# Gout and Hyperuricaemia Management > Gout and hyperuricaemia management for FMGE Medicine: acute colchicine dosing, allopurinol titration to urate targets and prophylaxis timing rules. - Canonical URL: https://prepelephant.com/topics/fmge/medicine/gout-and-hyperuricaemia-management - Exam / course: FMGE · Subject: Medicine - Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team - First published: 2026-10-02 - Last updated: 2026-10-02 - How to cite: "Gout and Hyperuricaemia Management", PrepElephant, https://prepelephant.com/topics/fmge/medicine/gout-and-hyperuricaemia-management ## Direct answer Acute gout is treated in the first 36 hours with a full-dose NSAID (for example diclofenac 75 mg twice daily with gastric protection), low-dose colchicine 0.5 mg two to three times daily, or corticosteroids (prednisolone 30-40 mg daily for 3-5 days) — chosen by comorbidity. Urate-lowering therapy is a separate decision made between attacks: allopurinol started at 100 mg daily (50 mg in renal impairment) and titrated every few weeks until serum urate sits below 6 mg/dL (below 5 with tophi), with anti-inflammatory prophylaxis (colchicine 0.5 mg once or twice daily) covering the first three to six months, since falling urate can itself trigger flares. Asymptomatic hyperuricaemia is not drug-treated. Febuxostat 40-80 mg is the main alternative, with cardiovascular caution. ## What you must remember - **Acute attack rules:** NSAID, low-dose colchicine, or steroid — pick by organ reserve: NSAIDs avoid in chronic kidney disease and peptic ulcer; colchicine avoid with strong CYP3A4/P-gp inhibitors (clarithromycin, atazanavir); steroids suit diabetes-and-renal-disease patients, with infection excluded. - **Colchicine dosing:** the modern low-dose course (0.5 mg two or three times daily) matches the old high-dose regimen for efficacy with far less diarrhoea — the classic GI-answer question. - **Urate-lowering indications:** recurrent attacks (two or three per year), tophi, radiographic damage, or urate stones; start after the acute flare settles (continuing an established drug through a flare is acceptable per current practice). - **Allopurinol protocol:** start 100 mg daily — never a full 300 mg dose in renal impairment — titrate by 50-100 mg every 2-4 weeks to target; screen HLA-B*5801 in Southeast Asian and Korean ancestry where feasible because of severe cutaneous risk. - **Targets:** serum urate below 6 mg/dL generally; below 5 mg/dL for tophaceous disease; treat to target, not to a prescription. - **Prophylaxis clause:** colchicine 0.5 mg once or twice daily (or an NSAID) for 3-6 months while urate-lowering therapy is initiated and titrated. - **Febuxostat cautions:** effective and renally friendlier, but a cardiovascular-mortality signal in established cardiovascular disease (CARES trial) demoted it behind allopurinol. - **Lifestyle and drug audit:** limit alcohol (especially beer) and fructose-sweetened drinks, moderate purine-rich food; and audit the culprit drugs — thiazides, low-dose aspirin, ciclosporin, pyrazinamide and ethambutol, the last two NTEP-relevant in a tuberculosis-endemic country. ## How to work through a first and a fifth attack A 45-year-old hypertensive man wakes with an exquisitely painful, red, swollen first metatarsophalangeal joint — podagra — his first such episode. Examination and a typical story suffice; joint aspiration showing negatively birefringent needle-shaped crystals is confirmatory but not obligatory in classic podagra. Diclofenac 75 mg twice daily with pantoprazole cover settles it in three days. His hydrochlorothiazide is reviewed — a common precipitant — and no urate-lowering drug is started, because a first attack does not qualify. Two years later he has had four attacks and a palpable olecranon tophus. Now the game changes: between attacks he begins allopurinol 100 mg daily with colchicine 0.5 mg twice daily prophylaxis, and returns monthly for urate checks, the dose climbing towards 300 mg until serum urate reads 4.8. He is warned that early months can bring flares, and that the target is a number, not the absence of pain. His audit also turns up his evening beer and his father's allopurinol-induced rash: had he carried established coronary disease, febuxostat would have been the second choice, not the first. ## How the FMGE frames it Three question families dominate. First, acute-attack drug choice by comorbidity — the stem hands you chronic kidney disease and the keyed answer shifts from NSAID to colchicine or steroid; the classic distractor is "start allopurinol now", which is wrong because initiating urate-lowering during a first or untreated attack provokes flares. Second, dosing conventions: low-dose colchicine and allopurinol's start-low-titrate rule (100 mg, lower in renal failure) with the HLA-B*5801 cutaneous-risk association. Third, crystal chemistry: negatively birefringent needles under polarised light versus the positively birefringent rhomboids of pseudogout with chondrocalcinosis. The Indian examiner adds the tuberculosis twist — pyrazinamide and ethambutol raise urate, so a patient on NTEP therapy who develops podagra has a drug answer, and aspirating for crystals before steroids is the discipline that separates gout from septic arthritis. ## Frequently asked questions ### Which drug should not be newly started during an acute gout attack? Allopurinol (or any urate-lowering drug) — initiation during a flare can provoke or prolong attacks; established therapy, however, is continued. ### How is allopurinol initiated and titrated? Start at 100 mg daily (50 mg with renal impairment) and titrate every 2-4 weeks until serum urate is below 6 mg/dL, below 5 mg/dL for tophi. ### What prophylaxis accompanies the start of urate-lowering therapy? Colchicine 0.5 mg once or twice daily, or an NSAID, continued for three to six months while urate levels fall. ### Which antituberculosis drugs cause hyperuricaemia? Pyrazinamide and ethambutol — relevant in India, where NTEP regimens frequently complicate gout-prone patients. ### How are gout and pseudogout crystals distinguished? Gout: needle-shaped, strongly negatively birefringent monosodium urate; pseudogout: rhomboid, weakly positively birefringent calcium pyrophosphate, often with chondrocalcinosis.