Investigation

• Serum uric acid to confirm hyperuricaemia (usually measured 4–6W after acute attack). Monosodium urate crystals occur when urate levels are persistently >380 micromol/L. Hyperuricaemia may be present without gout. The presence of hyperuricaemia does not equate with a diagnosis of gout, as most people with hyperuricaemia do not develop gout. Gout may be present without hyperuricaemia and a normal level of urate does not exclude the diagnosis. Normal levels are often found during an acute flare of gout, when plasma urate levels may fall to normal.

Management

• Acute attacks: NSAID + PPI cover or low-dose colchicine

• NSAIDs until 1-2 days after the attack has resolved, PPI for gastric protection, colchicine, (aspirin not indicated), joint aspiration if acute monoarticular gout and co-morbidity provided the diagnosis is certain, the person (and joint) are suitable for injecting

• Short course of oral corticosteroids or a single IM corticosteroid injection can be considered in people who cannot tolerate NSAIDs or colchicine

• Paracetamol as an adjunct for pain relief but not for primary treatment.

• Do not stop allopurinol or febuxostat during an acute attack if treatment established

• Urate-lowering therapy (ULT): ≥ 2 attacks of acute gout in 12M, tophi, chronic gouty arthritis, joint damage, renal impairment (eGFR <60), history of urinary stones, diuretic use, young age of onset of primary gout.

• Start urate-lowering therapy after the acute attack has resolved (unless attacks are so frequent that this is not possible)

• Allopurinol is the recommended first-line urate-lowering agent.

  • Start at a low dose and titrate upwards (where tolerated) every four weeks until the serum uric acid (SUA) level is below 300 micromol/L.

  • For people with renal impairment starting dose and titration guidance may differ. See Managing renal impairment.

• Consider febuxostat as an alternative second-line therapy if allopurinol is not tolerated or is contraindicated (for example if renal impairment prevents adequate allopurinol dose increases).

  • Check liver function tests prior to initiation.

  • Start at a low dose and increase after 4 weeks if SUA level is above 300 micromol/L.

  • Note: a prior history of hypersensitivity to allopurinol and/or renal disease may indicate potential hypersensitivity to febuxostat.

• Consider prescribing colchicine when initiating or increasing the dose of a ULT as prophylaxis against acute attacks secondary to ULT, and continue for up to 6 months.

  • If colchicine cannot be tolerated, consider a low-dose NSAID or coxib with gastroprotection as an alternative provided there are no contraindications.

  • Carefully consider the risk to benefit balance when considering long-term gout flare prophylaxis, particularly in people with comorbidities or taking medication with potential for interaction.

  • The risk of gout flare is particularly high when initiating febuxostat.

• Advise the person that:

  • Urate-lowering medication is normally lifelong and regular monitoring is needed.

  • Allopurinol or febuxostat may increase the risk of acute attacks of gout just after initiating treatment, and for some weeks afterwards. Explain that they should start their anti-inflammatory treatment as soon as possible and not to stop their allopurinol or febuxostat during acute attacks.

• Primary prevention of gout, tophi, cardiovascular disease or renal disease with ULT in people with asymptomatic hyperuricaemia is not recommended although lifestyle advice can be considered.

Can urate-lowering treatment be reduced or stopped in chronic gout?

• Once allopurinol or febuxostat is started, treatment is usually lifelong.

• After some years of treatment, once serum uric acid target is reached and clinical 'cure' has been achieved (acute attacks have stopped and tophi have resolved), consider reducing the dose of ULT to maintain the serum uric acid level between 300-360 micromol/L.

• Although in most people ULT will be required lifelong, consider stopping allopurinol or febuxostat only in people who have achieved a clinical 'cure', successfully addressed modifiable risk factors and had a normal serum uric acid level for many years.

• If considering discontinuing urate-lowering medication, explain that there is no certainty that a further episode of gout will not recur.

  • Continue to regularly monitor serum uric acid levels.

  • Consider providing an advance prescription of effective treatment for future attacks of gout but advise them not to start allopurinol or febuxostat immediately if an acute attack develops, and to seek medical advice.

  • Stress the importance of a healthy lifestyle and avoidance of trigger factors.

  • Provide early and close follow up as needed.

• Advise people with gout to:

Lifestyle advice

• • Aim for an ideal body weight if overweight, using dietary modification to achieve a gradual weight reduction — but avoid 'crash' dieting.

  • Eat sensibly — encourage a well-balanced diet which is low in fat and added sugar, and high in fibre and vegetables. Avoid excessive consumption of sugar-sweetened soft drinks and foods rich in purines (such as meats and seafood). Encourage a diet inclusive of skimmed milk, low-fat yoghurt, soybeans and cherries.

  • Drink alcohol sensibly — avoid excessive alcohol intake and binge drinking, especially beers and spirits. See the sections on Safer drinking limits and Unit of alcohol in the CKS topic on Alcohol - problem drinking for more information.

  • People with renal stones should be advised to avoid dehydration and encouraged to drink more than 2 litres of water a day.

  • Take regular exercise — but avoid intense muscular exercise and trauma to joints.

  • Stop smoking — see the CKS topic on Smoking cessation.

  • Consider taking vitamin C supplements.

• Provide written information and patient support such as resources via the UK Gout Society. For more information, see www.ukgoutsociety.org.

• f taking urate-lowering therapy (ULT) (allopurinol or febuxostat), check the serum uric acid (SUA) level and renal function every 4 weeks until SUA is in target range, then annually thereafter, and aim for a SUA level below 300 micromol/L.

  • Titrate the dose of ULT if appropriate and SUA target is not reached - see Drug treatment for preventing gout section.

  • If taking febuxostat, monitor liver function tests periodically, where clinically indicated.

  • If the person is still having frequent attacks of gout despite ULT:

    • Assess compliance with prophylactic medication or increase the dose if appropriate.

    • Review any trigger factors such as medication (for example diuretics), trauma, diet, weight gain, and excess alcohol consumption.

    • Consider providing an advance prescription of effective treatment for future attacks of gout.

    • Consider referral to secondary care.

  • After some years of treatment, once serum uric acid target is reached and clinical 'cure' has been achieved (acute attacks have stopped and tophi have resolved), consider reducing the dose of ULT to maintain the serum uric acid level between 300-360 micromol/L.

• Review cardiovascular risk factors and screen for renal disease at least annually, and provide ongoing lifestyle advice. For more information, see the CKS topic on CVD risk assessment and management.

  • In a person with hypertension taking a diuretic, consider changing to an alternative antihypertensive, provided that blood pressure is controlled. For more information, see the CKS topic on Hypertension - not diabetic.

  • In a person with heart failure, continue diuretics during an acute attack. If using a nonsteroidal anti-inflammatory drug (NSAID) for pain relief, monitor renal function closely.

• 
  

• Gout (NHS Choices), Gout (CKS), UK Gout Society (goutsociety.org)