• Acute hot swollen single joint must be treated as a septic arthritis with urgent diagnostic aspiration.

• NSAIDs in younger patients provided there is no renal impairment and other contraindications

• Colchicine can be initiated provided no renal impairment. Steroids can be added alongside.

• Pre-existing Urate Lowering Therapy should be continued during an acute flare

• Rheumatology Opinion if not responding to treatment and if there is any contraindication to acute treatment.

This is a controlled document. If you are using a printed copy, check it against the guidelines site to ensure you are using the latest edition. Print copies must be destroyed after use.

Abbreviations

Inflammatory arthritis due to deposition of monosodium urate monohydrate crystals.

1. Current symptoms

a. Joints affected -typically the first metatarsophalangeal joint. Other commonly affected joints: midfoot, ankle, knee, fingers, wrist and elbow joints although any joint can be affected. Gout is usually monoarticular but can be oligoarticular or rarely polyarticular.

b. Symptom severity and speed of onset — rapid onset of severe pain with associated swelling, redness, warmth and tenderness usually reaches maximum intensity within 24 hours.

c. A history of previous self-limiting (7-14 days) attacks, frequency and duration of past attacks.

d. Low grade fever and malaise during flares.

e. Precipitating factors - surgery, dehydration, intercurrent illness.

f. History of tophi - indicate chronicity.

2. Co-morbidities

a. Associated with Metabolic Syndrome.

b. CKD, Hemolytic Anemia, Psoriasis, Solid Organ Transplant, Myeloproliferative disorders.

3. Family History:

a. Gout, hyperuricaemia, nephrolithiasis or renal disease.

4. Drug History

a. Anti-tubercular Drugs

b. Aspirin

c. Cytotoxic Chemotherapy

d. Diuretics

e. Hormonal treatment

f. Immunosuppressants Agents

5. Lifestyle: Diet and Alcohol

6. Impact: ADL and work, Psychology

1.Look for:

a. Warm, red and swollen joints, tenderness - examine all joints as any joint can be affected.

b. Tophi (firm, white nodules under translucent skin).

• Tophi usually occurs over extensor joint aspects such as the elbow or knee, or Achilles tendon.

• can occur in other areas such as the helix of the ears or dorsum of hands or feet.

• They are usually pain-free but can become inflamed, infected or ulcerated, or discharge white material.

• Tophaceous disease can be the initial presentation without any flares.

c. Range of Movement: limited range of movement. 

• Septic arthritis

• Calcium pyrophosphate crystal deposition - pseudogout

• Inflammatory arthritis

1. FBC, CRP, U&E, LFTs, Serum Urate

Serum urate may not necessarily be elevated in acute gout

2. Joint Aspiration

Especially if it is an acute inflammatory monoarticular arthritis (IF PROSTHETIC JOINT - PLEASE REFER TO ORTHOPAEDIC FOR ASPIRATION)

Send for microscopy, C+S urgently

3. X- ray joint

1. Treating the acute attack

a. A nonsteroidal anti-inflammatory drug (NSAID) provided there are no contraindication.

- Continue the treatment until 1-2 days after the attack has resolved and up to 1-2 weeks if required.

Naproxen:

Initially 750mg for one dose then 250mg TDS.

b. Selective COX-2 inhibitors

• Etoricoxib:

120mg OD for maximum of 8 days

Consider the need to prescribe a proton pump inhibitor (PPI) for gastric protection.

Paracetamol can be added as adjunct if pain relief is inadequate

c. Colchicine

500 mcg 2-4 times per day until symptom relieved, total dose per course should not exceed 6mg, do not repeat course within 3 days provided there are no contraindications. Gastrointestinal side effects are frequent at this dose, typically diarrhoea. The dose of colchicine should be reduced in patient with renal impairment.

d. A short course of oral corticosteroid

Prednisolone 30mg once a day for 3-5 days.

e. Consider combining treatments if the response to monotherapy is inadequate.

f. Consider adjunctive non-pharmacological

RICE: Rest, Ice Compression, Elevations

g. Continue urate lowering therapy (ULT) during acute flares and DO NOT DISCONTINUE

2. Preventing Recurrent Attacks of Gout

Medication

a. Offer ULT using a treat-to-target strategy to people with gout who have:

• Multiple or troublesome flares.

• Chronic kidney disease (CKD) stages 3 to 5

• Diuretic therapy.

• Tophi.

• Chronic gouty arthritis.

If flares are more frequent, ULT can be started during a flare.

Aim for a target serum urate level below 300 micromol/L

i. Allopurinol: 50-100mg daily

ii. Febuxostat: 80mg daily, if allopurinol is not tolerated or renal function prevents further dose escalation.

1. Balanced, healthy diet: avoid purine and fructose rich food.

2. Weight loss: Aim for Ideal body weight (excess body weight can precipitate gout flares).

3. Alcohol Restriction; restricting alcohol consumption to 14 units per week with at least two alcohol-free days a week.

Avoid Alcohol Binge.

4. Adequate hydration unless there is a medical contraindication.

5. Steer patients to gain more insight: www.ukgoutsociety.org

1. The diagnosis of gout is uncertain.

2. The response to treatment has not been adequate or the treatment is not tolerated.

3. Treatment is contraindicated.

4. They have chronic kidney disease (CKD) stages 3b to 5 (GFR categories G3b to G5).

5. They have had an organ transplant.

1. Hui, M. et al. (2017) 'The British Society for Rheumatology Guideline for the Management of Gout', Rheumatology, 56(7), pp. e1-e20. Available at: https://doi.org/10.1093/rheumatology/kex156

2. National Institute for Health and Care Excellence [NICE] (2022) Gout: diagnosis and management. NG19. Available at: https://www.nice.org.uk/guidance/ng219 (Accessed: 23 August 2024).

3. Richette, P. et al. (2017) '2016 updated EULAR evidence-based recommendations for the management of gout', Annals of the Rheumatic Diseases, 76(1), pp. 29-42. Available at: https://doi.org/10.1136/annrheumdis-2016-209707

4. British National Formulary [BNF NICE] (2024) Key information on the selection, prescribing, dispensing and administration of medicines. Available at: BNF | NICE. (Accessed: 08 November 2024).

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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