Integrated Clinical Practice QR: QUICK READ

Guideline Manual on Gout I. Overarching Framework

Transcribed and Expanded by Dr. Mark Joseph Cervantes Domain PRA ACP APLAR PAFP AFP/AAFP
(2008) (2016) (2021) (2017) (2014–
2017)
Audience PH Internists Asia-Pacific PH Family
clinicians PCPs primary physicians
Table of Contents care
QR: Quick Read Tables Basis GRADE + ACP GRADE + Adopted Reviews &
1. Integrated Framework and Clinical Philosophy consensus GRADE Delphi ACP summaries
Approach Stepwise, Symptom- Treat-to- ACP- Balanced
2. Acute Gout Flare Management SUA- based target aligned view
3. Criteria for Urate-Lowering Therapy (ULT) Initiation targeted
Shared Implied Strongly Strongly Supporte Strongly
4. ULT Choices and Titration Protocols Decision- emphasize emphasize d emphasize
5. Flare Prophylaxis During ULT Making d d d
6. Lifestyle and Dietary Management
7. Gout in Special Populations II. Acute Gout Management
8. Patient Education and Counseling Techniques Compon PRA ACP APLAR PAFP AFP/
ent AAFP
9. Referral Guidelines and Red Flags
First-line Colchici Any of Same ACP- Same,
10. Case Scenarios and OSCE Training Sets drugs ne, three aligned evidence
11. Tophi Management and Advanced ULT Strategies NSAIDs, -rated
12. Appendices and Quick-Reference Tools Steroids
13. References Colchicin ≤4 1.8 mg Low-dose Same Low-
e dose tabs/day total preferred dose
emphasi
zed
Sources Integrated: Use of Predniso Equival Systemic/ Yes Preferred
 Philippine Rheumatology Association (PRA) 2008 steroids ne taper ent to intra- in
others articular elderly,
 American College of Physicians (ACP) 2016 CKD
 Asia-Pacific League of Associations for Rheumatology Reassess 7 days Not Yes Clinical Within 3–
(APLAR) 2021 time specifie discreti 7 days
 Philippine Academy of Family Physicians (PAFP) 2017 d on
endorsement of ACP
III. Urate-Lowering Therapy (ULT)
 American Academy of Family Physicians (AFP/AAFP) Compon PRA ACP APLAR PAFP AFP/
2014–2017 peer-reviewed reviews ent AAFP
Asympto No Strongly No unless No Avoid
matic discourage high risk unless
hyperuric d comorbidi
Note to the Reader emia ties
When to Recurrent/ Shared Recurrent/ Yes ≥2/year
start ULT tophi decision tophi or
This manual presents an integrated, practice-based approach to gout complicati
management tailored for Filipino primary care. It combines key ons
recommendations from the PRA, PAFP, APLAR, ACP, and AFP/AAFP, SUA <6 (or <5) No specific <6 (or <5) Case- <6 mg/dL
expanded with clinical reasoning, rural practice adaptations, and OSCE- target target based
ready tools. Preferred Allopurinol Allopurinol Allopurinol/ Allopuri Allopurino
ULT Febuxostat nol l; caution
w/
This manual was developed to serve as a practical and clinically grounded
febuxosta
guide for the diagnosis and management of gout in the Philippine primary t
care setting. Each section was expanded with consideration for real-world Prophylax Not 3–6 3–6 months Yes Strongly
challenges faced by Filipino physicians, including limited access to is emphasized months recomme
diagnostics, formulary restrictions, and varying levels of patient health nded
literacy.
IV. Non-Pharmacologic Management
Where applicable, guideline recommendations have been adapted to Domain PRA ACP APLAR PAFP AFP/
reflect what is feasible, safe, and effective in rural and resource- AAFP
constrained environments. OSCE cases, flowcharts, and bilingual patient Diet Reduce Not Strongly Filipin Bagoong,
tools are provided not only for ease of reference but also to support the purines emphasiz advised o lechon
training and continuing development of residents, clerks, and health , ed contex included
workers. alcohol t
Weight Yes Not Yes Yes Yes
Readers are encouraged to use this manual critically, in conjunction with
loss emphasiz
their clinical judgment, and to tailor its use based on the unique needs of
ed
each patient and practice environment.
Hydratio Yes No Strongly Yes Yes
n mention encourage
This is a living document. Updates and revisions are encouraged as new
d
guidelines and local experiences emerge.
Comorbi HTN, Optional Strongly Yes Yes
d control CKD emphasize
Disclaimer d

This document is intended for educational and clinical reference use only.
V. Special Populations
While it integrates peer-reviewed guidelines and best practice
Scenario PRA ACP APLAR PAFP AFP/
recommendations, it does not replace formal medical training or AAFP
individualized clinical judgment. Local availability of diagnostics, Elderly Avoid Favor Start low, go Yes Adjust all
medications, and specialist access should always be considered in colchicin steroids slow meds
decision-making. The author and contributors are not liable for the clinical e
outcomes resulting from the application of this manual without proper CKD Dose Avoid Prefer Yes Same
medical supervision. adjust NSAIDs febuxostat/l
ULT ow
allopurinol
CVD Not Not Avoid Cautious Same
discusse emphasiz febuxostat if use
d ed CV history
DM Not Not Address Yes Monitor
discusse addressed comorbidity steroid
d cluster effect
Inpatient Not IV/IM Avoid Formulary- Oral
address steroids NSAIDs guided steroids
ed preferred
Polyarticul Not No Systemic Function- Colchicin
ar address comment steroids based e less
ed effective
Tophi Start Shared Aggressive Treat Long-
ULT, <5 decision ULT aggressivel term ULT
target y
Diuretics Avoid Not Prefer Adjust Switch to
thiazides emphasiz losartan, losartan
ed CCB
Pregnancy Rare Not Avoid meds Contracepti Colchicin
covered on e C,
 avoid
allopurin
ol
Palliative Not Comfort- Use steroids Symptom No ULT,
address first focus steroid
ed only

VI. Pharmacologic Profiles (see full table in Section VIII)

 Allopurinol: First-line ULT, renal adjustment required,
monitor SUA, rash, hypersensitivity
 Febuxostat: 2nd-line ULT, avoid if CVD, LFT monitoring,
expensive in PH
 Colchicine: Acute + prophylaxis use, avoid in CKD, risk B. SUA Tracker Tool (Patient-Facing)
of diarrhea/myopathy Date SUA Medication Flare Notes
 NSAIDs: For acute flares, GI/CV/renal risk, avoid in Result s Taken (Yes/No (Diet,
elderly and CKD (mg/dL) ) Missed
Dose)
 Steroids: Effective in flares, safe in renal disease, taper Jan 5, 8.0 None Yes Ate lechon +
if >5 days 2025 beer
Feb 6, 6.8 Allopurinol No
VII. Lab Monitoring & Follow-up 2025 100mg
Paramet PRA ACP APLAR PAFP AFP/ Mar 9, 5.7 Allopurinol No Perfect
er AAFP 2025 200mg adherence
SUA <6 Not Required Sympto q2–6w C. ULT Titration Schedule Template
goal, required , q2–4w m-based until
q4–6 target
 Week 0: Start Allopurinol 100 mg/day
weeks  Week 2: Check SUA, renal fx; if >6 mg/dL, increase to
Renal Yes If high Required Yes Yes 200 mg/day
tests risk  Week 4: Repeat labs; if target not yet met, increase to
LFTs No No Yes with Case- Yes if on
febuxost based febuxost
300 mg/day
at at  Week 8+: Maintain or adjust dose based on SUA
CBC No No Yes if No Yes with
colchicin colchicin D. Quick Reference Algorithm (For Primary Care)
e >2 e 1. Suspected acute gout → treat with NSAID / colchicine /
weeks
steroid
HLA- Not yet Not Strongly Not yet Strongly
B*58:01 availabl discusse advised available advised 2. If first flare → no ULT yet
e d in Asians in 3. If ≥2 flares/year or tophi or CKD → initiate ULT +
Filipinos prophylaxis
with CKD 4. SUA target <6 mg/dL (<5 if tophaceous)
5. Monitor q4–6 weeks until controlled; maintain long-
VIII. Patient Education term follow-up
 Nature: Gout is chronic and progressive
 Cause: High uric acid from purines, kidneys,
comorbidities
 Triggers: Beer, red meat, shellfish, dehydration, stress
 Lifestyle: Avoid purines, hydrate, lose weight
 Adherence: Continue ULT lifelong if recurrent; flares
may worsen at start
 Prophylaxis: Colchicine prevents flares when starting
ULT

IX. Special Clinical Scenarios

 Elderly: Prefer steroids, adjust doses, avoid colchicine
if frail
 CKD: Avoid NSAIDs; titrate allopurinol slowly; test HLA-
B*58:01
 Tophi: Target SUA <5 mg/dL; may need combination
ULT
 Palliative: Use steroids for comfort, no ULT initiation
 Pregnancy: Avoid allopurinol and colchicine
X. OSCE/Case Modules
 Case 1: First flare – treat, educate, no ULT
 Case 2: Recurrent flares – restart ULT + colchicine
prophylaxis
 Case 3: Gout + CKD – use renal-adjusted allopurinol,
switch HCTZ to losartan
 Case 4: Palliative setting – short steroid course, no ULT
XI. Appendices

A. Commonly Used Brands in the Philippines

 Allopurinol: Zyloprim, Apo-Allopurinol, Allohexal
 Febuxostat: Adenuric, Feburic
 Colchicine: Colchicine MedPharma, Rhea-Colchicine
(0.5 mg)
 NSAIDs: Alaxan FR (Ibuprofen + Paracetamol), Ponstan
(Mefenamic acid), Arcoxia (Etoricoxib)
 Steroids: Prednisone (Deltacortril, Sterapred),
Methylprednisolone (Medrol), Kenacort IM
 Avoid Choose agents based on renal, GI, CV
complications profile
Prepare for long- Educate patient that this episode may
term care recur and require ULT in the future

B. Medication Options
Drug PRA ACP 2016 APLAR AFP/ Philippi
Class 2008 2021 AAFP ne
Conside
rations
NSAI First-line First-line; First- First-line Widely
Ds if no no specific line; in used;
GI/renal/ preference monitor uncompli screen
CVD comorbi cated for PUD,
issues dities cases HTN,
renal
I. Expanded Overarching disease
Colchi Max 4 1.2 mg ×1, Low- 1.2/0.6 Generic
Framework cine tablets/ then 0.6 dose regimen (0.5 mg)
day (0.5 mg after 1 regimen superior widely
mg/tabl hr preferre to high- available;
Element Details et) d dose dose
Target Family and community medicine doctors, adjust
Users rural physicians, general internists, nurse Steroi Predniso Equal Preferre 30–35 Safe,
ds ne 30– efficacy to d in mg/day affordabl
prescribers (oral) 40 NSAIDs/col renal/el or e; used in
Practice RHUs, barangay health stations, Level 1–2 mg/day chicine derly tapering RHUs
Setting private hospitals, training institutions × 3–5 patients strategie
Rationale Gout remains underdiagnosed and days s
for Local undertreated in PH, with frequent NSAID Intra- For Effective Strongly Useful Requires
Adaptation overuse and delayed ULT. Education gaps articu monoart but not preferre for knee, clean
lar icular always d if 1–2 ankle techniqu
persist among clinicians regarding flare steroi large practical joint e and
prophylaxis and titration. ds joints flares local
Integrated This guideline integrates evidence from: steroid
Sources prep
 PRA 2008: locally developed, but dated
 ACP 2016: internationally endorsed by PAFP C. Recommended Regimens (Philippines)
 APLAR 2021: regionally adapted for Asian Agent Standard Dose Dose Adjustment
comorbidities (Adult) Criteria
 AFP/AAFP 2014–17: primary care synthesis from U.S. Ibuprofen 400–800 mg TID Avoid in eGFR <60;
family medicine journals | × 5–7 days assess GI risk
| Approach Summary | Two models converge: Naproxen 500 mg BID Same as above
 Treat-to-symptom (ACP, PAFP): Flare-focused, Colchicine 1.2 mg stat, then If eGFR <30: 0.5 mg
cautious on overtreatment 0.6 mg after 1 once; avoid re-dosing
hour
 Treat-to-target (APLAR, AFP/AAFP, PRA): Reduce SUA Prednisone 30–40 mg OD × May taper or stop
to <6 mg/dL to prevent damage |
3–5 days abruptly if <7 days
| Role of Shared Decision-Making | All guidelines now agree
IA 10–40 mg (knee), Use with aseptic
that treatment initiation, especially ULT, should involve
Triamcinolon 10–20 mg (ankle) technique; confirm
discussion of:
e diagnosis first
 Flare frequency and burden
 ULT risks and monitoring
 Long-term joint and kidney outcomes D. Non-Pharmacologic Measures
This ensures realistic adherence, especially in Filipino cultural  Rest affected joint for 1–2 days
settings where patients may fear chronic pills. |  Elevate and apply cold compresses (not heat)
| Why a Filipino Synthesis is Needed | 1. Some patients get  Hydrate with at least 2 liters/day (unless
steroids repeatedly but no long-term plan. contraindicated)
 Educate patient to not stop allopurinol if already
2. ULT is often started without prophylaxis. taking it
3. Labs (SUA, Cr) may be delayed or unavailable.
4. Many local clinics still emphasize dietary myths over
evidence-based therapy. E. Clinical Reasoning Framework (OSCE)
5. Health literacy on urate is limited. | Question Example Answer (based on
| Clinical Outcomes Sought | - Early recognition of gout flares guideline)
without overdiagnosis What drug to NSAID if renal/GI/CVD risk low;
choose first? otherwise prednisone or colchicine
 Safe acute treatment even in elderly or renal patients When do you eGFR <60, history of ulcer, on
 Correct ULT initiation and titration avoid NSAIDs? anticoagulants
 Long-term joint preservation, disability prevention How do you use Low-dose (1.2 + 0.6) only; avoid if
colchicine safely? eGFR <30 unless supervised; monitor
 Patient self-management confidence GI symptoms
Can you use Yes, especially in elderly or
steroids alone? polyarticular gout
What if the patient Continue allopurinol during the flare;
II. Acute Gout Management is already on ULT? do not discontinue
🔎 Purpose
F. Teaching & Training Pearls
This section guides primary care providers on safe, effective  ⚠ Red flag for misdiagnosis: Monoarthritis + fever
treatment of acute gout flares, with special attention to renal may be septic arthritis—aspirate if unclear.
function, drug interactions, and local accessibility.  🔄 Avoid treatment delay: Most agents work best if
given within 24 hours of symptom onset.
A. Treatment Goals During Acute Flare  🧓 In elderly with mild dementia, avoid multiple
Goal Action drugs—choose oral prednisone for safety.
Relieve pain and Initiate anti-inflammatory therapy  💊 Do not “load” colchicine: High doses increase GI
inflammation within 24 hours toxicity and have no added benefit.
Protect function Encourage early mobility once pain
subsides
 Drug Dose Duration When to
Start
Colchicin 0.6 mg OD– 3–6 months Start same
e BID day as ULT
NSAID Naproxen 4–6 weeks Alternative if
250–500 (shorter) colchicine
mg BID not tolerated
Steroid Prednisone If Short-term
5–10 mg NSAID/colchicine only
OD contraindicated

F. Target Serum Uric Acid (SUA) Levels

Patient Type SUA Goal Guideline
Source
Typical gout, no <6 mg/dL PRA, APLAR, AFP
tophi
Tophaceous <5 mg/dL APLAR, AFP
disease
Elderly/fragile <6 mg/dL ACP (shared
patients (cautiously) decision)
CKD patients <6 mg/dL (adjust APLAR, PRA
dose)

III. Urate-Lowering Therapy (ULT) G. OSCE Clinical Framing: “When and How to Start ULT”
Examiner Ideal Answer from Examinee
A. Rationale for ULT Question
When to Start ULT Explanation & Guideline “Will you start Yes, if already on it; if new, wait until
Alignment allopurinol during flare settles.
After ≥2 flares/year PRA, APLAR, AFP, AAFP: Strong this flare?”
indication “What is your Colchicine 0.6 mg OD × 3–6 months
Presence of tophi, Indicates longstanding prophylaxis plan?” from ULT start.
joint damage, hyperuricemia; treat-to-target “How do you counsel Explain that ULT is long-term, flares
erosions approach recommended the patient?” may worsen initially, but adherence
Uric acid >9 mg/dL, APLAR allows ULT to prevent renal prevents damage.
even if asymptomatic complications “What labs will you SUA q4–6 weeks; Cr; LFTs if
CKD (eGFR <60) or ULT helps reduce kidney damage; monitor?” febuxostat; watch for rashes if
urate nephrolithiasis ACP supports shared decision allopurinol.
“What is your SUA <6 mg/dL or <5 mg/dL if tophaceous.
goal?”
B. When NOT to Start ULT
Situation Rationale
First, self-limited gout ACP and PAFP: avoid
flare overtreatment; low recurrence
risk
H. Filipino Clinical Tips
Patient has no Rule out other arthropathies
confirmed before starting lifelong therapy  Do not rush escalation: Many Filipinos experience
hyperuricemia rash when started on 300 mg allopurinol immediately.
Patient lacks ULT needs lab monitoring and  Generic colchicine is affordable (₱5–10/tablet);
commitment to follow- adherence support instruct patients not to skip during ULT titration.
up  Emphasize long-term control, not flare-only
treatment: patients often expect pain = disease.
C. ULT Agents Overview  If HLA-B*58:01 is not available, assess rash history
Agent Role Dose & Monitoring carefully; avoid high-dose first starts.
Titration Needs
Allopurin First-line Start 50–100 SUA q4–6 weeks,
ol ULT mg/day → Cr, HLA-B*58:01
increase q2–4 (if CKD)
weeks
Febuxost Second- Start 40 SUA, LFTs,
IV. Lifestyle Modification and
at line ULT mg/day → 80 ECG/cardiac Counseling in Gout
mg if SUA not history
at target
Probene Rarely 250–500 mg SUA, urinalysis A. Purpose of Lifestyle Advice
cid used in BID (not for (risk of stones)
PH eGFR <50) Lifestyle alone cannot replace pharmacologic therapy in
moderate to severe gout, but:
 It reduces flare frequency
D. Allopurinol Initiation Protocol (Philippines)
 It supports medication adherence
Stepwise Schedule  It addresses metabolic syndrome, common in gout
Wee Dose Recommendation Action if SUA patients
k >6 mg/dL  It gives patients an active role in controlling disease
0 100 mg/day Start with
colchicine 0.6 mg Guideline Consensus: PRA, APLAR, and AFP/AAFP emphasize
OD lifestyle as adjunctive therapy. ACP de-emphasizes diet alone
2–4 Increase to 200 mg/day Continue but supports education as part of shared decision-making.
monitoring
6–8 Increase to 300 mg/day Add diet B. Core Lifestyle Recommendations
counseling
Lifestyle Specific Advice Evidence
10+ Adjust as needed to reach SUA May consider Component Level
goal <6 mg/dL (<5 mg/dL if Febuxostat if
Diet Avoid red meat, liver, sardines, Moderate
tophi) allergic
(Purines) shellfish, anchovies, bagoong,
balut
E. Prophylaxis During ULT Initiation Alcohol Avoid beer and spirits (strongly Strong
 urate-producing); wine in
moderation if any
Fructose Limit sugary drinks (e.g., soda,
sweet iced tea); avoid
Strong V. Gout in Special Populations
sweetened juices
Water Aim for at least 2 L/day unless Strong A. Elderly Patients (≥65 years)
Intake fluid restricted Challenge Recommendation
Weight Recommend gradual weight Strong Higher risk of drug Prefer oral steroids over NSAIDs or
Loss loss if overweight/obese (BMI side effects colchicine for flares
>25) Polypharmacy Minimize drug interactions (e.g., avoid
Exercise Moderate activity encouraged Moderate colchicine if on clarithromycin)
between flares; avoid joint Renal decline Adjust allopurinol starting dose to 50–
strain during flares 100 mg/day
Salt & BP Avoid high sodium processed Strong Fall risk Avoid high-dose prednisone (>40 mg),
Control food; screen for hypertension NSAID-induced orthostasis
Key Point: All guidelines favor low-dose, slowly uptitrated ULT
in elderly.
C. Cultural Adaptation: Common Filipino Foods to Watch
Avoid Often Limit Encouraged
Occasionally Choices B. Chronic Kidney Disease (CKD)
Sardinas, dilis, Chicken liver, Fresh vegetables, CKD Acute Flare ULT Consideration
tuyo beef tofu, legumes Stage Management
Bagoong, isaw, Crab, shrimp Eggs, low-fat milk, eGFR NSAIDs still possible Start allopurinol 100
balut whole grains 60–89 short-term mg/day
Lechon, Red meat in small Banana, pineapple, eGFR Avoid NSAIDs; use Allopurinol 50–100
chicharon, portions watermelon 30–59 prednisone or IA mg/day; uptitrate q4wk
longganisa eGFR Colchicine: max 0.6 Allopurinol ≤50 mg/day
Beer, gin, 1–2 glasses Water, buko juice <30 mg/day ×1 only or use febuxostat
lambanog wine/week (max) (unsweetened) On Avoid colchicine & Allopurinol may still be
Sweetened iced Fruit shakes with Plain water with dialysis NSAIDs used (specialist input)
tea, soda added sugar lemon HLA-B*58:01 testing is strongly advised in CKD before
allopurinol in Asian populations (APLAR, AFP). Limited
availability in PH.
D. Suggested Counseling Script (English–Tagalog Blend)

“Doc, bawal ba ako sa lahat?” C. Patients with Cardiovascular Disease (CVD)

Issue Recommendation
Response: Risk of NSAID- Prefer steroids or colchicine for flares
induced events
“Hindi naman po lahat. Ang gout ay sanhi ng sobrang uric acid. Febuxostat black- Avoid in those with prior MI/stroke if
Kaya ang ilang pagkain tulad ng lamang loob, sardinas, at beer box warning alternatives available
ay dapat iwasan. Pero marami pa pong masustansyang pagkain BP and glucose Required if on steroids
na puwede: itlog, gulay, prutas, at isda gaya ng bangus (huwag monitoring
lang ‘yung tuyo o dilis). Mahalaga rin ang pag-inom ng APLAR recommends using allopurinol preferentially in CVD
maraming tubig at pag-iwas sa sobrang timbang.” patients; febuxostat only if intolerant and stable.

E. Behavioral Tips for Improving Compliance

Strategy How to Apply in Practice D. Diabetics or Metabolic Syndrome
Visual tools Use food pyramid handouts, SUA charts, Concern Recommendation
or flare trackers Obesity, insulin Emphasize weight loss, dietary
Link to Explain gout as related to “diabetes at resistance adherence
common altapresyon” to show importance of Polypharmacy with Avoid NSAIDs due to renal and CV
diseases prevention oral agents effects
Use family Encourage a family member to join ULT safety Allopurinol remains safe; monitor
support counseling, especially for elderly patients renal function regularly
Reinforce at Even if medications dominate the Lifestyle modification is especially impactful in this group; link
every visit encounter, repeat 1–2 key lifestyle points gout management with diabetes counseling.
Use local terms “Pagkaing pampalasa gaya ng bagoong
and examples at chicharon” often resonates better than
‘purines’
E. Inpatients / Hospitalized Patients
Clinical Scenario Recommendation
F. Training Pearls (OSCE/Teaching Use) Acute flare on Use IV methylprednisolone, or oral
Examiner Prompt Expected Response from Trainee admission prednisone
“What will you tell Foods high in purine (organ meats, Gout vs. septic Always aspirate joint if red, swollen,
the patient to avoid?” sardines, alcohol), sugary drinks arthritis febrile
“How will you explain At least 8–10 glasses/day, unless Restarting ULT Continue if already on; defer if
water intake?” patient has CHF or CKD stage 4–5 initiating
“Can they still eat Yes, in moderation (e.g., tilapia, Do not stop maintenance allopurinol during inpatient flares
seafood?” bangus) but avoid shellfish and dried unless patient is septic or has rash.
fish
“Do you use a Referral is ideal but education
dietitian?” should begin at the primary care F. Polyarticular Gout
level Situation Management Strategy
Flare in ≥3 joints Indicates severe burden; treat
simultaneously systemically
G. Summary Table for Patients Avoid NSAID stackingUse oral prednisone or short course
Do Eat More Eat Avoid These IM steroid
Occasionally Consider ULT Yes, after flare resolves; high
Eggs, tofu, fresh Chicken, lean Sardinas, chicharon, initiation disease activity justifies early ULT
fish pork liver, balut APLAR and PRA recommend earlier ULT for polyarticular cases,
Leafy greens, White rice, white Beer, lambanog, even after one flare.
vegetables bread sweetened drinks
Banana, papaya, Mango (in Soda, iced tea, sweet
melon moderation) fruit shakes G. Tophaceous Gout
Concern Management Strategy
Multiple Aggressive ULT: goal SUA <5 mg/dL
 subcutaneous tophi s
Adherence critical Provide clear explanation of slow Teaching Avoid loading doses. Use low-dose protocol
tophus regression Pearl to minimize toxicity.
Combination Allopurinol + febuxostat or
therapy uricosurics (specialist referral)
2. NSAIDs (Naproxen, Ibuprofen, Indomethacin)
PRA emphasizes treat-to-target for tophaceous disease; PAFP
supports same if lab monitoring available. Parameter Details
Indication Acute gout flare
Formulatio Naproxen 500 mg; Ibuprofen 400–600 mg;
H. Pregnancy and Lactation n Indomethacin 25 mg (less used)
Drug Use in Notes Dosing Naproxen 500 mg BID × 5–7 days
Pregnancy Renal Avoid if eGFR <60 or in elderly with volume
Colchicin Category C; avoid Theoretical teratogenicity; Caution depletion
e unless critical limited data GI/CV Risk Screen for ulcer history, hypertension, CHF
NSAIDs Avoid in 3rd May cause premature Common GI bleed, fluid retention, BP rise
trimester ductus closure; use AEs
paracetamol if pain Teaching Always co-prescribe with food or PPI if risk
Steroids Safe (short-term) Prednisone preferred Pearl present
Allopurin Not Animal teratogenicity in
ol recommended high doses
Delay ULT initiation until postpartum. Manage acute flares 3. Corticosteroids (Prednisone, Methylprednisolone)
conservatively. Parameter Details
Indication Acute flares in patients intolerant to
NSAIDs/colchicine
I. Palliative or Terminally Ill Patients Formulatio Prednisone (5 mg, 20 mg),
Principle Action n Methylprednisolone (oral or IV)
Comfort > Do not initiate or continue ULT unless Dosing 30–40 mg/day × 3–5 days; may taper if >5
chronic control severe tophaceous burden days
Acute flares Treat with oral or IM steroids for Renal Safe in CKD
symptom relief Caution
Uric acid levels Not necessary to monitor Common Hyperglycemia, mood changes, insomnia, BP
APLAR, ACP, and AFP agree: comfort-focused care means AEs rise
avoiding polypharmacy and lab-driven targets. Teaching Educate patient that short-course steroids are
Pearl not lifelong
J. OSCE and Teaching Notes
Examiner Question Ideal Trainee Response B. Urate-Lowering Therapy (ULT)
“How do you manage Avoid NSAIDs, use steroids or
gout in CKD?” low-dose colchicine; adjust 1.
allopurinol Allopurinol
“What’s the SUA target in <5 mg/dL Parameter Details
tophaceous gout?” Indication First-line for chronic hyperuricemia
“Would you give ULT to a No; focus on comfort and short- Formulatio 100 mg, 300 mg tablets (widely available)
dying patient?” term symptom relief n
“Is febuxostat safe in Not preferred; use only if no Starting 100 mg/day (or 50 mg if CKD), titrate q2–4
patients with stroke other option Dose weeks
history?” SUA Target <6 mg/dL (or <5 if tophaceous)
Renal Adjust dose per eGFR; start low and go slow
Caution
Major AE Allopurinol Hypersensitivity Syndrome
(AHS) – rare but fatal
HLA- Strongly advised for CKD patients (not widely
B*58:01 available in PH)
Teaching Never initiate at 300 mg/day outright in
Pearl Filipino patients

2.
Febuxostat
Parameter Details
Indication Second-line if allopurinol-intolerant or
ineffective
Formulation 40 mg, 80 mg tablets (limited availability
in PH; expensive)
Dosing Start at 40 mg/day → 80 mg if target SUA
not reached
Renal None needed; safe in CKD
Adjustment
VI. Drug Profiles for Gout Treatment CVD Caution Avoid in patients with prior MI/stroke (per
CARES study)
A. Acute Flare Medications Common AEs Elevated LFTs, nausea, rash
Monitoring SUA, LFTs, ECG if cardiac history
1. Colchicine Teaching Ideal if patient has CKD and cannot
Parameter Details Pearl tolerate allopurinol
Indication Acute gout flare (early use), flare prophylaxis
during ULT 3.
Formulatio Tablet 0.5 mg (generic widely available in Probenecid
n PH) (Rarely Used)
Dosing Flare: 1.2 mg stat, then 0.6 mg in 1 hr (max Parameter Details
1.8 mg/day)Prophylaxis: 0.6 mg OD–BID Indication Alternative ULT in underexcretors of uric
Renal If eGFR <30, single 0.6 mg dose only; avoid acid
Caution repeated use Formulation Not widely available in PH; compounded
Common Diarrhea, abdominal pain, nausea, myopathy or imported
AEs (esp. with statins) Dosing 250–500 mg BID
Drug CYP3A4 inhibitors (clarithromycin), P-gp Renal Caution Ineffective if eGFR <50
Interaction inhibitors, statins Contraindicati Urolithiasis, G6PD deficiency
 ons
Teaching Requires high fluid intake to prevent stone
Pearl formation E. Common Monitoring Pitfalls in Philippine Practice
Issue Prevention Tip
No SUA done after ULT Emphasize that goal is not pain
C. Comparison Chart for Quick Teaching start relief alone but urate reduction
Drug Acute Safe in Risk in Needs Cost/Access
or ULT CKD Elderly Monitoring (PH) ULT titrated based on Always base titration on SUA
Colchicin Acute Low GI/muscle Minimal ₱5–10/tablet flares, not SUA level—not just symptoms
e dose toxicity
only
Patient stopped meds Educate that gout is a chronic
NSAIDs Acute Avoid Yes Creatinine, ₱5–15/tablet after first improvement metabolic disease
BP No renal function check Check Cr at baseline and every
Steroids Acute Yes Safer Glucose, BP ₱10–30/
tablet
during allopurinol use 6–12 months, esp. elderly
Allopurin ULT Yes AHS risk SUA, Cr, ₱7–20/tablet
ol (start rash
low) F. Patient Self-Monitoring Tools (Training Use)
Febuxost ULT Yes CVD SUA, LFTs ₱50–80/
at caution tablet
Tool Use in Clinic and Teaching
Probeneci ULT No (<50 GI, uric SUA, urine Not standard SUA Tracker Patients record their own uric acid results
d eGFR) stones pH Card on a foldable wallet card
Flare Diary Checklist of symptoms, triggers, and
medication intake during attacks
Lifestyle Patients sign a 3-month diet and hydration
Pledge Sheet commitment form
VII. 🧪 Expanded Section: Laboratory Medication
Calendar
Monthly refill and dose chart to track ULT
and prophylaxis adherence
Monitoring and Clinical Follow-Up
G. OSCE Integration and Clinical Teaching Prompts
A. Monitoring Goals Examiner Prompt Ideal Trainee Response
Objective Why It Matters “When will you repeat SUA At 6–8 weeks or after titration
Confirm response Ensure SUA reduction to target levels after starting allopurinol?”
to ULT “When do you stop If no flares in 3–6 months and
Detect drug Prevent complications from colchicine, colchicine prophylaxis?” SUA is <6
toxicity early allopurinol, febuxostat “What labs do you monitor SUA, LFTs (ALT), renal if elderly
Reinforce Frequent visits improve counseling, in febuxostat?”
adherence especially in rural areas “Should SUA be done No, levels may be falsely low
Adjust dose Titrate ULT based on lab and symptom during an acute flare?” during flares
safely changes “What if SUA is 3.2 but Consider maintaining dose or
patient is well?” lowering slightly; monitor
closely
B. Target SUA Goals (Per Risk Group)
Patient Type Target SUA Guideline
Source
Typical gout, no <6.0 mg/dL ACP, APLAR, PRA
tophi VIII. Patient Education and
Tophi, erosive <5.0 mg/dL APLAR, PRA
disease
Counseling Techniques
CKD, frail elderly <6.0 mg/dL, ACP (shared
cautiously decision) A. Core Educational Goals
Goal Target Outcome
C. Recommended Monitoring Schedule Improve disease Patient can explain what gout is and
Visi Timeframe Labs Action Point understanding what triggers it
t from ULT Ordered Support adherence Patient understands why uric acid
No. Start to ULT needs to be controlled even without
V1 Day 0 SUA, Cr, ALT Start ULT + pain
(baseline) prophylaxis Promote lifestyle Patient reduces intake of high-purine
V2 2–4 weeks None Assess flare modification food, alcohol, sugary drinks
(symptom frequency, Prevent medication Patient avoids stopping ULT during
check) tolerability misuse flares or overdosing colchicine
V3 6–8 weeks SUA, Cr Adjust ULT if SUA Key Teaching Principle (PRA, APLAR, AFP): “Gout is a
>6 chronic disease, not just a flare problem.”
V4 3 months SUA, Cr, ALT Confirm downward
(if febuxostat) trend; reinforce B. Bilingual Teaching Script for Lay Patients (English–
adherence Tagalog Blend)
V5 6 months SUA Stop prophylaxis if
no flares in past 3 Intro (First diagnosis):
months
V6 Annually SUA, Cr, ALT Continue “Doc, bakit po ako nagka-gout?”
(if high dose maintenance, adjust Response:
or elderly) for age/weight “Ang gout ay sakit na dahil sa labis na uric acid sa dugo. Kapag
changes ito ay naiipon, nagiging parang buhangin sa kasukasuan. ‘Pag
If SUA <6 but patient still flaring, assess for nonadherence, dumami ito, sumasakit—lalo sa gabi. Hindi lang ito ‘trangkaso
tophi dissolution, or other diagnoses. ng kasukasuan’. Maaaring maulit kung hindi maagapan.”

When starting ULT:

D. Dose Adjustment Triggers
SUA Result Action “Ang gamot tulad ng allopurinol ay hindi pampawala ng sakit—
>6.0 mg/dL Increase allopurinol (by 100 mg) or ito ay pangbaba ng uric acid. Kailangan inumin araw-araw
febuxostat (to 80 mg) kahit walang sakit. Para hindi lumala at hindi na maulit ang
<5.0 mg/dL Maintain current dose atake.”
with no flares
<3.0 mg/dL Consider dose reduction to avoid over- Diet counseling:
lowering (risk: uric acid nephropathy
rebound) “Hindi bawal lahat. Iwasan lang po ‘yung pagkaing may lamang
loob (atay, balunbalunan), tuyo, sardinas, chicharon, at alak.
Puwede pa rin ang prutas, itlog, gulay, isda—basta’t hindi
maalat o tuyo.”
C. Standard Visual Aids and Teaching Tools
Tool Description Adapted
for PH?
Gout Food Categorizes foods by “Eat More / ✅ Yes
Pyramid Eat Less / Avoid”
Uric Acid Pocket-sized card where patients ✅ Yes IX. Referral Guidelines and Red
Tracker log SUA and next check-up date Flags
Card
Flare Table to record pain scale, ✅ Yes A. Why Referral Matters
Diary triggers, meds used, and flare
duration Most gout cases can be managed in primary care, but delays in
Myth- “Hindi totoo na lahat ng gulay ay ✅ Yes specialist referral may lead to:
Buster bawal” / “Hindi lahat ng gout ay
Sheet dahil sa pagkain”
 Joint deformities
 Chronic tophaceous gout
 Missed mimics (e.g., septic arthritis, CPPD)
D. Education Reminders for Rural/Low-Literacy Settings
 Medication toxicity
Challenge Solution
Belief that gout is just Explain that it’s in the blood and PRA and APLAR emphasize early referral in complex cases;
from “uric sa tuhod” affects kidneys and joints PAFP supports strengthening the role of family physicians as
Patient takes meds only Emphasize that daily ULT primary gatekeepers with clear thresholds for escalation.
during attack prevents flares—not for pain relief
only
Misconceptions about Clarify that not all seafood is bad; B. Indications for Referral to Rheumatologist or Internist
veggies and shrimp not all vegetables are purine-rich Clinical Scenario Referral Justification
Herbal alternatives Respect beliefs, but explain ULT is Refractory gout SUA remains >6 mg/dL despite
preferred needed long-term for crystal despite ULT max dose of allopurinol/febuxostat
control Severe tophaceous Needs combination ULT or
PRA and AFP emphasize culturally sensitive education: do not gout advanced imaging
scold, negotiate instead of dictate. Suspected drug e.g., rash from allopurinol, unclear
hypersensitivity cause
Multiple e.g., CKD, CVD, hepatic
E. Teach-Back Technique Examples
comorbidities dysfunction
Ask the Patient: Purpose complicate Rx
“Paki ulit po—anong Assess if the patient Recurrent gout with Evaluate for mimics (e.g.,
dahilan ng gout?” understands uric acid normal SUA pseudogout, TB arthritis)
mechanism
Gout with May need urate imaging (e.g.,
“Paano niyo po iinumin Reinforce daily maintenance deforming arthritis DECT) or intra-articular therapy
ang allopurinol?” even when no pain
Patient preference After shared decision-making,
“Anong mga pagkain ang Confirm lifestyle learning or nonresponse patient requests higher-level care
dapat iwasan?”
In most PH settings, referral is to IM for medication optimization.
“Kailan dapat bumalik sa Ensure follow-up is remembered Rheumatology referral is ideal when available, especially in
clinic?” tertiary centers.

F. Adherence Checklist for Follow-Up Visits C. Red Flags – Urgent Evaluation Required
Red Flag Consider/Action
✅ Takes ULT daily even when asymptomatic
Monoarthritis with fever Rule out septic arthritis;
✅ Knows SUA target level
aspirate joint
✅ Able to name 3 foods to avoid
Rapidly progressive Joint aspiration or imaging
✅ Knows when to stop colchicine prophylaxis
swelling and pain
✅ Knows not to stop ULT during flare
Joint involvement atypical Shoulder, spine → consider
✅ Has SUA tracker or flare diary
for gout alternative dx
A patient who scores 5–6/6 on this checklist is considered well- Systemic symptoms Evaluate for malignancy, TB,
educated on gout self-management. (weight loss, anemia) autoimmune
Unexplained polyarthritis Refer to Rheumatology (rule
out RA, SLE, CPPD)
G. OSCE Teaching Prompts ACP cautions against attributing every joint pain in older
Examiner Question Ideal Answer patients to gout—avoid misdiagnosis.
“How do you explain “It’s not for pain, it’s to prevent
allopurinol to a farmer?” crystals from building up again.”
D. When to Refer for Joint Aspiration
“Can you counsel a Yes; use simple analogies (“asin
patient in Filipino?” sa kasukasuan”) Indication Practical Tip
“What tools can you give Uric acid card, food pyramid, Suspected septic arthritis Fever, leukocytosis, joint
a patient?” flare diary warmth
“What myths need to be Gout is not just from food; ULT is First flare with no Consider CPPD or trauma
corrected?” not only for attacks hyperuricemia
Nonresponse to typical Confirm diagnosis before
gout treatment escalating therapy
Primary care doctors should refer to facilities with joint
aspiration capacity rather than empirically treating all
monoarthritis as gout.

E. Local Philippine Context Considerations

Constraint Strategy
Lack of Refer to IM with gout focus or
Rheumatologist in connect via telemedicine
area
No joint aspiration Use CRP + ESR + imaging + CBC as
available interim support
 Labs not affordable Monitor clinically + low-cost SUA  Do not assume every monoarthritis in gout patient =
testing when possible gout

OSCE Prompt:
F. OSCE and Clinical Decision Prompts
“What features suggest infection over gout?”
Examiner Question Ideal Answer
“When should you refer Refractory SUA, drug reactions,
gout to IM?” CKD or tophaceous burden E. Case 5 – Patient Education in Rural Clinic
“What red flags suggest Fever, monoarthritis, warmth,
septic arthritis?” WBC elevation Setting: 58-year-old farmer with known gout, not on ULT,
“How do you distinguish Older age, wrist/knee believes “sardinas lang talaga problema”
CPPD from gout?” involvement, normal SUA Language: Bicol-Tagalog mixed
“Should you refer all Yes, especially if progressive or Complaint: Wants only “gamot sa sakit” during flares
tophaceous cases?” affecting function
Teaching Points:

X. 🩺 Clinical Case Scenarios and  Explain uric acid as root cause in lay terms
 ULT is not for pain; emphasize long-term prevention
OSCE Training Sets  Demonstrate use of Gout Diet Card (Filipino-adapted)
 Address food myths without shaming
A. Case 1 – Classic Acute Monoarthritis (First Flare)
OSCE Prompt:
Setting: 54-year-old tricycle driver, presents with sudden “How would you explain urate-lowering therapy in simple
painful swelling in left MTP joint (big toe) Filipino?”
Exam: Erythema, warmth, severe tenderness, no trauma
Vitals: T 37.2, BP 130/80 F. Case 6 – Inpatient Flare While on Maintenance
Labs: SUA 8.9 mg/dL, Cr 1.0, ESR 25 Allopurinol
Key Teaching Points: Setting: 71-year-old diabetic, admitted for pneumonia;
 Most likely gout; typical joint and age developed left ankle pain on Day 3
 NSAIDs or colchicine can be given History: On allopurinol 100 mg/day for 2 years
 No ULT yet (ACP: don’t start after first flare unless high Vitals: T 37.8°C; Cr 1.5, SUA unknown
risk)
 Lifestyle advice begins now Teaching Points:
 Continue ULT during flares (do not stop allopurinol)
OSCE Prompt:  Treat flare with prednisone (avoid colchicine/NSAIDs if
“How would you confirm gout and manage this patient?” unstable)
 Screen for drug interaction before adding new meds
B. Case 2 – Recurrent Gout with CKD
OSCE Prompt:
Setting: 62-year-old male with DM and CKD stage 3b “Should ULT be stopped during an inpatient flare?”
History: ≥3 flares/year, on self-medicated colchicine
Labs: SUA 10.1 mg/dL, eGFR 38, Cr 1.8
Medication: Irregular allopurinol intake 300 mg PRN G. Quick Recap Table: OSCE Key Themes
Theme What Examinee Should Show
Teaching Points: Diagnosis Can identify gout vs. mimics using history &
 Allopurinol PRN is incorrect; ULT must be daily exam
 Start at 50 mg/day, slow titration (renal-adjusted) Initial Chooses correct med and route (e.g., avoid
 Colchicine max 0.6 mg ONCE per flare in eGFR <30 treatment NSAIDs in CKD)
 Start colchicine prophylaxis with new ULT plan ULT timing Understands when to start and how to
titrate
OSCE Prompt: Patient Explains gout mechanism and long-term
“Patient is using allopurinol incorrectly. How do you fix this education control well
plan?” Referral Knows when to refer to IM or Rheum
decisions

C. Case 3 – Febuxostat Initiation in Allopurinol Allergy

Setting: 45-year-old with prior rash on allopurinol (AHS ruled XI. 🧊 Expanded Section:
out), persistent SUA 9.2
History: 2 tophaceous flares; hesitant to restart treatment Management of Tophaceous Gout
Exam: No current flare, stable vitals, normal LFTs
eGFR: 60, ECG normal
and Advanced ULT
Teaching Points: A. What Are Tophi?
 Safe to initiate febuxostat 40 mg/day Feature Description
 Counsel on long-term need; use flare prophylaxis Composition
Deposits of monosodium urate crystals with
(colchicine) granulomatous inflammation
 Avoid in prior MI/stroke patients per APLAR, ACP Common Olecranon, pinna of ear, Achilles tendon,
Locations fingers, toes, joints
OSCE Prompt: Long-standing hyperuricemia, delayed ULT,
“How do you start febuxostat safely?” Risk Factors
poor adherence, CKD
Diagnostic Clinical exam, x-ray (erosions), dual-energy
D. Case 4 – Gout vs. Septic Arthritis Red Flag Tools CT (DECT) if available
In Philippine practice, clinical diagnosis of tophi is accepted.
Setting: 68-year-old male, history of gout, now with left knee Imaging is optional unless diagnosis is unclear.
swelling + fever
Vitals: T 38.5°C, WBC 16,000 B. Goals of Treatment in Tophaceous Gout
Exam: Warm, red, effused joint; unresponsive to prior colchicine Treatment Goal Rationale
Dissolve tophi (urate Prevent joint deformity and
Teaching Points:
crystal burden) improve function
 Septic arthritis must be ruled out → aspirate joint Prevent new tophus Maintain SUA <5.0 mg/dL
 Empiric antibiotics may be started pending aspirate formation
Control flares Use prophylaxis during ULT
 titration  Take regular photos or hand-drawn maps of tophi to
Avoid adverse drug CKD, elderly at risk during document changes
effects aggressive therapy
J. OSCE Teaching Prompts
C. Pharmacologic Strategy Examiner Question Ideal Answer
Strategy Details “What SUA target is needed in <5.0 mg/dL
Aggressive Start allopurinol 100 mg/day → titrate tophaceous gout?”
ULT every 2–4 weeks until SUA <5 “Can we use febuxostat in Yes, if no CVD history
Combination May use allopurinol + probenecid (rare in patients with CKD and tophi?”
Therapy PH) or allopurinol + febuxostat under “When is surgery considered?” If tophi cause deformity,
Rheum supervision ulceration, or severe pain
Target SUA <5.0 mg/dL to facilitate tophus dissolution “Is tophus resolution No, takes months to years
Monitor SUA Reassess and adjust ULT dose accordingly immediate?” even with optimal therapy
q4–8 weeks

D. Role of Febuxostat in Tophaceous Gout

Consider If… Notes
Cannot tolerate high- Febuxostat 80 mg may be used
dose allopurinol
Has CKD Stage 3–4 Febuxostat safe without renal
adjustment
Has no prior MI or CARES trial: avoid febuxostat in
stroke high-risk CVD unless no other option
APLAR and PRA approve febuxostat as effective for lowering
SUA in severe disease if monitored properly.

E. Role of Uricosurics (Probenecid)

Use Only If… Notes XII. Appendices and Quick-
Underexcretor (24h urine Rarely done in PH due to test
<600 mg uric acid) limitations Reference Tools
No CKD (eGFR >50) Ineffective if renal function is
low A. Quick Treatment Algorithm (Primary Care Use)
No uric acid nephrolithiasis Risk of stones from increased
uric acid excretion 🩺 Acute Gout Flare
Probenecid is rarely used in PH but still valid if access and 1. Confirm typical monoarthritis (MTP, ankle, knee)
renal function allow. 2. Rule out infection (fever, systemic signs, atypical joint)
3. Start anti-inflammatory:
o Colchicine: 1.2 mg stat → 0.6 mg in 1 hr
(max 1.8 mg/day)
o NSAIDs: Naproxen 500 mg BID x 5 days
F. Role of Pegloticase (Not Available in PH) o Steroids: Prednisone 30–40 mg/day × 3–5
Indication Notes
days
Refractory For patients with destructive gout
4. Do not start or stop ULT during a flare
tophaceous gout and failed oral ULT
Converts urate to Rapid SUA drop but risk of
allantoin anaphylaxis and cost 💊 Chronic ULT Initiation
IV infusion only Requires premedication and 1. Indications:
monitoring o ≥2 flares/year
Pegloticase is not registered in the Philippines (2025), but o Tophi
some references include it for completeness in board exams.
o CKD ≥ stage 2
o Uric stones
G. Monitoring During Tophi Dissolution
2. Start low:
Parameter Frequency Purpose
SUA Every 4–8 Track ULT response and
o Allopurinol 100 mg/day (or 50 mg if CKD)
weeks titrate o Add colchicine prophylaxis 0.6 mg OD–BID
Cr, ALT Every 3–6 Ensure safety of ULT in long- 3. Titrate q2–4 weeks:
months term use o Target SUA <6.0 mg/dL
Flare At every Should decrease as urate o If tophi: target <5.0 mg/dL
frequency visit level drops 4. Continue prophylaxis for 3–6 months
Physical exam At every Document size reduction
(tophi) visit (can take months to years)
Warn patients that tophi shrink slowly—even if SUA is normal, B. Uric Acid Tracker Card (Print-Ready Template)
improvement is gradual. Dat SUA Dose Notes (Flares,
e (mg/dL) (Allopurinol/Febuxostat Tophi, Side
) Effects)
H. Role of Surgery Instructions to Patient: Bring this card every visit. Take meds
Indication Notes daily. Target SUA: <6 mg/dL.
Severe deformity or E.g., finger contractures, tendon
disability impingement
Infected or ulcerated Requires debridement C. Gout Food Pyramid (Tagalog-English Adapted)
tophus
Cosmetic concern Patient preference if function is ✅ Eat Often
(selected cases) preserved  Gulay (malunggay, pechay, carrots)
Surgery should not replace ULT. Tophi will recur if urate burden  Prutas (banana, pakwan, melon)
is not corrected.  Tubig (8–10 baso bawat araw)
I. Patient Education Points ⚠️Eat Moderately
 Explain that dissolving tophi may cause flares—  Isda (tilapia, bangus – hindi tuyo)
continue colchicine or NSAID prophylaxis  Itlog, low-fat dairy
 Emphasize adherence and monitoring: this is a long  Kanin (1–2 tasa kada kain)
game (6–24 months)
❌ Avoid
  Sardinas, tuyo, dilis, chicharon febuxostat or allopurinol in patients with gout. New England Journal of
Medicine, 378, 1200–1210. https://doi.org/10.1056/NEJMoa1710895
 Bagoong, isaw, balut
 Beer, sweetened drinks (softdrinks, iced tea) Patient Education and Literacy Tools

Sweis, N., Smith, J., & Menon, S. (2021). Bridging the health literacy gap in
D. Medication Summary Table
gout: The role of visual and culturally adapted tools. BMJ Open
Drug Use Dose Caution Cost Rheumatology, 9(1), e000844. https://doi.org/10.1136/bmjrh-2020-
(initiation) (PH 000844
est.)
Colchicin Flare, 0.6 mg OD–BID CKD, elderly ₱5–10/
e prophyla tab
xis
Allopurin ULT 100 mg/day AHS risk, ₱7–20/
ol (start low) renal dosing tab
Febuxost ULT 40 mg → 80 CV history, ₱50–
at mg/day LFTs 80/tab
Naproxen Flare 500 mg BID GI, BP, Cr ₱5–15/
tab
Predniso Flare 30–40 mg/day x DM, BP, ₱10–
ne 3–5 days mood 30/tab

E. Bilingual Counseling Handout

Ano ang Gout?

Ang gout ay sakit sa kasukasuan na galing sa sobrang uric acid.
Naiipon ito sa tuhod, paa, at siko—parang buhangin. Nagdudulot
ito ng matinding kirot.

Paano gamutin?
Hindi sapat ang gamot sa sakit lang. May gamot na pangbaba
ng uric acid (tulad ng allopurinol). Kailangan inumin araw-araw
kahit walang nararamdaman.

Ano ang dapat iwasan?

❌ Tuyo, sardinas, atay, chicharon

❌ Softdrinks, iced tea, beer
✅ Kumain ng gulay, prutas, itlog
✅ Uminom ng maraming tubig

XIII. References
Philippine-Based Sources

Philippine Rheumatology Association (PRA). (2020). Clinical Practice

Guidelines for the Diagnosis and Management of Gout in the Philippines.
PRA Guidelines Committee.

Philippine Academy of Family Physicians (PAFP). (2023). Practice-Based

Guidelines on Gout

Department of Health – Philippines. (n.d.). Philippine National Formulary

and Drug Database. Retrieved from https://www.doh.gov.ph/philippine-
national-formulary

MIMS Philippines. (n.d.). Drug monographs: Colchicine, Allopurinol,

Febuxostat, Naproxen, Prednisone. Retrieved from
https://www.mims.com/philippines

International Guidelines

American College of Rheumatology [ACR]. (2020). 2020 ACR guideline for

the management of gout. In J. D. FitzGerald, A. Dalbeth, T. Mikuls, J.
Brignardello-Petersen, D. L. Guyatt, R. R. Singh, & L. K. Turgunbaev (Eds.),
Arthritis Care & Research, 72(6), 744–760.
https://doi.org/10.1002/acr.24180

American College of Physicians [ACP]. (2017). Management of acute and

recurrent gout: Clinical practice guideline from the American College of
Physicians. In A. Qaseem, M. R. Harris, T. Forciea, M. Starkey, & P. M.
Denberg, Annals of Internal Medicine, 166(1), 58–68.
https://doi.org/10.7326/M16-0570

Asia Pacific League of Associations for Rheumatology [APLAR]. (2020).

APLAR consensus statement on treatment of gout in Asia-Pacific region. In
A. L. Tan, A. Dalbeth, P. Sriranganathan, & E. P. Tan (Eds.), International
Journal of Rheumatic Diseases, 23(3), 301–316.
https://doi.org/10.1111/1756-185X.13720

Evidence Base and Trials

Stamp, L. K., Dalbeth, N., & Barclay, M. (2017). Allopurinol dose escalation
to achieve target serum urate: A systematic review and meta-analysis.
Rheumatology (Oxford), 56(5), 679–689.
https://doi.org/10.1093/rheumatology/kew474

White, W. B., Saag, K. G., Becker, M. A., Borer, J. S., Gorelick, P. B.,
Whelton, A., … & CARES Investigators. (2018). Cardiovascular safety of