GGC Medicines


Adult Therapeutics Handbook

Management of Gout

Management of Gout

This guideline outlines the acute management of gout with brief guidance on long-term management. For further details search for the 'Acute and Chronic Gout Management' guideline on NHSGGC StaffNet / Clinical Info / Clinical Guideline Directory (link only active if accessing via NHS computer). 

Introduction

Gout is a common condition, particularly in men. It is due to the deposition of uric acid in the joints and periarticular tissues. Typically acute symptoms develop over a few hours and last 3-10 days. After an acute attack, 62% of patients may experience a repeat attack within a year.

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 (treatment of asymptomatic hyperuricaemia is not recommended)
  • Obesity
  • Excess alcohol (especially beer and spirits)
  • 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:

  • Serum 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 usually involved at some stage.

General management

Lifestyle Modifications

Patients should be advised to:

  • Reduce alcohol consumption
  • Modify diet to achieve BMI in optimal range
  • Alter diet to avoid purine rich foods (e.g. red meat, seafood, fructose)
  • Address cardiovascular risk factors.

In an acute attack, advise the patient to rest, raise the limb and avoid knocking or damaging the affected joint. Ice packs also help. 

Treatment options for acute gout attack

If patient is already on medication for chronic gout then do not stop it. 

  • Non-steroidal anti-inflammatory drug (NSAID) oral – e.g. naproxen oral 500mg twice daily unless contraindications +/- proton pump inhibitor (PPI) for 1 to 2 weeks until the acute attack settles. See here under 'Treatment Options' for further information on choice as well as management of side effects 
  • Alternatively, colchicine oral 500micrograms twice daily for up to 6 days. N.B.: Licensed courses of colchicine for acute attacks do not exceed 6mg (12 tablets) in total, with 3 days between courses. Use of colchicine is limited by the development of toxicity at higher doses, but it is of value if NSAIDs are contraindicated, not tolerated or ineffective, and in patients with heart failure since, unlike NSAIDs, it does not induce fluid retention, moreover it can be given to patients receiving anticoagulants. Seek specialist advice as appropriate. 
  • Corticosteroids oral (e.g. prednisolone oral 7.5–15mg each day for 3–5 days) useful when NSAIDs and colchicine are contraindicated, not tolerated or ineffective. Alternative is intramuscular corticosteroids - discuss with Rheumatology.
  • +/- joint aspiration / intra-articular injection in mono-articular gout after infection excluded by negative synovial fluid culture (e.g. methylprednisolone or triamcinolone) - discuss with Rheumatology.

Long-term management of gout

Further attacks of gout can be prevented by making lifestyle and risk factor changes to reduce uric acid levels, as well as medication. Urate lowering therapy should be discussed and offered to all patients who have a diagnosis of gout, particularly in patients with the following:

  • Recurring attacks (≥2 attacks in 12 months)
  • Tophi
  • Chronic gouty arthritis
  • Joint damage
  • Renal impairment (eGFR <60ml/minute)
  • A history of urolithiasis 
  • Diuretic therapy use
  • Primary gout starting at a young age (under 40 years)
  • Very high serum urate (>500micromol/L).

Drug treatment - prophylaxis

Do not commence urate lowering therapy until 1-2 weeks after the acute attack has settled, and continue it indefinitely. If attacks are so frequent to make this difficult then therapy may need to be started during acute inflammation, along with treatment for acute gout.

Allopurinol (first-line) - 

  • Initial oral dose 100mg daily (preferably after food), for maintenance dose adjust according to serum urate level. Maintenance oral dose 100-900mg daily (usual oral dose is 300mg /day in divided doses).
  • In all grades of renal impairment, usually commence with 100mg/day and increase if serum urate response is unsatisfactory. Doses less than 100mg/day may be required in some patients. In severe renal impairment, eGFR <30ml/minute, discuss with Rheumatology if >100mg/day maintenance dose is needed
  • Check serum urate levels every 4 weeks and increase allopurinol by 100mg daily until serum urate is ≤300micromol/L.

The initiation of urate lowering therapy may precipitate an acute attack of gout and therefore an NSAID or colchicine should be used as a prophylactic during initial urate lowering therapy - see full guideline ('Acute and Chronic Gout Management' on NHSGGC StaffNet / Clinical Info / Clinical Guideline Directory (link only active if accessing via NHS computer) for further details. 

Febuxostat - 

  • Febuxostat oral 80mg daily, increased after 4 weeks to 120mg daily if necessary to achieve target serum urate level.
  • Restricted to patients intolerant of allopurinol (side effects of high dose can include severe rash), when allopurinol is contraindicated or in symptomatic patients whose uric acid levels have failed to respond adequately despite optimal dosing of allopurinol. It is not recommended for patients with ischaemic heart disease or congestive cardiac failure. For further details search for the 'Acute and Chronic Gout Management' on NHSGGC StaffNet / Clinical Info / Clinical Guideline Directory (link only active if accessing via NHS computer). 

 

Content updated August 2019.