Gout is the most common form of inflammatory arthritis, and Healthier SG Primary Care Pages notes an estimated local prevalence of 4.1% in 2012. Treatment splits cleanly into two jobs: settle the current flare quickly, then lower uric acid for the long term so future flares do not happen. ACE and Healthier SG guidance make this straightforward, but many uncontrolled gout cases persist because treatment is stopped, under-dosed, or not titrated to the uric-acid target.
How gout medications work
Gout is caused by sustained high blood uric acid (hyperuricaemia) — usually above 420 µmol/L in men and 360 µmol/L in women — which crystallises in joints and soft tissue, triggering inflammation. Medications fall into two broad groups:
- Anti-inflammatories — settle an acute flare (NSAIDs, colchicine, oral steroids).
- Urate-lowering therapy (ULT) — reduces uric acid to prevent future flares (allopurinol, febuxostat, probenecid, pegloticase).
Singapore targets for serum uric acid on ULT:
- Most gout patients: < 360 µmol/L (6 mg/dL)
- Tophi, frequent flares, chronic gouty arthropathy: < 300 µmol/L (5 mg/dL)
Managing an acute flare
Treatment works best when started within 12 hours of the first joint pain. Three options, often used in combination:
1. NSAIDs
Strong anti-inflammatory effect for an acute flare. Common in Singapore: naproxen 500 mg twice daily, ibuprofen 400 mg three times daily, etoricoxib 120 mg once daily (often preferred for GI tolerance and easier dosing).
Typical course: 5–7 days, or until 1–2 days after the flare fully settles.
Watch for: GI bleeding (avoid if peptic ulcer history; pair with a proton-pump inhibitor in higher-risk patients), kidney impairment, fluid retention.
Avoid in: eGFR below 30 mL/min, active heart failure, recent stroke or MI.
2. Colchicine
An old, plant-derived medication that interrupts the inflammatory crystal response. Singapore dosing for acute flare: 1 mg once, followed by 0.5 mg one hour later — total 1.5 mg in the first day. Then 0.5 mg two to three times daily for 2–3 more days.
Older "high-dose" colchicine regimens (1 mg every 2 hours) are now obsolete and unsafe — the low-dose regimen above is as effective with much less diarrhoea.
Watch for: diarrhoea (dose-related), drug interactions (clarithromycin, ciclosporin, statins, verapamil, diltiazem — all raise colchicine levels), bone marrow suppression with prolonged high-dose use.
3. Oral corticosteroids
Useful when NSAIDs and colchicine are contraindicated. Typical course: prednisolone 30–40 mg daily for 5 days, sometimes tapering over a further 5 days. Intra-articular steroid injection is an alternative for a single inflamed joint.
Watch for: short-term glucose rises (especially in diabetes), insomnia, mood effects; if multiple flares a year, this is a sign that ULT (below) is needed rather than repeated steroid courses.
Long-term urate-lowering therapy (ULT)
ULT is recommended in Singapore when:
- Two or more flares in a year, or
- Tophi (visible urate deposits in skin or joints), or
- Erosive joint damage on imaging, or
- Serum uric acid > 540 µmol/L on a confirmed reading, or
- Kidney stones related to urate.
1. Allopurinol
First-line ULT in Singapore. Inhibits xanthine oxidase, the enzyme that produces uric acid. Starting dose: 100 mg daily (50 mg in CKD), titrated up by 100 mg every 2–4 weeks until target uric acid is reached — most patients need 300–600 mg daily. The maximum licensed dose is 900 mg/day.
HLA-B*5801 testing: HSA states that routine HLA-B*5801 genotyping before allopurinol is not required as standard of care in Singapore. Doctors may consider testing in patients with pre-existing risk factors for allopurinol-induced severe cutaneous adverse reactions, such as renal impairment or older age, and should discuss the availability of testing before starting therapy. If HLA-B*5801 is positive or SCAR risk is high, allopurinol is generally avoided and an alternative is chosen.
Watch for: initial flare risk in the first 6 months (prevented by flare prophylaxis — see below), rash (stop and reassess if any rash develops, even mild), raised liver enzymes (uncommon).
2. Febuxostat
Another xanthine oxidase inhibitor, used when allopurinol is not tolerated or HLA-B*5801 positive. Dose: 40–80 mg once daily (max 120 mg).
Strengths: not associated with HLA-B*5801 SCAR risk in the same way, and does not need dose adjustment in mild-to-moderate CKD.
Watch for: cardiovascular safety signal in patients with known cardiovascular disease (CARES trial); current guidance is to use cautiously if there is a history of MI or stroke. More expensive than allopurinol.
3. Probenecid
Increases uric acid excretion in the kidneys. Used occasionally as an add-on or alternative; works less well in CKD (needs reasonable kidney function). Less common as first-line in Singapore.
4. Pegloticase
An IV uricase enzyme that dramatically lowers uric acid. Reserved for severe refractory gout, given as an infusion. Available through specialist channels.
Flare prophylaxis when starting ULT
Paradoxically, starting allopurinol or febuxostat can trigger flares in the first 3–6 months as urate crystals dissolve and shift. To prevent this, doctors prescribe low-dose anti-inflammatory cover alongside the ULT for at least 3–6 months:
- Colchicine 0.5 mg once or twice daily (first-line; reduce in CKD or with interacting drugs), or
- Low-dose NSAID (e.g., naproxen 250 mg twice daily) with a PPI, or
- Low-dose prednisolone 5–10 mg daily if both above are contraindicated.
Monitoring schedule
- Serum uric acid every 2–4 weeks while titrating ULT, then every 6 months once at target.
- Renal function at baseline, then 1–2 weeks after each dose change, then annually.
- Liver enzymes at baseline and after any new agent, then annually.
- Full blood count if on long-term colchicine.
- Blood pressure — hypertension and gout often coexist; some BP medications (thiazide diuretics) raise uric acid and worsen control.
Drug interactions to know
- Colchicine with clarithromycin, erythromycin, verapamil, diltiazem, ciclosporin, statins — raises colchicine levels; pause or reduce dose.
- Allopurinol with azathioprine or 6-mercaptopurine — combination can cause severe bone marrow toxicity; needs careful specialist supervision.
- NSAIDs with ACE inhibitors/ARBs and diuretics — "triple whammy" can precipitate acute kidney injury, especially in dehydration.
- Thiazide diuretics (HCTZ, indapamide) and loop diuretics — raise uric acid; consider switching to losartan (which lowers uric acid slightly) for BP control in gout patients.
Special populations
- CKD: start allopurinol at a lower dose and titrate slowly; check renal function frequently. Febuxostat can be used in selected patients with mild-to-moderate CKD, but cardiovascular history still matters.
- Heart disease: prefer allopurinol over febuxostat if there is a history of MI or stroke.
- Diabetes: SGLT2 inhibitors lower uric acid as a bonus; consider this when choosing diabetes medications in a patient who also has gout.
- Pregnancy: ULT is generally stopped during pregnancy; flares are managed with paracetamol, low-dose prednisolone or local cooling.
Self-management checklist
- Drink at least 2 litres of plain water daily.
- Cap alcohol — especially beer; one glass of wine is generally tolerated.
- Replace sugar-sweetened drinks with water, unsweetened tea, or low-fat dairy.
- Take ULT every day, even when you feel well — flares return within months of stopping.
- Always carry a short course of NSAIDs or colchicine for rescue use at the first sign of a flare.
- Log flares (date, joint, trigger) — patterns guide adjustments to ULT or diet.
MediSave and adherence in Singapore
Gout is covered under the MediSave Chronic Disease Management Programme (CDMP). Under the current MediSave500/700 scheme, patients may use up to S$500/year from MediSave for outpatient treatment of selected chronic conditions, or S$700/year if they meet the complex chronic disease criteria. Generic allopurinol is inexpensive — a month's supply at 300 mg/day typically costs S$5–10. Febuxostat is more costly but available as a generic in Singapore.
When to see a doctor
Speak to a doctor if:
- You have had two or more flares in a year — this is the threshold for ULT.
- A flare is severe, lasts more than a week, involves more than one joint at a time, or is accompanied by fever — this can mimic septic arthritis and needs urgent assessment.
- You are on allopurinol but still flaring frequently — your dose is probably too low.
- You develop a rash on allopurinol — stop immediately and seek same-day review.
- You have visible tophi, joint deformity or kidney stones related to urate.
- You are planning to start ULT and want to know whether HLA-B*5801 testing is relevant for your risk profile.
A short teleconsult is usually enough for routine gout review and ULT titration. $15 nett with an SMC-registered GP; same-day medication delivery for colchicine, NSAIDs and allopurinol.
Frequently asked questions
Why do I keep flaring even though I am on allopurinol?
The most common reason is the dose is too low — many patients are left on 100–200 mg/day, well below what most need to reach the uric acid target (300–600 mg/day is typical). Other causes: missed doses, ongoing high-purine diet, alcohol, dehydration, or starting a thiazide diuretic. A repeat uric acid level guides the next step.
Should I stop allopurinol when I have a flare?
No. Continue allopurinol at the same dose during a flare and treat the inflammation separately. Stopping ULT during a flare prolongs it and makes future flares more likely.
How long does urate-lowering therapy take to work?
Uric acid begins falling within 2 weeks and reaches a new steady state after 4–8 weeks. However, the risk of flares is highest in the first 3–6 months — this is why flare prophylaxis (low-dose colchicine or NSAID) is co-prescribed during that period.
Do I need a blood test before starting allopurinol?
Yes — baseline renal function, liver enzymes, and uric acid are standard. HSA says HLA-B*5801 genotyping is not routinely required for every new allopurinol patient in Singapore, but doctors may consider it when pre-existing SCAR risk factors such as renal impairment or older age are present.
Does MediSave cover gout medications in Singapore?
Yes — gout is one of the chronic conditions under the MediSave CDMP. Patients can use up to S$500/year, or S$700/year if they meet the complex chronic disease criteria, from their own or a family member's MediSave account towards consultations and approved medications.
Sources reviewed
- ACE: Gout - achieving the management goal
- Healthier SG Primary Care Pages: Gout Care Protocol
- HSA: Allopurinol-induced SCAR and HLA-B*5801 genotyping
- HSA: Safe use of allopurinol
- CPF: Using MediSave for outpatient treatments
The bottom line
Acute gout flares respond rapidly to NSAIDs, colchicine or short steroid courses. Long-term control depends on staying on urate-lowering therapy at a dose high enough to bring uric acid below target, with individualised SCAR risk assessment and HLA-B*5801 testing where indicated before starting allopurinol. Most patients can be well controlled on inexpensive generics.
If you would like a Singapore-licensed GP to review your uric acid, adjust ULT and arrange MediSave-claimable refills, you can book a $15 nett teleconsult and have your medication delivered the same day.
