1. sUA <0.36mmol/l Acute Treatment Treat pain and inflammation as soon as possible, continuing until acute flare has settled Full dose NSAID (eg naproxen 500mg bd or diclofenac 50mg tid +/- PPI) or Full dose oral Colchicine (500mcg 2-4 times daily) or Cortico-steroid (oral prednisolone 30mg od for 5 days or IM methyl prednisolone 80-120mg. Where expertise is available consider IA methylprednisolone 40-80mg or triamcinolone 20-40mg) Advise patient to apply an ice pack periodically to affected joint (wrap in a towel to avoid ice burn) Review appointment (4-6 weeks) Assess lifestyle factors, blood pressure, lipid profile and perform serum urate, kidney and liver function & glucose Optimise weight, increase exercise, modify diet, reduce alcohol, treat underlying cardiovascular risk factors Long term treatment Initiate urate lowering therapy if patient has had ≥2 flares per year based on patient preference and clinical judgement First line treatment Allopurinol, Second line Febuxostat, Third line Sulphinpyrazone Co-prescribe low dose NSAID(eg naproxen 250mg bd or diclofenac 25mg TID) +/- PPI or low dose colchicine (500mcg 2 times daily) for at least 6 weeks Reconsider diagnosis Persistent symptoms without diagnosis should be referred to secondary care. Note that serum urate frequently falls during gout attacks, so it is important that serum urate is measured after resolution of the flare. sUA ≥ 0.36mmol/l Repeat sUA (2-4 weeks) sUA ≥ 0.36mmol/lsUA <0.36mmol/l Titrate up urate lowering therapy (please see separate flow chart for prescribing in renal impairment and details of drug dosage) Maintain prophylactic colchicine for up to 6 months during dose titration  Continue urate lowering therapy unless causing side effects  Repeat convalescent serum urate in patients suffering recurrent attacks Likely diagnosis of gout (exclude septic arthritis)

2. Start 100mg allopurinol od Maximum 900mg od eGFR <10 Commence 80mg febuxostat od with 6 months colchicine 500mcg 1-2 tab daily if tolerated Escalate to 120mg febuxostat od after 2-4 weeks if target urate not achieved Start sulfinpyrazone 200mg od and titrate to maximum 800mg od Consider adding allopurinol if no contra-indication Refer to secondary care for consideration of benzbromarone +/- further allopurinol titration Intolerance or inefficacy of febuxostat Continue urate lowering therapy through any subsequent attacks Check convalescent serum urate in patients suffering recurrent attacks and escalate treatment if no longer at target Sulfinpyrazone dose may be reduced for maintenance Intolerance/inefficacy of sulfinpyrazone +/- allopurinol Intolerance or inefficacy of allopurinol Urate Lowering Therapy prescribing based on renal function Offer flare prophylaxis for at least 6 weeks with 500mcg colchicine od or bd if tolerated. Measure serum urate every 2-4 weeks and titrate therapy until target of serum urate <0.36mmol/l. Check compliance before assuming inefficacy. Target urate achieved Start 50mg allopurinol od Maximum 100mg od eGFR 20-50eGFR 10-20eGFR >50 Start 100mg allopurinol od Maximum 200mg od Start 100mg allopurinol od Maximum 300mg od eGFR >= 30 eGFR >=90 eGFR <30 eGFR <90 or Target urate achieved