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​Guideline of the month: intervening earlier to manage gout

July’s key guideline

The guideline

The British Society for Rheumatology has updated its guideline to include new advice on acute attacks, lifestyle modification and optimal use of urate-lowering therapy.

Key points for GPs

  • Urate-lowering therapy should be offered to all patients who have a diagnosis of gout. Starting therapy is best delayed until inflammation has settled.
  • Allopurinol is the recommended first-line urate-lowering drug.
  • The target serum uric acid level has now been reduced to 300µmol/l.
  • Educate patients to treat acute attacks as soon as the attack occurs. Urate-lowering therapy should be continued throughout an attack.
  • An NSAID at maximum dose, or colchicine at doses of 500μg, are the drugs of choice for managing acute attacks where there are no contraindications.
  • Corticosteroid injections are effective for monoarticular gout and should be considered in those with comorbidities.
  • In patients with acute gout where response to monotherapy is insufficient, combinations of treatment can be used.

Practical issues

The guideline calls for a change from what is currently common practice: GPs will need to discuss urate-lowering therapy with patients on first presentation, checking urate after the first attack. The document also advises that GPs offer ‘written and verbal’ information on lifestyle and prevention.

Expert comment

Dr Louise Warburton, a GPSI in musculoskeletal medicine in Telford, says: ‘The updated guideline encourages GPs to take gout more seriously. Traditionally, we have tended to reserve discussions about urate-lowering therapy to the second or third attack. Now we’re advised to explain the risks of gout and forewarn patients of the need for therapy.

‘Allopurinol is still the drug of choice but should be started at a low dose of 50-100mg daily and then increased every four weeks until target urate levels are reached. This is probably much faster than we would normally consider.’

The guideline

Hui M et al. The British Society for Rheumatology Guideline for the Management of Gout. London; BSR: 2017.

 

 This article was corrected and updated on 10 July 2017. It originally implied that urate-lowering therapy would need to be started before a first attack of gout.

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Readers' comments (3)

  • Cobblers

    How on earth are you going to discuss urate lowering therapy on first presentation? Do you have a crystal ball? Presumably you will want the uric acid level which, we are told, needs to be taken 4-6 weeks after an acute attack has resolved. Then maybe talk about urate lowering options.

    So then at second or maybe third consultation after presentation.

    Damned Ivory Tower merchants.

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  • As a member of the guideline development group, I would like to correct an inaccuracy in the Practical Issues section above and respond to the comment from Cobblers. The text above states that urate-lowering therapy (ULT) should be discussed "with patients on first presentation, rather than after an attack", implying that ULT should be started during the attack. However, the guideline does not recommend starting ULT during the attack but rather, as Cobblers states, checking the urate level once the first attack has resolved. The key recommendation is that the opportunity is taken to discuss ULT with the patient early in the course of disease rather than waiting for them to develop recurrent attacks.

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  • Are we really going to put someone on allopurinol for life after one episode, that may never recur, with all the expense, possible side effects and polypharmacy involved? Seems overkill to me and hardly a holistic approach. What is the supposed downside to delaying? Possible 1st MTPJ OA? Is that something that come up often on GP lists? If there were a risk of other pathology then we would likely be discussing allopurinol anyway.

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