Referral Criteria

1)            Tophaceous gout, when progressive despite adequate treatment

2)            Refractory gout – after 3 attacks whilst on adequate treatment

3)            If relative contraindication to febuxostat and allopurinol contraindicated or ineffective


 Primary Care Management

Acute attackprompt treatment works best


·         Intra articular steroid injection if feasible – this is the most effective treatment if a single large joint is affected

·         Naproxen 500mg bd lasting 2 days after symptoms settle + PPI

·         If NSAID contraindicated then colchicine 1mg once, then 0.5mg once an hour later, then stop – this is as good as the 6mg regimen (1)

·         Prednisolone 30 - 50mg daily, dependant on bodyweight, until resolution, then taper over 7-10 days



UrateIs not diagnostic and may be falsely normal in an acute attack. The main use of urate is in titrating prophylactic treatments e.g. allopurinol



Recurrent gout


Lifestyle modifications – see patient information leaflet here


Consider precipitating drugs e.g. diuretics / aspirin / salicylates


Consider allopurinol if;

1)    2 or more attacks per year

2)    renal impairment (lowering urate is renoprotective)

3)    urate stones

4)    tophi

5)    erosions on xray

6)    need to continue diuretic therapy


Allopurinol Dosing


·         Start at 300mg if normal renal function; titrate up by 100mg per month until serum urate <0.36 (or urate <0.3 in tophaceous gout)

·         Don’t start until disease in remission

·         Give naproxen + PPI or colchicine (0.5 - 1mg per day) for a week before and the first 3-6 months of allopurinol to prevent a flare – a frequent cause of relapse is inadequate NSAID / colchicine protection 

·         Prophylactic treatment as above can be given for up to 12 months if breakthrough symptoms

Explain allopurinol treatment is lifelong and may initially precipitate flares – continue the treatment through the flare


Febuxostat(see BNF for cautions / contraindications)


If allopurinol intolerant or treatment not successful then consider febuxostat 80mg od and increase to 120mg after 1 month if urate not <0.36 mmol/l ( <0.3 in tophaceous gout).

Note CI cvs disease; in this instance, refer to rheumatology for off license prescription


Red Flags – septic arthritis


·         gout usually presents in  MTP joint – if first episode not in MTP joint then joint needs aspirating

·         systemic features of sepsis

·         septic joints get worse rather than better

·         prostheses in-situ

·         gout is very rare in premenopausal women or men under 30yrs 

·         Please refer suspected septic joints to the on-call orthopedic team for joint aspiration



(1)   Terkeltaub RA, Furst DE, Bennett K, Kook KA, Crockett RS, Davis MW. High versus low dosing of oral colchicine for early acute gout flare: Twenty-four–hour outcome of the first multicenter, randomized, double-blind, placebo-controlled, parallel-group, dose-comparison colchicine study. Arthritis & Rheumatism. 2010 Apr 1;62(4):1060-8.