Gout Referral Guideline

Warning

exp date isn't null, but text field is

Most patients with gout are managed in primary care. Where there is suspicion of septic arthritis urgent referral is indicated. Consider routine referral if there is diagnostic uncertainty or genuine treatment resistance (noting that compliance with therapy is notoriously poor).

History

  • Severe pain usually in a single joint
  • Acute onset (typically less than 24 hours, often overnight) with episodes lasting 1 to 2 weeks
  • Frequently involves 1st MTPJ, foot or ankle, but may involve any joint especially if coexistent osteoarthritis

Examination

  • Tender, hot, red, swollen joint(s)
  • Tophi appear as chalky white deposits and are markers of severe disease. Typically form in digits or over elbows.

Helpful Investigations

  • CRP – often elevated
  • FBC, U&E, LFTs
  • Urate –baseline often normal, 4-6 weeks post attack often elevated.
  • X-ray of symptomatic joints (characteristic erosions in established disease).
  • Good practice recommends screening patients for cardiovascular risk factors.
  • Synovial aspirate usually not performed in primary care.

Primary Care Management

Acute Gout

  • Exclude septic arthritis.
  • Continue allopurinol if on this already.
  • Treat as early as possible.
  • NSAIDs at maximum doses are the treatment of choice if no contra-indications.
  • Colchicine: 0.5mg bd - qds is an alternative to NSAIDs (Can be used safely if eGFR <30ml/min at reduced doses).
  • Corticosteroids (intra-articular or oral Prednisolone 20mg tapered over 1-2 weeks) are an alternative in those where NSAIDs & colchicine are not tolerated or are contraindicated.
  • Adjunctive non-pharmacological treatment (eg topical, ice, rest)
  • Review at 4-6 weeks:
    • Assess lifestyle factors (diet, exercise, alcohol, sugary drinks).
    • Assess cardiovascular risk factors (obesity, hypertension, lipids, diabetes).
    • Review prescribed medication (diuretics).
    • Perform SUA, renal function.

Allopurinol

Indications
  • Two or more attacks of uncomplicated gout within one year.
  • One attack of gout with gouty tophi; or renal insufficiency; or uric acid stones; or need to continue treatment with diuretics.
Dose Titration
  • Start 1-2 weeks after acute attack settled.
  • Increase dose every 4 weeks aiming for target uric acid <300micromol/l.
  • Start at a dose of 50-100mg titrating the dose by 50-100mg every 4 weeks to a target SUA of < 300 micromol/l and maximum dose of 900mg.
  • Lower doses are usually required to achieve target SUA in those with renal impairment.

Acute Gout Prophylaxis

  • Flares of gout may continue for 12 months after urate control, and are paradoxically more common with aggressive urate lowering.
  • To reduce flares prophylaxis should be offered with colchicine 500mcg b.d. for up to 6 months. Consider low dose NSAID in patients intolerant of colchicine.

Alternatives to Allopurinol

  • If allopurinol contraindicated or intolerance use Febuxostat 80 -120mg.

Who to Refer

  • Tophaceous gout, when progressive despite adequate treatment.
  • Refractory gout – after 3 attacks whilst on adequate treatment.
  • If relative contraindication to febuxostat and allopurinol contraindicated or ineffective.
  • Those where the diagnosis is unclear with persistent symptoms.

Who Not to Refer

  • Those who have a clear diagnosis of gout who are responding to treatment.
  • Tophaceous gout that is improving with treatment.
  • Check compliance with medication and patient understanding of treatment rationale in those who do not appear to be responding to treatment before referring.

For More Information

Hui M., Carr A., Cameron S., Davenport G., Doherty M., Forrester H., Jenkins W., Jordan K.M., Mallen C.D., McDonald T.M., Nuki G., Pywell A., Zhang W., Roddy E. (2017) British Society for Rheumatology Standards, Audit and Guidelines Working Group. The British Society for Rheumatology Guideline for the Management of Gout. Rheumatology, 56(7), pp. e1-e20. DOI: https://doi-org.knowledge.idm.oclc.org/10.1093/rheumatology/kez672.

Last reviewed: 01 November 2020

Next review: 01 November 2022

Author(s): Dr Anna Ciechomska

Co-Author(s): Rheumatology team: Dr Robin Munro, Dr Karen Donaldson, Dr Elizabeth Murphy, Dr James Dale, Dr Sanjiv Nandwani, Dr Georgiana Young, Dr May Chee, Mr Nico Groenendijk; GP representatives: Dr Tyra Smith, Dr Mark Russell, Dr Linda Findlay, Dr Paul Deehan, Dr Lucy Munro; Medical directorate: Dr Mehrdad Malekian

Approved By: Dr Karen Donaldson

Reviewer Name(s): Dr Anna Ciechomska