Gout

 

 

Gout is the most common form of inflammatory arthritis.

It is caused by accumulation of excess urate crystals (monosodium urate) in joint fluid, cartilage, bones, tendons, bursas and other sites.

Symptoms: joint swelling and pain during gout attacks, known as acute gouty arthritis.

In some patients, the frequency and duration of acute attacks increases over time and leads to chronic gout, which may be associated with deposits of uric acid crystals known as tophi.

Management of Acute Gout

Affected joints should be rested, elevated and kept cool, can use ice packs.

Start anti-inflammatory/analgesic therapy as early as possible and continue for 1-2 weeks.

1st line: Maximum dose of fast acting NSAID:

• Naproxen (750mg then 250mg every 8 hours) or
• Diclofenac 50mg tds (caution in patients at higher risk of CVD) or
• Indometacin 50mg tds-qds

Co-prescribe a PPI (Lansoprazole or Omeprazole) for gastric protection in patients at high risk of peptic ulcers and gastric bleeds

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

2nd line: Colchicine 500 micrograms (µg) twice to three times per day, until symptoms are relieved. Do not exceed three times daily due to intolerance. Course not to be repeated within three days.

3rd line: Corticosteroids

Oral -Prednisolone 20-40mg daily for 5 days

Intramuscular injection: (Off-license use: stat IM into gluteal muscle)

• Methylprednisolone 40-120mg or
• Triamcinolone acetonide 40-80mg

The dose will depend on the size of the joint and the severity of the condition

Intra-articular injection: (Off-license use: If single joint involvement only)

• Methylprednisolone 10-80mg (small and large joints) or
• Hydrocortisone acetate 12.5- 25mg (small joints) or
• Triamcinolone acetonide 20-40mg (large joints)

Other analgesics

Consider paracetamol, with or without codeine

Referral

Immediate: Refer to Secondary Care immediately if Septic Arthritis is suspected (note: it is possible for both gout and septic arthritis to co-exist).

Routine: Refer by routine referral if patient suffers complications relating to gout e.g. nephropathy, patient requires intra-articular therapy and primary care are not able to provide this, there is diagnostic uncertainty, the serum uric acid is unresponsive to uric acid lowering therapy, if gout persists despite uric acid levels.

Useful Links

CKS NICE Non-steroidal anti-inflammatory drugs prescribing issues

CKS NICE Acute Gout: Febuxostat Feb 2018

NICE clinical knowledge Summaries: Gout, Revised Feb 2018.

UK Gout Society. Patient Information Leaflets

British Society for Rheumatology guideline for the Management of Gout. June 2017.