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Gout

 

Red Flags

  • ? Septic arthritis-  Refer to on call orthopaedic team. (NB It is possible for gout and septic arthritis to coexist).
  • Gout usually presents in the first metatarsophalangeal joint (MTPJ) – if first episode not in MTPJ review diagnosis and consider referral for septic arthritis. Nb. Septic joints get worse not better.
  • Systemic evidence of sepsis.
  • Prosthesis in-situ.
  • Gout rare in premenopausal women and men under 30 years of age.

 

Who to Refer To Secondary Care:

  1. Tophaceous gout, progressive despite treatment.
  2. Refractory gout, after 3 attacks whilst on adequate treatment.
  3. Patient suffers complications relating to gout eg. arthropathy, neuropathy.
  4. Gout persists despite serum uric acid (SUA) <300 micromol/L.
  5. The SUA is unresponsive to treatment.
  6. Patient requires intra-articular therapy and primary care are not able to provide.
  7. Relative contraindication to Allopurinol or Febuxostat.
  8. There is diagnostic uncertainty.

 

Investigation prior to referral:

FBC, U&E, eGFR, LFTs, bone profile, SUA ( note can be normal in acute attack), CRP.

(Investigations for inherited metabolic disorders should be reserved for those with a relevant family history.)

 

Management of Acute Gout

1st Line:-

Start NSAID as early as possible and continue for 1-2 weeks .

Naproxen (750mg then 250mg every 8 hours).

Etoricoxib (120mg OD).

Diclofenac (50mg TDS).

Co-Prescribe a PPI in patients at risk.

If NSAIDs are effective, continue for 48 hours after attack has resolved.

 

2nd Line:-

Colchicine 500 micrograms twice to four times per day, until symptoms resolve.  Do not exceed a total dose of 6mg per course.

Course not to be repeated within 3 days.

 

3rd Line:-

Corticosteroids.

Oral – Prednisolone 20mg daily for 5 days.

Intramuscular injection (off license use) – Methyl Prednisolone 120mg or Triamcinolone 80mg.

Intra-articular injection (single joint) – Methyl Prednisolone 10-80mg (small and large joints), Triamcinolone 20-40mg (medium and large joints).



Other primary care management:

Check Serum uric acid 4-6wks after acute attack

Check BP, blood glucose, renal function, blood lipids.

Assess lifestyle factors (diet, exercise, alcohol).

Assess and treat cardiovascular risk factors.

Consider drug induced gout:- diuretics, betablockers, ACE inhibitors, ARBs.

                                                Nb.High dose Aspirin can interfere with UA excretion.

 

 

Who needs prophylaxis/ uric acid lowering therapy?

  1. 2 or more attacks per year
  2. Presence of tophi.
  3. Presence of gouty erosive disease.
  4. Evidence of gout nephropathy.
  5. Urate stones
  6. eGFR <60ml/min
  7. Need to continue diuretic therapy.
  8. Young age at onset.

 

1st Line:-

Allopurinol

Start 1-2 weeks after acute attack, as may experience further attacks.

Start 100mg OD and increase by 100mg every 4 weeks to 300mg OD.

(Target SUA 300 micromol/L).

Consider lower starting dose in elderly patients or those with renal or hepatic impairment.

Usual maintenance dose 300mg OD.

Moderately severe 300mg-600mg daily and severe up to 900mg daily.  (Doses over 300mg daily should be in divided doses).

 

2nd Line:-

Febuxostat

Start at 80mg OD to achieve SUA <300 micromol/L.

Increase to 120mg OD after 4 weeks if target SUA not reached.

Max 80mg OD in mild liver impairment (check LFT’s before starting treatment).

Avoid in patients with ischaemic heart disease, heart failure, stroke.

 

For either of allopurinol or febuxostat initiation-

Co-prescribe prophylactic Colchicine (500mcg BD for 6 months) or an NSAID (Naproxen 250mg OD for 6 months) to prevent an acute attack. 

If Colchicine and NSAIDs are contraindicated consider low dose Prednisolone (5mg-7.5mg OD for 6 months).

 

Gout attacks during ULT

Manage flares as appropriate with acute gout medications listed above.

Do not interrupt ULT treatment during an acute attack.

Review any trigger factors (medications, trauma, diet, alcohol).

Assess compliance with prophylactic medication.

Reassure patient that continued ULT will reduce the frequency and intensity of further attacks.

 

Clinical remission and target SUA (<300 micromol/L) achieved(tophi resolved, attacks ceased).

Consider reducing dose of ULT to maintain SUA <300 micromol/L.

Check SUA annually.
Consider lifelong ULT in patients who have recurrent attacks of gout when trying to stop ULT and patients with renal impairment, gouti tophi, uric acid stones, taking long term diuretics.

Consider stopping ULT in patients who have had a normal SUA for years with no acute attacks of gout.

 

 

Patient information:

https://www.versusarthritis.org/media/1253/gout-information-booklet.pdf

 

References:

https://cks.nice.org.uk/topics/gout/

British Society of Rheumatology Guidelines Management of Gout, 2017, https://academic.oup.com/rheumatology/article/56/7/e1/3855179

 

Contributors:

Dr Tim Jenkinson (Consultant Rheumatologist, RCHT)

Dr Bridgitte Wesson, GP & Kernow RMS Rheumatology Guideline Lead

 

 

Date Reviewed                          05/05/2021

Next Review Date                      05/05/2022

Author                                       Dr B Wesson (RMS GP Lead for Rheumatology)