Management of Gout
Gout is a common condition encountered in both hospital inpatients and primary care particularly in men. It is due to the deposition of uric acid in the joints and periarticular tissues.
First attacks of gout commonly present as monoarthritis, but polyarticular presentations and chronic tophaceous gout may also be encountered.
Risk factors for gout include: hyperuricaemia (note: most people with hyperuricaemia never suffer an attack of gout), obesity, excess alcohol (especially beer), renal impairment, metabolic syndrome (hypertension, hyperlipidaemia, diabetes mellitus (type 2)).
More information can be found on the British Society for Rheumatology website.
Assessment / Monitoring
The differential diagnosis can be septic arthritis or pseudo-gout (pyrophosphate arthritis). Check:
- Urate level. This can sometimes fall during an acute attack, so if the level is normal, then repeat once the acute attack has resolved.
- U&Es / LFTs, consider glucose / lipids
- Joint aspiration (large joints) for gram stain, culture and microscopy for urate crystals. This is not needed if diagnosis has previously been established and there is no suspicion of septic arthritis.
- X-ray feet. The first metatarsophalangeal joint is involved at some stage in 90% of cases.
Patients should be advised to:
- Reduce alcohol consumption
- Modify diet to achieve ideal body weight
- Address cardiovascular risk factors
Management of acute attack
Stop diuretics (if possible) and consider:
- Non-Steroidal Anti-Inflammatory Drug (NSAID) – see here under 'Treatment Options' for information on choice and management of side effects or etoricoxib (COX-2 selective NSAID) oral 90-120mg daily for short term use
- Colchicine oral 500micrograms 2–3 times daily (stop if diarrhoea develops). Courses exceeding 6mg in total are unlicensed but may be appropriate. Seek specialist advice.
- Prednisolone oral 7.5–15mg each day for 3–5 days only and discuss with rheumatology.
- Intra-articular steroid – useful for monoarthritis after infection excluded by negative synovial fluid culture (discuss with rheumatology).
Allopurinol should be initiated only once an acute attack has settled but if acute attack occurs in a patient already receiving allopurinol, do not stop allopurinol.
Long-term management of gout
Long-term uric acid lowering therapy will be required for patients with:
- >2 attacks in 1 year or
- Gouty tophi or
- Urate renal calculi or
- Radiological damage (erosions) secondary to gout or
- Serum urate >0.6mmol/L
Allopurinol should be initiated only once an acute attack has settled.
- Start on allopurinol oral 100mg each day
- Increase allopurinol by 100 mg every month until serum uric acid is ≤0.35mmol/L. Usual maintenance dose is allopurinol oral 300 mg each day (maximum dose 900 mg / day)
- To prevent flares of gout, during the initiation of allopurinol co-prescribe either:
- Colchicine oral 500micrograms twice daily (for up to 6 months – note this exceeds the licensed maximum dose of 6mg per course) or
- NSAIDs for up to 2 months. See here under 'Treatment Options' for information on choice and management of side effects .
In patients whose uric acid levels have failed to respond adequately, despite optimal dosing of allopurinol or those who are intolerant, an alternative is febuxostat oral 80mg daily (increased to 120mg daily after 4 weeks if the serum urate still >0.3mmol/L). As with allopurinol, prophylaxis for flares of gout should continue for the first 6 months of treatment (see above). Febuxostat is not recommended for patients with ischaemic heart disease or heart failure.