Gout

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Patient Information

http://cks.nice.org.uk/gout#!topicsummary

http://www.patient.co.uk/pdf/4258.pdf

https://matthewwelck.com/wp-content/uploads/2019/12/gout.pdf

GP Information

Background Information

  • A disorder of purine metabolism characterised by hyperuricaemia and urate crystal deposition in the joints or soft tissues.
  • Patients typically complain of a red, hot, swollen joint with pain on passive ROM.
  • 1st MTPJ is classic followed by, ankle, knee finger, wrist, and elbow.
  • Tophi are firm white translucent nodules that typically present 10 yrs after first attack, and are normally asymmetrical.
  • Differential diagnosis include; Septic arthritis (A&E referral required), Pseudogout, OA, Reactive arthritis, Rheumatoid arthritis.

Investigation Guidelines

  • No initial investigations are required to manage gout-like symptoms.
  • Joint fluid microscopy and culture is indicated in cases of suspected septic arthritis or diagnostic uncertainty.
  • Serum uric acid should be measured 6 weeks after an acute attack to confirm hyperuricaemia (upper limit M=420micromol/L, F=360micromol/L)
  • Consider an XR of the affected joint to look for chondrocalcinosis.
  • Click here for American College of Rheumatology criteria for diagnosis of acute gouty arthritis (image).

Management Recommendations

Acute Gout

  • If symptoms are mild and pt has high risk adverse effects consider self care > medications.
  • Prescribe an NSAID (Diclofenac / Indometacin / Naproxen) ASAP and continue for 48hr after symptom resolution.
  • Co-prescribe a PPI in at risk patients.
  • If NSAIDs are contra-indicated prescribe oral Colchicine.
  • If NSAIDs and Colchicine are contra-indicated consider oral corticosteroids.
  • Advise patient to return if not improved after 3 days.

Patient Self care during acute gout

  • Rest and elevate limb.
  • Avoid trauma to joint.
  • Ice.
  • Review lifestyle advice.

Treatment Failure
If no improvement after 3 days:

  • Review diagnosis and compliance and increase to maximum dosage medications.
  • If still no improvement try alternative medication or refer for specialist assessment.

Follow up

  • Review patient after 4 weeks.
  • Check serum uric acid level, BO, fasting glucose, renal function and lipid profile.
  • Manage any underlying co-morbidities; hypertension, renal disease, diabetes.
  • Recommend lifestyle advice.
  • Consider prophylactic medication if pt has 2 + attacks/yr (e.g. Allopurinol).

Lifestyle Advice

  • Aim for ideal body weight.
  • Restrict red meat and protein intake.
  • Avoid binge or excessive alcohol intake.
  • Avoid dehydration.
  • Convert to skimmed milk.
  • Limit consumption of high sugar snacks.
  • Stop smoking.

Referral Indications:

  • Suspected septic arthritis (A&E referral required)
  • Diagnostic uncertainty
  • Pregnancy or <25yrs old
  • Recurrent attacks on maximum dose Allopurinol.
  • Requirement for IA steroid (but not skilled).
  • Troublesome Tophi.

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