1. Look for sudden severe pain, swelling, warmth and erythema.
Gout can be confidently diagnosed on clinical grounds when there are classical features present, such as rapid-onset, severe symptoms, tophi or podagra. Desquamation is a common, though non-specific, sign. The first metatarsophalangeal joint is most commonly affected. Other commonly affected joints include the tarsus, ankle, knee and wrist.
Repeated and uncontrolled attacks may lead to chronic tophaceous gout, which often involves the small joints of the hands – particularly those affected by nodal osteoarthritis.
2. Assume an acute hot joint is infected until proven otherwise.
Pseudogout, septic arthritis and palindromic rheumatismare the key differential diagnoses. Always consider arthrocentesis to confirm the diagnosis and exclude infection – which requires urgent referral. Synovial fluid should be examined for crystals and culture should always be performed to exclude infection.
3. Measure serum urate between acute attacks.
The serum uric acid may be normal during an acute attack of gout, so a normal serum urate does not exclude gout. It is better to measure serum urate between acute attacks – hyperuricaemia is likely to be found. Hyperuricaemia is the main risk factor for developing gout, but the diagnosis of gout can only be made with certainty by confirming the presence of monosodium urate crystals in synovial fluid. If the diagnosis is uncertain and you are not confident in doing arthrocentesis, refer the patient to secondary care for joint aspiration to allow polarised microscopy for MSU crystals.
4. Commence short-acting NSAIDs as soon as possible.
Use NSAIDs as a first-line treatment for acute gout, unless there are definite contraindications – for example, allergy to NSAIDs, warfarin therapy, renal impairment, active peptic ulcer disease or asthma that is known to be sensitive to NSAIDs. Trydiclofenac 50mg tds, indomethacin 50mg tds, naproxen 500mg bd or ibuprofen 800mg tds. Continue NSAIDs for five to seven days. Consider co-prescription of a PPI in patients at increased risk of peptic ulceration and gastrointestinal bleeding.
5. Only use colchicine in low doses.
Colchicine is an effective alternative to NSAIDs in acute gout, but should only be used in low dosesto improve tolerability – for example 0.5mg bd to qds for three days.
Oral prednisolone 25-35mg once daily for five to seven days is a suitable third-line treatment, as is an intramuscular dose of methylprednisolone 120mg or intra-articular steroids. However, septic arthritis needs to have been excluded before prescribing these. Both colchicine and steroids can be used in patients on warfarin, but IM and joint injections are probably best avoided if the INR is greater than 2.5.
6. Start urate-lowering therapy in patients with two or more acute attacks of gout per year.
Other indications for urate-lowering therapyinclude chronic tophaceous gout, recurrent urate stones, erosive change in radiographs, renal impairment and a continued need for diuretics – for example, in congestive cardiac failure. Delay starting urate-lowering therapyuntil two weeks after an acute attack has settled.
Initial long-term urate-lowering therapyshould be with allopurinol 100mg once daily. Increase the dose in 100mg increments every two to three weeks according to tolerability and serum urate. The typical maintenance dose of allopurinol is 300mg daily, the maximum daily dose being 900mg.
Febuxostat 80-120mg once daily is an alternative to allopurinol and has been approved by NICE for use in patients with hyperuricaemia and gout who are unable to tolerate or who are resistant to treatment with allopurinol. Uricosuric drugs such as probenecid, sulphinpyrazone and benzobromarone are alternative second-line drugs.
7. Urate-lowering therapy can be used safely in patients with renal impairment.
Allopurinol can be used safely in patients with renal impairment, but the dose should rarely exceed 300mg daily and renal function should be closely monitored. The dose may have to be reduced considerably in patients with more advanced renal failure – for example, to 100mg on alternate days.
Febuxostat and benzbormarone may also be used in renal impairment, down to a GFR of 30ml/min and 20ml/min respectively.
8. Aim for a serum urate level under 0.36mmol/l in patients on urate-lowering therapy.
Measure serum urate every two to three weeks until the target level is consistently achieved.
In patients with more severe disease such as those with chronic tophaceous gout or polyarticular flares, a target serum urate of less than 0.30mmol/l is more appropriate.
9. Advise patients on weight loss and alcohol consumption.
Patients with gout should be actively encouranged to achieve an ideal BMI, modify their diet and reduce their intake of alcohol.
Avoid crash diets and diets which are high in protein. Restrict intake of foods high in purines such as offal, shellfish, nuts and yeast extract, and avoid carbonated soft drinks containing fructose. Including skimmed milk, low-fat yogurt, vitamin C supplements, soybeans and cherries in the diet may help.
Go to pulsetoday.co.uk/tools-and-resources to download a factsheet on diet and treatment in gout produced by the UK Gout Society.
Restrict alcohol consumption to fewer than 21 units per week in men and fewer than 14 units per week in women. The risk of gout is highest with beer – particularly bitter and stout – port and fortified wines, and is lowest with spirits.
10. Screen patients for metabolic syndrome.
Patients presenting with gout should be screened for metabolic syndrome. This includes blood pressure measurement (off NSAIDs), weight or BMI, fasting lipid profile and fasting glucose or HbA1c.
If diuretics are being used for hypertension, alternatives should be considered. Losartan has a mild uricosuric effect and can counteract the effect of thiazides on serum urate.
In patients found to have hypertriglyceridaemia, consider using fenofibrate. This too has a mild uricosuric effect. However, statins are still likely to be more appropriate in patients with both gout and hyperlipidaemia, and fenofibrate should only be used in patients already receiving a statin on specialist advice.
Dr Alastair Hepburn is a consultant rheumatologist at Western Sussex Hospitals NHS Trust and is a trustee of the UK Gout Society
Competing interests: None declared
The UK Gout Society (ukgoutsociety.org) is a registered charity that aims to promote greater public awareness of this common metabolic arthropathy. It provides information for patients on the causes, treatment and prevention of gout. Patient information leaflets on the treatment of gout, dietary modification and the links between gout and the metabolic syndrome are available to download via its website.
