Gout: Management

Key points

• Gout: monosodium urate deposition from chronic hyperuricaemia · a normal serum urate during an acute attack does not exclude gout — recheck at least 2 weeks after it settles.
• Acute attack: an NSAID or colchicine first-line — maximum NSAID dose until 1-2 days after symptoms settle, with PPI gastroprotection · colchicine has slower onset, and diarrhoea is the main dose-limiting effect · use lower colchicine doses in renal impairment.
• If NSAIDs and colchicine are contraindicated: oral prednisolone, or an intra-articular steroid injection · always CONTINUE urate-lowering therapy through an acute attack if already established.
• Offer urate-lowering therapy to ALL patients after a first attack, discussing it with them — particularly with 2 or more attacks in 12 months, tophi, chronic gouty arthritis, joint damage, renal disease, uric acid stones, or diuretic/cytotoxic use.
• TREAT TO TARGET (NICE NG219), the core of modern gout care: allopurinol OR febuxostat first-line, started low and titrated monthly against serum urate until the target is reached — below 360 micromol/l, or below 300 micromol/l where there are tophi, chronic gouty arthritis or ongoing frequent flares · offer ALLOPURINOL first-line where there is major cardiovascular disease (previous MI or stroke, or unstable angina).
• Timing: start urate-lowering therapy at least 2–4 weeks after a flare has settled, though it can be started during a flare if flares are frequent · ULT is normally lifelong and is continued once the target is reached.
• Cover the start of urate-lowering therapy with colchicine (or an NSAID) for up to 6 months, because starting it can precipitate attacks · do not stop urate-lowering therapy when a flare occurs.

Decision points in this pathway

• NSAIDs and colchicine both contraindicated?
• Tophi, chronic gouty arthritis, or ongoing attacks?

The full step-by-step algorithm, including what to do at each branch, opens in the app for approved members.