Likely diagnosis of gout (exclude septic arthritis)
Acute Treatment
Treat pain and inflammation as soon as possible, continuing until acute flare has settled
• Full dose NSAID (eg naproxen 500mg bd or diclofenac 50mg tid +/- PPI) or
• Full dose oral Colchicine (500mcg 2-4 times daily) or
• Cortico-steroid (oral prednisolone 30mg od for 5 days or IM methyl prednisolone 80-120mg. Where expertise is available consider IA
methylprednisolone 40-80mg or triamcinolone 20-40mg)
Advise patient to apply an ice pack periodically to affected joint (wrap in a towel to avoid ice burn)
Review appointment (4-6 weeks)
• Assess lifestyle factors, blood pressure, lipid profile and perform serum urate, kidney and liver function & glucose
• Optimise weight, increase exercise, modify diet, reduce alcohol, treat underlying cardiovascular risk factors
sUA ≥ 0.36mmol/l
sUA <0.36mmol/l
Reconsider diagnosis
Long term treatment
• Persistent symptoms without diagnosis
should be referred to secondary care.
Note that serum urate frequently falls
during gout attacks, so it is important that
serum urate is measured after resolution
of the flare.
• Initiate urate lowering therapy if patient has had ≥2 flares per year based on patient
preference and clinical judgement
• First line treatment Allopurinol, Second line Febuxostat, Third line Sulphinpyrazone
• Co-prescribe low dose NSAID(eg naproxen 250mg bd or diclofenac 25mg TID) +/- PPI
or low dose colchicine (500mcg 2 times daily) for at least 6 weeks
Repeat sUA (2-4 weeks)
sUA <0.36mmol/l


Continue urate lowering therapy unless causing side effects
Repeat convalescent serum urate in patients suffering recurrent
attacks
sUA ≥ 0.36mmol/l
•Titrate up urate lowering therapy (please see separate flow chart
for prescribing in renal impairment and details of drug dosage)
• Maintain prophylactic colchicine for up to 6 months during dose
titration
Urate Lowering Therapy prescribing based on renal function
Offer flare prophylaxis for at least 6 weeks with 500mcg colchicine od or bd if tolerated. Measure serum urate every 2-4 weeks and
titrate therapy until target of serum urate <0.36mmol/l. Check compliance before assuming inefficacy.
eGFR <10
eGFR 10-20
eGFR 20-50
eGFR >50
Start 50mg allopurinol od
Start 100mg allopurinol od
Start 100mg allopurinol od
Start 100mg allopurinol od
Maximum 100mg od
Maximum 200mg od
Maximum 300mg od
Maximum 900mg od
Intolerance or inefficacy of allopurinol
eGFR <30
or
Target urate achieved
eGFR >= 30
Commence 80mg febuxostat od with 6 months colchicine 500mcg 1-2 tab daily if tolerated
Escalate to 120mg febuxostat od after 2-4 weeks if target urate not achieved
Intolerance or inefficacy of febuxostat
eGFR <90
or
Target urate achieved
eGFR >=90
Start sulfinpyrazone 200mg od and titrate to maximum 800mg od
Consider adding allopurinol if no contra-indication
Intolerance/inefficacy of sulfinpyrazone
or
Target urate achieved
+/- allopurinol
Continue urate lowering therapy through any subsequent attacks
Refer to secondary care for consideration of
benzbromarone +/- further allopurinol titration
Check convalescent serum urate in patients suffering recurrent attacks
and escalate treatment if no longer at target
Sulfinpyrazone dose may be reduced for maintenance