clinically significant in its urate lowering effect compared with
allopurinol in gout.99, level I
• Fibrates
In a meta-analysis of six RCTs on patients with type 2 diabetes mellitus
and hyperlipidaemia with mostly normal urate level, fibrate reduced
plasma urate concentration compared with placebo (WMD= -1.50 mg/
dL (-90 µmol/L), 95% CI -2.38 to -0.63). Subgroup analysis showed
that fenofibrate was effective but not bezafibrate.100, level I The included
primary papers were of moderate quality.
In a cross-sectional study on gout, patients co-treated with XOIs

and fenofibrate had lower SU compared with those on allopurinol or
febuxostat alone (p=0.043). There were no significant differences in
the levels of creatinine, blood urea nitrogen, and aminotransferases
between patients treated with and without fenofibrate.101, level III
• Statins
A meta-analysis on patients with dyslipidaemia showed atorvastatin
increased SU level compared with fenofibrate [MD=1.48 mg/dL (88.8
µmol/L), 95% CI 0.88 to 2.08].102, level I The primary papers were of low
quality.
In a more recent meta-analysis in patients with hypercholesterolaemia

and CHD, statins reduced plasma urate compared with control (WMD=
-25.58 µmol/L, 95 % CI -50.25 to -0.91). Among all the statins, only
atorvastatin and simvastatin showed significant effect.103, level I The
included primary papers had low to moderate quality of evidence.
• Urine alkalinisers
Regarding urine alkalinisation among hyperuricaemic patients, a small
RCT showed no significant difference in urinary urate excretion and
SU level with either allopurinol alone or when combined with citrate
preparation. However, for subjects with CrCl <90 ml/min, combination
therapy significantly increased CrCl values from 71.0 to 85.8 ml/min.
There was no significant difference in AEs between the groups.104, level I
As for the types of urine alkalinisation, an RCT on gout patients treated

with benzbromarone, citrate mixture group had lower proportion of
41
patients with two gout flares than sodium bicarbonate group (p=0.0037).
However, there were no significant differences in mean SU level and
urine pH at week 12 between the groups. There was also no significant
difference in AEs between them.105, level I
• More evidence is warranted before adjunctive therapy can be

recommended in the treatment of gout.
42
15. MONITORING AND FOLLOW-UP
Monitoring is essential in the management of gout to ensure compliance

with the T2T strategy for optimal patient outcomes. Evaluation of possible
drug-related AEs is also vital during the follow-up of patients. Patients
should be concomitantly screened for associated comorbidities.
15.1 Clinical outcomes
The following clinical parameters should be monitored:

• height, weight, BMI, BP
• gout flares
• number and size of tophi
• joint damage
15.2 Treat-to-target strategy
The following tests are to be done 4-weekly while titrating the ULT
dose until the SU target is achieved. Thereafter, they can be performed
6-monthly.
• Serum urate
SU is the key parameter in monitoring disease control in accordance
with the T2T strategy.49 - 50, level I
• Renal function test/profile

Renal function test/RP is monitored in parallel with SU measurement as
it influences therapeutic decisions as mentioned in Subchapter 12.2.
15.3 Drug-related adverse events
As allopurinol is the most widely used ULT, it is paramount that health

care professionals are aware of its rare but potentially life-threatening
hypersensitivity reactions.
• Allopurinol-induced SCAR
 Educate patients to be alert to symptoms and signs e.g. rash,
pruritus or other allergic skin reactions, unexplained eye redness
and oral or genital ulcers.
 Emphasise the importance of prompt discontinuation of the drug
at their first occurrence and to seek medical advice early.
Rare but serious hypersensitivity reactions to febuxostat have also

been reported in post-marketing experience.106, level III
43
Refer to Table 4 for investigations that are done periodically for drug
monitoring.
Table 4. Summary of investigations for T2T strategy, drug

monitoring and screening of comorbidities associated with gout
during follow-up
Investigation Allopurinol Febuxostat Probenecid Benzbromarone Colchicine

FBC Every 4 Every 4 Every 4
weeks weeks weeks Annually
during dose during dose during dose
LFT titration and titration and titration and Every 3
Every 4 weeks
then every 6 then every 6 then every 6 months
for first 6 months
months months months
and then every 3
when dose when dose when dose
months
is stable is stable is stable
SU and RP Every 4 weeks until SU <360 µmol/L then every 6 months

FBS, FSL,
Haemoglobin A1c At least annually
(HbA1c)
During clinical review
Urine FEME (urine protein to creatinine ratio or albumin to creatinine ratio if there is
concurrent hypertension/diabetes mellitus)
Plain radiography
of affected joints, Repeat when indicated
USG KUB
ECG
Echocardiogram When clinically indicated
(ECHO)
Source:
1. Richette P, Doherty M, Pascual E, et al. 2016 updated EULAR evidence-based
recommendations for the management of gout. Ann Rheum Dis. 2017;76(1):29-
42.
2. Colchicine [package insert]. Malaysia: Noripharma; 2017.
3. Febuxostat [package insert]. Phatheon France: Astellas Pharma Malaysia; 2019.
4. MIMS Online (Available at: https://www.mims.com/).
Recommendation 11
• Monitoring of patients with gout should include:*
 clinical outcomes
 drug-related adverse events; notably allopurinol-induced severe
cutaneous adverse reaction
 blood investigations for adverse effects of drugs
 serum urate and comorbidity screening
*Refer to above text and table.
44
16. REFERRAL
Gout is the most common inflammatory arthritis globally2, level III with the
majority of patients managed in primary and general medical healthcare
facilities.107, level III The benefit of understanding the entire patient and
associated comorbidities enables the family care providers to have a
holistic approach in treating gout and other associated complicated
diseases.108, level III As family physicians and general physicians treat
most of gout cases, they are encouraged to refer the more challenging
and complex cases to the relevant specialties or subspecialties. The
criteria for referral are summarised below.68
16.1 Referral criteria for rheumatology care

• Diagnostic indication
 Diagnosis is uncertain in cases with atypical clinical presentations
including suspected gout in
- women with onset before menopause
- men with early onset at age <30 years without predisposing risk
factors for gout
• Therapeutic indication
 Refractory to conventional therapy despite drug adherence
- Gout flare that fails to resolve despite treatment as
- Recurrent flares although SU target of <360 µmol/L is achieved
- Failure to achieve SU target of <360 μmol/L after a trial of at
least three months of allopurinol at a maximally tolerated dose
- Tophaceous gout with progressive joint damage, active
 Complicated gout with destructive joint changes
 Hypersensitivity or intolerance to allopurinol
• Special group indication
 Gout in pregnancy
Surgical management for tophi is generally considered as a last resort.

Tophi tend to recur if the underlying hyperuricaemia is not treated with
ULT. Decreasing SU to target reduces the size and number of tophi
and facilitates their complete resolution.49, level I However, surgical
intervention may be considered when there is uncontrolled infection,
entrapment neuropathy or risk of permanent joint destruction.109, level III
16.2 Referral criteria for orthopaedic/surgical care

• Current or impending debilitating complications of tophaceous deposits
 Uncontrolled infection including discharging sinus
 Ulceration with risk of infection
 Entrapment neuropathy e.g. carpal tunnel syndrome at the wrist
 Major joint destruction
 Joint instability
45
 Impaired joint motion that affects activities of daily living, work or

safety
 Functional impairment e.g. the inability to wear shoes or clothing
• Cosmetic surgery e.g. ear lobe tophi
 Should be elective and only after an adequate trial of medical
therapy, as risk of complications may outweigh benefits
• Urolithiasis (should be assessed by a urologist)
Post-surgical complications are mostly minor and delayed wound

healing is the most common.
Recommendation 12
• Referral of gout patients to a rheumatologist may be considered for
the following:
 diagnostic indications
- unclear diagnosis with atypical clinical presentations including
suspected gout in
 women with onset before menopause
 men with early onset at age <30 years without predisposing
risk factors for gout

 therapeutic indications
- refractory to conventional therapy despite drug adherence
 gout flare that fails to resolve despite treatment as
 recurrent flares although SU target of <360 µmol/L is
achieved
 failure to achieve SU target of <360 μmol/L after a trial of
at least three months of allopurinol at a maximally tolerated

dose
 tophaceous gout with progressive joint damage, active
- complicated gout with destructive joint changes
- hypersensitivity or intolerance to allopurinol
 special group indication
- gout in pregnancy
• Surgical management of tophi may be considered when there is:
 uncontrolled infection
 entrapment neuropathy
 risk of permanent joint damage
• Gout with urolithiasis should be assessed by a urologist.
46
17. IMPLEMENTING THE GUIDELINES
Management of gout should be guided by the latest evidence and

availability of local resources to provide quality care to patients. Several
factors may affect the implementation of recommendations in the CPG.
17.1 Facilitating and Limiting Factors
Existing facilitators for application of the recommendations in the CPG

include:
• availability of CPG to health care providers (hard copies and soft
copies/online)
• regular seminar/conference/course for health care providers
on management of gout including those involving professional
bodies (e.g. Malaysian Society of Rheumatology)
• public awareness activities during World Arthritis Day
• involvement of governmental/non-governmental organisations
e.g. Malaysian Society of Rheumatology and Arthritis Foundation
of Malaysia
• accessibility to relevant multidisciplinary teams
Limiting factors in the CPG implementation include:

• limited awareness and understanding/knowledge in management
of gout among health care providers
• variation in clinical management and preferences
• insufficient resources in terms of budget, expertise, access to
diagnostic tests and medications (gout placed at low priority by
stakeholders)
• misconception about the disease and its management by the
public
• no national registry on gout
17.2 Potential Resource Implications
T2T strategy is an important concept in gout management. However,

many clinicians especially those in the primary care may not know and
understand it. T2T strategy entails proper investigations and treatment
of gout patients so that crippling chronic gouty arthritis, disabling
comorbidities, poor quality of life and premature death can be minimised
or even avoided.
In T2T strategy, more visits and frequent blood investigations are

required to ensure SU level of <360 µmol/L is achieved. This can be
done by a dedicated team in both primary and secondary care. It should
include trained allied health care professionals. They can also provide
regular health education (pathogenesis and natural course of disease,
lifestyle modification, diet and exercise as well as the importance of
47
adherence to treatment) on gout to improve patient empowerment.

Apart from that, appropriate initiation and optimisation of ULT usage
should be addressed well. Allopurinol 100 mg tablet should be readily
available in primary care and general medicine.
The issues discussed above require adequate human and financial

resources. As gout is the commonest arthritis globally and increasing in
its prevalence, T2T strategy should be emphasised in gout management
throughout all levels of care.
17.3 Clinical Audit Indicators
The following are proposed as clinical audit indicators for quality

management of gout:
• Percentage Number of incident gout patients
of incident gout indicated for ULT in whom ULT is
patients indicated actually started in a year
= x100%
for ULT in whom Number of incident gout patients
ULT is actually indicated for ULT in a year
started
• Percentage
of incident gout Number of incident gout patients who
patients who achieve SU level <360 µmol/L in a period
= x100%
achieve SU level Number of incident gout patients
<360 µmol/L in the same period
Implementation strategies will be developed following the approval of
the CPG by MoH which include launching of the CPG, Quick Reference
and Training Module.
48
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54
Appendix 1
EXAMPLE OF SEARCH STRATEGY
Clinical Question: What are the safe and effective pharmacological

treatments for acute flare of gout?
1. GOUT/
2. gout*.tw.
3. ARTHRITIS, GOUTY/
4. (gouty adj1 arthriti*).tw.
5. CRYSTAL ARTHROPATHIES/
6. 1 or 2 or 3 or 4 or 5
7. ACUTE DISEASE/
8. (acute adj1 disease*).tw.
9. ACUTE PAIN/
10. (acute adj1 pain*).tw.
11. SYMPTOM FLARE UP/
12. (acute adj2 symptom flare*).tw.
13. (symptom adj2 (flare up* or flare-up* or flareup*)).tw.
14. (symptom adj2 flaring up*).tw.
15. 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14
16. 6 and 15
17. ANTI-INFLAMMATORY AGENTS,NON-STEROIDAL/
18. (anti-inflammatory adj1 analgesics).tw.
19. ((anti-inflammatory or anti inflamatory) adj2 (non-steroidal agent*
or nonsteroidal agent*)).tw.
20. nsaids.tw.
21. CYCLOOXYGENASE 2 INHIBITORS/
22. ((cox2 or cox-2 or cox 2) adj1 inhibitor*).tw.
23. coxibs.tw.
24. ((cyclooxygenase 2 or cyclooxygenase-2) adj1 inhibitor*).tw.
25. ANALGESICS, NON-NARCOTIC/
26. ((nonnarcotic or non narcotic or non-narcotic) adj1 analgesic*).tw.
27. (nonopioid or non opioid or non-opioid) adj1 analgesic*).tw.
28. COLCHICINE/
29. colchicine.tw.
30. ADRENAL CORTEX HORMONES/
55
31. (adrenal cortex adj1 hormone*).tw.

32. corticoids.tw.
33. corticosteroids.tw.
34. GLUCOCORTICOIDS/
35. ((glucocorticoid or glucorticoid) adj1 effect*).tw.
36. glucocorticoid*.tw.
37. ADRENOCORTICOTROPIC HORMONE/
38. acth.tw.
39. (adrenocorticotrop* adj1 hormone*).tw
40. adrenocorticotropin.tw.
41. corticotrop*.tw.
42. GOUT SUPPRESSANTS/
43. (antigout adj1 agent*).tw.
44. antihyperuricemic*.tw.
45. (gout adj1 suppressant*).tw.
46. Interleukin-1 inhibitor.tw.
47. ANTI-INFLAMMATORY AGENTS/
48. ((antiinflammator* or anti-inflammator* or anti inflammator*) adj1
agents).tw.
49. (antiinflammatory* or anti-inflammator* or anti inflammator*).tw.
50. Canakinumab.tw.
51. Rilonacept.tw.
52. INTERLEUKIN 1 RECEPTOR ANTAGONIST PROTEIN/
53. Anakinra.tw.
54. interleukin 1 receptor antagonist protein.tw.
55. kineret.tw.
56. 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27 or 28
or 29 or 30 or 31 or 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39 or
40 or 41 or 42 or 43 or 44 or 45 or 46 or 47 or 48 or 49 or 50 or 51
or 52 or 53 or 54 or 55
57. 16 and 56
58. limit 57 to (english language and humans and yr=”2008 -Current”)
56
Appendix 2
CLINICAL QUESTIONS
1. What are the accurate diagnostic tools/tests for gout?

2. What are the safe and effective preventive strategies in gout?
3. What are the safe and effective pharmacological treatments for
acute flare of gout?
4. What are the safe and effective treatments for flare prophylaxis in
gout?
5. What are the indications for urate-lowering therapy in asymptomatic
hyperuricaemia?
6. What are the indications for urate-lowering therapy in gout?
7. What are the safe and effective urate-lowering therapies in gout?
8. What are the safe and effective adjunctive therapies in gout?
9. What are the safe and effective non-pharmacological treatments
in gout?
10. When to escalate/de-escalate or discontinue urate-lowering
therapies in gout?
11. What are the associated comorbidities and risk factors for
cardiovascular disease in gout?
12. What are the criteria for referring patients with gout to
rheumatologists?
13. What are the effective monitoring parameters in gout?
57
Appendix 3
A. ALCOHOL SERVING SIZE
Types of Drink (Percentage of alcohol) 1 Serving
Regular beer (5%) 12 fl oz (355 ml)

Malt liquor (7%) 8 - 9 fl oz (237 - 266 ml)
Wine (12%) 5 fl oz (147 ml)
Distilled spirits (40%) 1.5 fl oz (44 ml)
 Gin, rum, tequila, vodka, whiskey, etc.
Adapted: National Institute on Alcohol Abuse and Alcoholism (NIAAA): What is a

standard drink? (Available at: https://www.niaaa.nih.gov/alcohols-effects-
health/overview-alcohol-consumption/what-standard-drink Accessed 2
August 2021)
B. DIETARY APPROACHES TO STOP HYPERTENSION (DASH)

DIET RECOMMENDATIONS
• Eat more vegetables, fruits and whole grains

• Include low-fat/fat-free dairy products, fish, poultry, beans, nuts and
vegetable oils
• Limit intake of saturated fats
• Limit intake of sugar-sweetened beverages and sweets
(Based on 1600 - 2000 kcal/day)
Food Group Daily Serving Size Types of Food

Servings
Grains 6-8 1 slice bread Wholegrain bread

½ cup cooked rice, kuetiau, and pasta,
bihun, pasta brown rice,
1/3 cup noodles chapati/pita bread,
1 cup rice porridge cereals and oatmeal,
1/3 piece chapati tosai, idli
1/2 piece tosai
1 piece idli
3 tbsp oats
Vegetables 3-5 1 cup raw leafy vegetables Broccoli, carrots,

(ulam) green beans,
½ cup cut-up raw or cooked green peas, kale,
vegetable potatoes, spinach,
½ cup vegetable juice squash,
sweet potatoes,
tomatoes,
long beans
58

Servings
Fruits 4-5 1 medium fruit orange, apple,

custard apple (nona),
starfruit, pear, peach,
persimmon,
sapodilla (ciku),
kiwi
1 small banana
6 whole hog plum (kedondong)
2 whole (small) mangosteen, plum
8 pieces duku langsat, grapes,

langsat, longan,
small water apple
(jambu air)
5 whole lychee, rambutan
5 slices pomelo
1 slice papaya, pineapple,

watermelon, soursop
½ fruit small mango, guava
4 pieces cempedak, jackfruit

(nangka)
3 pieces prunes, dried dates
2 medium seeds durian
20g (2 tablespoon) raisin
½ cup fruit juice, frozen

or canned fruit
¼ cup dried fruit
Low-fat/Skimmed 2-3 1 cup milk or yogurt Skimmed or low-fat

milk and dairy 1 slice cheese milk, yogurt or cheese
products
Lean meats, ≤6 1 oz cooked meats, Select only lean and

poultry, fish poultry or fish trim away visible fats;
1 egg broil, roast or poach -
remove skin from
poultry
Nuts, seeds and 3 - 5/week ½ cup nuts Almonds, hazelnuts,

legumes 2 tbsp peanut butter mixed nuts, peanuts,
2 tbsp seeds walnuts, sunflower
½ cup cooked legumes seeds, peanut butter,
(beans, peas) kidney beans, lentils,
split peas
59

Servings
Fats and oils 2-3 1 tsp vegetable oil Soft margarine,

1 tbsp mayonnaise vegetable oil
1 tsp soft margarine (e.g. canola, corn,
2 tbsp salad dressing olive, or safflower),
low-fat
mayonnaise,
light salad dressing
Sweets/added ≤5/week 1 tbsp sugar Jelly, pudding, sugar,

sugars 1 tbsp jam or kaya gula melaka, kuih
Adapted: 1. National Institutes of Health (NIH), National Heart, Lung and Blood
Institute: Your Guide to Lowering your Blood Pressure with DASH.
(Available at: https://www.nhlbi.nih.gov/files/docs/public/heart/new_
dash.pdf)
2. Malaysian Medical Nutrition Therapy Guidelines for Type 2 Diabetes
Mellitus, 2013
C. DIETARY RECOMMENDATIONS FOR GOUT
1. Fluid intake of at least two litres a day unless on fluid restriction.
2. Healthy, balanced diet as in DASH diet recommendations.
3. Specific food recommendations:
a. Restriction advised
i. Animal-based purine-rich foods

• Meat extract (e.g. Bovril), bouillon, broth, consommé, gravy
• Internal organs
- Brain
- Heart
- Sweetbread
- Kidney
• Seafood (e.g. shellfish, scallop, shrimp, lobster)
• Goose
• Red meat (e.g. beef, pork, mutton)
ii. Fructose/Sugar
• High-fructose corn syrup
• Sugar-sweetened beverages
• High intake of fruit juices
• Honey
• Sugars, syrups, sweets
• Desserts
• Processed tomato sauce and chilli sauce
• Fruit jam
iii. Alcoholic beverages (e.g. beer, wine, liquor)
60
b. No restriction required
i. n-3 PUFA-rich fish*

• Anchovies
• Mackerel (ikan kembung, tenggiri, makarel)
• Herring (ikan parang)
• Sardines (ikan sardin, tamban)
• Salmon
• Trout
ii. Plant-based purine-rich foods#

• soy-based food and non-soy legumes e.g. peas, beans, lentils
• spinach
• mushrooms
• cauliflower
• oats
• nuts and seeds$
*Benefits of n-3 PUFA-rich fish in reducing cardiovascular events outweigh the

potential detrimental effect derived from its high purine content.
#
Plant-based purine-rich foods are not associated with increased risk of gout.
$
Nuts and seeds are not associated with increased risk of gout.
Adapted:
1. Lichtenstein AH, Appel LJ, Vadiveloo M, et al. 2021 Dietary Guidance to
Improve Cardiovascular Health: A Scientific Statement From the American Heart
Association. Circulation. 2021;144(23):e472-e487.
2. Ministry of Health, Malaysia. Malaysian Dietary Guidelines 2020. Putrajaya: MoH;
2020.
3. Zhang M, Zhang Y, Terkeltaub R, et al. Effect of Dietary and Supplemental
Omega-3 Polyunsaturated Fatty Acids on Risk of Recurrent Gout Flares. Arthritis
Rheumatol. 2019;71(9):1580-1586.
4. Li R, Yu K, Li C. Dietary factors and risk of gout and hyperuricemia: a meta-analysis
and systematic review. Asia Pac J Clin Nutr. 2018;27(6):1344-1356.
5. Teng GG, Pan A, Yuan JM, et al. Food Sources of Protein and Risk of Incident Gout
in the Singapore Chinese Health Study. Arthritis Rheumatol. 2015;67(7):1933-
1942.
6. Zhang Y, Chen C, Choi H, et al. Purine-rich foods intake and recurrent gout attacks.
Ann Rheum Dis. 2012;71(9):1448-1453.
61
Appendix 4
APPLICATION OF ICE PACK
Use of ice pack for gout flare

affecting first toe.
Wrap towel around ice pack.
Place wrapped ice pack around

affected joint.
62
Appendix 5
PHARMACOLOGICAL TREATMENT FOR GOUT

A. URATE-LOWERING THERAPY IN GOUT
Drug Recommended dose Possible AEs Contraindication/ Common drug

Caution interaction#
Allopurinol Initial: 100 mg/day, adjusted in increments of 100 mg every 2 - 4 Common: Contraindication: • Azathioprine/
weeks according to SU concentration until target is achieved • Dermatologic • Hypersensitivity mercaptopurine
Maintenance: ≥300 mg/day are usually needed to reach the Maculopapular rash, pruritus to allopurinol Reduces
desired SU target • GI metabolism of
Maximum: 900 mg/day Nausea, vomiting Caution: azathioprine
Frequency: Once daily in a single dose or in 2 or 3 divided • HLA-B*58:01 and
doses if >300 mg/day Serious: -positive patient mercaptopurine;
• Dermatologic increases risk of
Dosage modifications in renal impairment: Hypersensitivity reactions ranging bone marrow
63
eGFR from mild maculopapular rash to toxicity
(ml/min Initial dose Dose increment severe cutaneous adverse reaction, • Warfarin
/1.73m2) including Stevens-Johnson Prolongs
syndrome (SJS), Toxic Epidermal half-life of
>60 100 mg daily Increase by 100 mg every 4
Necrolysis (TEN), drug reaction with warfarin
weeks* if tolerated until SU
eosinophilia and systemic • Ciclosporin
target is reached or to a
symptoms (DRESS) May increase
maximum of 900 mg daily
• Hepatic levels of
30 - 60 50 mg daily Increase by 50 mg every 4
Transaminitis, cholestasis ciclosporin
weeks if tolerated until SU
• Haematologic • Theophylline
Bone marrow suppression May inhibit
maximum of 900 mg daily**
metabolism of
<30 50 mg every Increase to 50 mg every day
theophylline
other after 4 weeks, then increase
day by 50 mg every 4 weeks
thereafter if tolerated until SU
maximum of 900 mg daily**

*More rapid titration e.g. every 2 weeks is possible, although
this needs to be balanced against the increased risk of
adverse effects
**Consider referral to or discussion with rheumatologist if SU
targets are not achieved or increase in dose is not tolerated
Probenecid Initial: 250 mg BD for 1 week; may increase to 500 mg BD; if Common: Contraindications: • Aspirin
needed, may increase to a maximum of 1000 mg BD • Dermatologic • Hypersensitivity Aspirin
(increase dosage in 500 mg increment every 4 weeks) Rash to probenecid decreases
• GI • Urolithiasis uricosuric action
Renal impairment of CrCl <30 ml/min: Avoid use Nausea, vomiting • Blood dyscrasias of probenecid
• Paracetamol/
Maintain adequate fluid intake (2 - 3 L/day) if not on Serious: naproxen/
medically advised fluid restriction diet • Dermatologic lorazepam/
64
SJS rifampicin/
• Haematologic acyclovir
Aplastic anaemia, leukopenia, Probenecid may
thrombocytopenia, neutropenia increase their
• Hepatic: serum
Hepatic necrosis concentration
• Immunologic: • Methotrexate
Anaphylaxis, hypersensitivity May potentiate
reaction methotrexate
toxicity
• Sulphonylurea
Increases the
hypoglycaemic
effect of
sulphonylurea
• Most
beta-lactam
antibiotics
Increases level
of beta-lactam
antibiotics
Febuxostat Initial: 40 mg OD; if SU level is >6.0 mg/dL (360 µmol/L) Common: Contraindications: • Azathioprine/
after 2 - 4 weeks, 80 mg OD may be considered • Dermatologic • Hypersensitivity mercaptopurine
Maintenance: 40 mg or 80 mg OD, dose may be increased Rash to febuxostat Increased
to 120 mg OD if clinically indicated • GI • Concomitant use plasma
Diarrhoea, nausea of azathioprine/ concentrations
Dosage modifications in renal impairment: • Hepatic mercaptopurine result in severe
Liver function abnormalities due to increase toxicity of
CrCl (ml/min) Dose
65
in toxicity azathioprine and
≥30 No adjustment mercaptopurine
Serious:
15-29 Maximum dose 40 mg OD • Dermatologic • Methotrexate
DRESS, SJS, TEN May enhance
Dosage modifications in hepatic impairment:
hepatotoxic
CrCl (ml/min) Dose Black Box Warning effect of
A or B No adjustment Cardiovascular: methotrexate
C Use with caution • Gout patients with established CV
disease treated with febuxostat had
a higher rate of CV death compared
with those treated with allopurinol in
a CV outcomes study.
• Consider the risks and benefits
when prescribing febuxostat or
continuing treatment.
• Febuxostat should only be used in • Theophylline

patients who have an inadequate May increase
response to a maximally titrated serum
dose of allopurinol, who are concentration of
intolerant to allopurinol or whom theophylline
treatment with allopurinol is not
advisable.
Benzbromarone Doses of 50 - 200 mg daily may be used Common: Contraindications: • Warfarin
Usual dose of benzbromarone is 50 - 100 mg/day • GI • Urolithiasis May increase
Renal impairment of eGFR <20 ml/min: Avoid use nausea, vomiting, diarrhoea effect of warfarin
Maintain adequate fluid intake (2 - 3 L/day) if not on • Hepatic
medically advised fluid restriction diet May cause liver damage
66
Pegloticase IV infusion 8 mg every 2 weeks Common: Contraindications: • Discontinue
• Dermatologic • Hypersensitivity use of oral ULT
Urticaria to pegloticase agents prior to
• GI • G6PD deficiency pegloticase
Constipation, nausea, vomiting therapy and do
not initiate
Serious: during the
• Immunologic course of the
Infusion-related reaction therapy. These
• Haematologic may delay
Glucose-6-phosphate interpretation of
dehydrogenase deficiency (G6PD) ineffective
related anaemia pegloticase
• CV treatment and
Congestive heart failure increase risk of
infusion reaction.
Black Box Warnings
Anaphylaxis and infusion
reactions:
Anaphylaxis may occur at any
infusion rates. Patient should be
premedicated with antihistamines
and corticosteroids and closely
monitored.
G6PD deficiency associated
haemolysis and
methaemoglobinaemia
Screen patients at risk of G6PD
deficiency prior to initiation.
67
#
Dosage adjustment of the medications should be considered.
B. TREATMENT OF FLARE AND FLARE PROPHYLAXIS IN GOUT

Colchicine Gout flare Common: Contraindications: • CYP3A4
Initial dose: 1 mg, then 0.5 mg after 1 hour. No further tablets • GI • Concomitant use inhibitor/P-
should be taken for 12 hours. Nausea, vomiting, diarrhoea of drugs that are glycoprotein
After 12 hours, treatment can be resumed if necessary with a both P-glycoprotein inhibitor
maximum dose of 0.5 mg every 8 hours until symptoms are Serious: and CYP3A4 Increased risk
relieved. The course of treatment should end when • Haematologic inhibitors in of toxicity
symptoms are relieved or when a total of 6 mg (12 tablets) Myelosuppression patients with • Statin/fibrates/
has been taken. After completion of a course, another course • Neuromuscular and skeletal renal or hepatic digoxin/
should not be started for at least 3 days (72 hours). Neuromuscular disease, impairment ciclosporin
neuromyotoxicity • Concomitant use Increased risk
Flare prophylaxis of P-glycoprotein of myopathy
0.5 mg OD or BD. Prophylactic therapy may be beneficial for or CYP3A4 and
at least the first 3 to 6 months of ULT therapy. inhibitors in rhabdomyolysis
68
patients with
Treatment of gout flare during prophylaxis with renal or hepatic
colchicine impairment
Do not exceed 1 mg at the first sign of flare, followed by 0.5 • Patients with
mg 1 hour later, wait for 12 hours and then resume both renal and
prophylactic dose. hepatic
impairment
Initiate prophylactic dose at least 12 hours after treatment • Blood dyscrasia
dose and continue until gout flare resolves.
Dosage modifications in renal impairment:

CrCl Gout flare Gout flare
(ml/min) treatment* prophylaxis
>60 - 89 No dosage No dosage
adjustment, monitor adjustment, monitor
closely for AE closely for AE

30 - 60 No dosage Limit dose to 0.5

adjustment, monitor mg daily
closely for AE
<30, renal Consider alternative Consider

replacement therapy alternative
therapy therapy
*Use of colchicine to treat gout flares is not recommended in
patients with renal impairment (CrCl <80 ml/min) already
receiving prophylactic colchicine.
Dosage modifications in hepatic impairment:

Hepatic Gout flare Gout flare
69
Impairment treatment** prophylaxis
Mild to No dosage No dosage
moderate adjustment, monitor adjustment,
closely for AE monitor closely
for AE
Severe Dosage adjustment Consider dosage
not required but may adjustment
be considered;
treatment course
should not be
repeated more
frequently than every
14 days
**Use of colchicine to treat gout flares is not recommended in

patients with hepatic impairment already receiving prophylactic
colchicine.
Dosage modifications in patients receiving or have

recently (within 14 days) received a moderate or potent
CYP3A4 inhibitor or an inhibitor of the P-glycoprotein
transport system:
Recent or Gout flare Gout flare
concomitant treatment*** prophylaxis
therapy
Potent 0.5 mg at first sign of 0.25 mg OD or
CYP3A4 flare, followed by 0.25 every other day
inhibitor e.g. mg one hour later
clarithromycin,
ketoconazole,
itraconazole
and certain
70
protease
inhibitors
Moderate 1 mg at first sign of 0.25 mg BD, 0.5
CYP3A4 flare mg OD or 0.25
inhibitor e.g. mg OD
diltiazem,
erythromycin,
fluconazole,
verapamil
P-glycoprotein 0.5 mg at first sign of 0.25 mg OD or
inhibitor e.g. flare every other day
cyclosporin,
ranolazine
Use of colchicine to treat gout flares is not recommended in
patients receiving prophylactic dose of colchicine and
CYP3A4 inhibitors.
***Do not repeat courses of colchicine therapy until 3 days

have elapsed.
NSAIDs/COX-2 inhibitors
Ibuprofen 400 - 800 mg TDS Common: Contraindications: • Antiplatelets/
(maximum: 3200 mg/day) • Gl • Hypersensitivity anticoagulants/
Diclofenac 50 mg BD/TDS GI Intolerance to NSAIDs corticosteroids
Naproxen 550 - 1100 mg in 2 divided doses (275 mg tablet) • CV • Perioperative Increased risk
750 mg initially, then 250 mg TDS (250 mg tablet) Elevated blood pressure, oedema pain in the of GI bleeding
Meloxicam Maximum 15 mg/day • Dermatological setting of • Lithium
Celecoxib 400 mg stat followed by 200 mg BD subsequently Rash coronary artery NSAIDs may
Etoricoxib 120 mg/day • Hepatic bypass graft increase serum
Abnormal LFT surgery concentration of
• History of GI lithium
bleeding, • Methotrexate
perforation or Increased levels
ulceration related and risk of
71
to NSAIDs toxicity of
therapy methotrexate
• Current GI
bleeding,
perforation or
ulceration
• Severe hepatic
or renal
impairment
• Severe cardiac
failure
Corticosteroids
Prednisolone Flare treatment: Common: Contraindications: • CYP3A4
30 to 40 mg/day once daily or in 2 divided doses for 5 days. • CV • Hypersensitivity inhibitors (e.g.
If a longer duration is needed for more severe flare, a Body fluid retention, hypertension to prednisolone ketoconazole)
gradual taper over 7 to 10 days is an option. • Dermatologic • Concomitant May increase
Acne administration serum

A slower taper (e.g. over 14 to 21 days) maybe required, • Gl with live vaccines concentration of
particularly in patients with multiple recent flares. GI bleeding or live attenuated prednisolone
• Endocrine metabolic virus vaccines • CYP3A4
Decreased body growth, (with inducers (e.g.
hyperglycaemia immunosuppres- phenobarbitone,
• Musculoskeletal sive doses of rifampicin)
Osteoporosis corticosteroids) May decrease
• Neurologic serum
Headache Caution: concentration of
• Active infections prednisolone
• NSAIDs
Increased risk
of GI bleeding
•
72
Anticoagulant
Increased risk
of bleeding
• Loop diuretics
Enhances
hypokalemic
effect of loop
diuretics
Triamcinolone Intra-articular: Common: Contraindications: • Ciclosporin
Large joint: 40 mg as a single dose • Haematologic • Hypersensitivity Increase in both
Medium joint: 30 mg as a single dose Bruise to triamcinolone ciclosporin and
Small joint: 10 mg as a single dose • Neuromuscular and skeletal • Bleeding corticosteroids
Joint swelling diastheses activity when
Intramuscular: • Respiratory used
40 to 80 mg as a single dose; Cough, sinusitis concomitantly
May repeat at ≥48-hour intervals if there is no flare
resolution
#
Dosage adjustment of the medications should be considered.
C. TREATMENT OF GOUT IN PREGNANCY AND LACTATION
Drug Pregnancy Lactation

Allopurinol Category C Limited human data; potential toxicity
Probenecid Category B Limited human data; probably compatible
Febuxostat Category C No human data; potential toxicity
Benzbromarone No data No data
Pegloticase No data No data
Colchicine Category C Limited human data; probably compatible
NSAIDs
Ibuprofen Restricted to first and second trimester Compatible
Diclofenac No human data; probably compatible
73
Naproxen Limited human data; probably compatible
Meloxicam No human data; probably compatible
COX-2 inhibitors
Celecoxib Should be avoided Limited human data
Etoricoxib No data
Corticosteroids
Prednisolone Category C Compatible
Triamcinolone Category C No human data; probably compatible
FDA Pregnancy Categories
Category Definitions
A Generally acceptable
Controlled studies in pregnant women show no evidence of fetal risk
B May be acceptable
Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies
done and showed no risk
C Use with caution if benefits outweigh risks

Animal studies show risk and human studies not available or neither animal nor human studies done
74
D Use in LIFE-THREATENING emergencies when no safer drug available
Positive evidence of human fetal risk
X Do not use in pregnancy (contraindicated)

Risks involved outweigh potential benefits
Safer alternatives exist
NA Information not available

Boxed Warnings - US FDA
This type of warning is also commonly referred to as a “black box warning.” It appears on a prescription drug’s label and is designed to call attention to
serious or life-threatening risks.
Adapted:
1. Ministry of Health Medicines Formulary 2021. (Available at: https://www.pharmacy.gov.my/v2/ms/dokumen/formulari-ubat-kementerian-kesihatan-
malaysia.html)
2. Wolters Kluwer Clinical Drug Information, Inc. UpToDate® [Mobile application software]
3. Mims Gateway. (Available at: http://www.mimsgateway.com/malaysia/overview.aspx)
4. Micromedex® Solution. (Available at: https://www.micromedexsolutions.com/)
5. Managing gout in primary care, Controlling gout with long term urate-lowering treatment, The Best Practice Advocacy Centre New Zealand (bpacnz),
2021. (Available at: https://bpac.org.nz/2021/gout-part2.aspx)
6. Richette P, Doherty M, Pascual E, et al. 2016 updated EULAR evidence-based recommendations for the management of gout. Ann Rheum Dis.
2017;76(1):29-42
7. FDA adds Boxed Warning for increased risk of death with gout medicine Uloric (febuxostat), US Food & Drug Administration, 2019. (Available at:
https://www.fda.gov/drugs/drug-safety-and-availability/fda-adds-boxed-warning-increased-risk-death-gout-medicine-uloric-febuxostat)
8. Briggs GG and Freeman Roger K. Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk. 10th Edition. Philadelphia:
Lippincott Williams & Wilkins; 2015;1-1579.
9. Hui M, Carr A, Cameron S, et al. The British Society for Rheumatology Guideline for the Management of Gout. Rheumatology (Oxford).
2017;56(7):e1-e20.
75
LIST OF ABBREVIATIONS
ACE inhibitors Angiotensin-converting enzyme inhibitors

ACR American College of Rheumatology
ADL activities of daily living
AE(s) adverse event(s)
AGREE (II) Appraisal of Guidelines for Research and Evaluation II
AHS Allopurinol Hypersensitivity Syndrome
AP Anteroposterior
BCE before common era
BMI body mass index
BSR British Society for Rheumatology
CHD coronary heart disease
CI confidence interval
CKD chronic kidney disease
COPD chronic obstructive pulmonary disease
COX-2 inhibitors cyclooxygenase-2 inhibitors
CPG(s) clinical practice guidelines
CrCl creatinine clearance
CT computed tomography
CV(D) cardiovascular (disease)
CXR chest X-ray
DASH Dietary Approaches to Stop Hypertension
DCS double contour sign
DECT dual-energy computed tomography
DG development group
DRESS drug reaction with eosinophilia and systemic symptoms
DVT deep vein thrombosis
ECG electrocardiogram
ECHO echocardiogram
eGFR estimated glomerular filtration rate
EULAR European League Against Rheumatism
FBC full blood count
FDA Food and Drug Administration
fl oz fluid ounce
GFR glomerular filtration rate
GI gastrointestinal
GRADE Grading Recommendations, Assessment, Development and Evaluation
G-CAN Gout, Hyperuricemia and Crystal-Associated Disease Network
HbA1c haemoglobin A1c
HR hazard ratio
IL-1 interleukin-1
IM intramuscular
kcal/day kilocalorie per day
kg/m2 kilogramme per meter square
LFT liver function test
MaHTAS Malaysian Health Technology Assessment Section
MD mean difference
mg milligramme
mg/day milligramme per day
mg/dL milligramme per decilitre
76
µmol/L micromol per litre

ml/min millilitre per minute
MoH Ministry of Health
MSU monosodium urate
MTP metatarsophalangeal
NNT number needed to treat
NNTB number needed to benefit
NNTH number needed to harm
NSAID(s) nonsteroidal anti-inflammatory drug(s)
n-3 PUFA(s) omega-3 polyunsaturated fatty acid(s)
OD once a day
OR odds ratio
PAR population attributable risks
PE pulmonary embolism
PGA Patient Global Assessment
RC review committee
RCT(s) randomised controlled trial(s)
RP renal profile
ROC receiver operating characteristic
RR risk ratio
SAE(s) severe adverse event(s)
SCAR severe cutaneous adverse reaction
SJS Stevens-Johnson syndrome
SF synovial fluid
STAT immediately
SU serum urate
tbsp tablespoon
TDS three times a day
TEAE(s) treatment-emergent adverse event(s)
TEN toxic epidermal necrolysis
TFT thyroid function test
tsp teaspoon
T2T treat-to-target
ULT urate-lowering therapy
Urine FEME full and microscopic examination of urine
US(A) United States (of America)
USG KUB ultrasound of the kidneys, ureters and bladder
VAS Visual Analogue Scale
VTE venous thromboembolism
vs versus
WMD weighted mean difference
XOI xanthine oxidase inhibitor
77
ACKNOWLEDGEMENT
The members of the CPG DG would like to express their gratitude and
appreciation to the following for their contributions:
• Panel of external reviewers who reviewed the draft
• Technical Advisory Committee of Technical Advisory Committee of
CPG for their valuable input and feedback
• Health Technology Assessment and Clinical Practice Guidelines
Council for approval of the CPG
• Ms. Zamilah Mat Jusoh@Yusof and Ms. Subhiyah Ariffin, Information
Specialists, MaHTAS on retrieval of evidence
• Ms. Chu Aireen, Occupational Therapist, Hospital Tuanku Jaa’far
Seremban and Fatin Nabila Mokhtar, Assistant Director, MaHTAS
for illustrating and designing the front cover of this CPG
• All those who have contributed directly or indirectly to the
development of the CPG
DISCLOSURE STATEMENT
The panel members of both Development Group and Review Committee

had completed disclosure forms. None hold shares in pharmaceutical
firms or act as consultants to such firms. Details are available upon
request from the CPG Secretariat.
SOURCE OF FUNDING
The development of the CPG on Management of Gout (Second Edition)

was supported financially in its entirety by the MoH Malaysia.
78

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Management of Gout (Second Edition)

Malaysian Health Technology Assessment Section (MaHTAS)

The copyright owner of this publication is MaHTAS. Content may be

Available on the following websites:

Also available as an app for Android and IOS platforms: MyMaHTAS

This clinical practice guideline (CPG) is meant to be a guide for

UPDATING THE CPG

These guidelines were issued in 2021 and will be reviewed in a minimum

No. Title Page

No. Title Page

12.2 Pharmacological Treatment 30

No. Title Page

I Evidence from at least one properly randomised controlled trial

II-1 Evidence obtained from well-designed controlled trials without

II-2 Evidence obtained from well-designed cohort or case-control

II-3 vidence from multiple time series with or without intervention;

III Opinions of respected authorities based on clinical experience;

SOURCE: US / CANADIAN PREVENTIVE SERVICES TASK FORCE 2001

In line with new development in CPG methodology, the CPG Unit of

The following recommendations were highlighted by the CPG

Risk Factors and Preventive Strategies

dairy products and saturated fats

• Demonstration of monosodium urate (MSU) crystals in synovial

• Treat-to-target strategy aiming for serum urate of <360 μmol/L should

• Patients with gout should be treated with urate-lowering therapy

Monitoring and Follow-up

• Monitoring of patients with gout should include:

• Referral of gout patients to a rheumatologist may be considered for

 men with early onset at age <30 years without predisposing

risk factors for gout

recommended by the CPG

least three months of allopurinol at a maximally tolerated dose

 tophaceous gout with progressive joint damage, active

GUIDELINES DEVELOPMENT AND OBJECTIVES

A systematic literature search was carried out using the following

References were also made to other guidelines as listed below:

A total of 13 main clinical questions were developed under different

recommendations formulated after that were agreed upon by both the

Literature used in these guidelines were graded using the US/Canadian

On completion, the draft of the CPG was reviewed by external

Objectives of the CPG are to provide evidence-based recommendations

This document is intended to guide health care providers and relevant

Primary, secondary and tertiary care

Dr. Loh Yet Lin

Members (in alphabetical order)

Dr. Asmah Mohd Dr. Norliza Zainudin

Dr. Chong Hwee Cheng Dr. Rizawati Ramli

Ms. Chu Ai Reen Dr. Ruhaila Abdul Rahim

Dr. Ding Hui Jen Ms. Siti Mariam Mohtar

Dr. Kan Sow Lai Associate Professor Dr. Syahrul

Dr. Mollyza Mohd Zain

Members (in alphabetical order)

Dr. Chow Sook Khuan Ms. Nik Mahani Nik Mahmood

Dato’ Dr. Gun Suk Chyn Dr. Nik Mazlina Mohammad

Dr. Izzuna Mudla Mohamed Ghazali Dr. Ong Swee Gaik

Dr. Lily Mushahar Professor Dr. Sargunan Sockalingam

Dr. Mohamad Saprin Dr. Ummu Kalsum Mustapha

EXTERNAL REVIEWERS (in alphabetical order)

The following external reviewers provided feedback on the draft:

Associate Professor Dr. A T M Tanveer Hasan