Acute attacks should be treated as early as possible (as soon as an attack occurs).

Self-care

Advise the person to:

• Rest and elevate the limb
• Avoid trauma to the affected joint
• Keep the joint exposed and in a cool environment
• Consider the use of an ice pack or bed-cage

Discuss lifestyle measures such as weight loss, exercise, diet, alcohol consumption, and fluid intake.

Pharmacological management

Choice of first-line agent depends on patient preference, renal function and co-morbidities.

Consider paracetamol as an adjunct for pain relief.

Do not stop allopurinol or febuxostat during an acute attack of gout if the person is already established on these drugs.

Prescribe either of the following first-line agents, provided that there are no contraindications:

• An oral non-steroidal anti-inflammatory drug (NSAID) at a maximum dose as early as possible and continue the treatment until 1-2 days after the attack has resolved e.g.
  • Ibuprofen 800mg every 8 hours
  • Naproxen 750mg initially, then 250mg every 8 hours
  • NICE CKS (2018): Gout: states that there is no current evidence of superiority of any specific NSAID for this indication. Any NSAID may be used provided no contraindications exist.
  • For risks associated with different NSAIDs and guidance for when to prescribe gastric protection refer to Prescribing non-steroidal anti-inflammatory drugs
  • Aspirin is not indicated in gout
  • See 10.1.1 Non-steroidal anti-inflammatory drugs (NSAIDs)
• Colchicine
  • The BNF states: 500 micrograms 2–4 times daily until symptoms relieved, maximum 6mg per course; course not to be repeated within 3 days
  • Local specialists may suggest alternative regimens
  • MHRA drug safety update (2014): Colchicine has a narrow therapeutic index and is extremely toxic in overdose
  • Colchicine is of value for patients with heart failure since, unlike NSAIDs, it does not induce fluid retention. It can also be given to patients receiving anticoagulants
  • See 10.1.4 Gout and cytotoxic-induced hyperuricaemia

A short course of oral corticosteroids or a single intramuscular corticosteroid injection may be considered in people who cannot tolerate NSAIDs or colchicine, and if intra-articular injection is not possible (see below).

• Prednisolone
  • 20-30mg daily for 5 days

Joint aspiration and intra-articular injection of corticosteroids (unlicensed use) are an option in people with acute monoarticular gout and co-morbidity provided the diagnosis is certain, the person (and joint) are suitable for injecting and the expertise to inject the joint is available.

Irrespective of the treatment used, advise the person to return if symptoms get worse, or if there is no improvement after 1-2 days.

Treatment failure

If there is an inadequate response to treatment after 1-2 days:

• Review the diagnosis and exclude any other underlying pathology
• Check medication compliance and encourage self-care strategies
• Ensure that the maximum dose of colchicine (if tolerated) or NSAID is being used and consider adding paracetamol
• If unable to tolerate the chosen treatment, consider switching to an alternative first-line drug provided there are no contraindications
• If response to monotherapy is insufficient, consider combining treatments
• Consider seeking specialist advice, especially if the person may be at risk of adverse effects, if there is diagnostic uncertainty or if there is failure to respond to standard treatment.

Follow up

After an acute attack of gout has resolved, follow up the person after 4–6 weeks, and:

• Check serum uric acid level to confirm hyperuricaemia
• Identify and manage underlying conditions such as hypertension, diabetes, dyslipidaemia or renal impairment, and assess the person's overall cardiovascular risk
• Measure blood pressure and arrange additional blood testing for HbA1c, renal function, and lipid profile
• Review cardiovascular risk factors and screen for renal disease at least annually, and provide ongoing lifestyle advice
• Provide advice on risk factors such as obesity, diet, excessive alcohol consumption, smoking and exercise
• Advise that acute flares of gout should be treated as early as possible
• Consider providing an advance prescription of effective treatment for future attacks of gout
• Discuss the use of urate-lowering therapy (ULT) – see long-term control of gout, below.

Consider the underlying cause of hyperuricaemia.

Review all medication and consider any that may cause hyperuricaemia or gout such as diuretics, β-blockers and ACE inhibitors and non-losartan angiotensin II receptor blockers.

The British Society for Rheumatology Guideline for the Management of Gout (2017) states that Losartan should not be used as primary ULT but where treatment for hypertension is required, it may be considered as possessing a weak uricosuric effect.

Lifestyle advice

Discuss lifestyle measures such as weight loss, exercise, diet, alcohol consumption, smoking cessation and fluid intake:

• Avoid excessive consumption of sugar-sweetened soft drinks and foods rich in purines (such as meats and seafood). Encourage a diet inclusive of skimmed milk, low-fat yoghurt, soybeans and cherries. Dietary advice is available from the UK Gout Society.
• Avoid excessive alcohol intake and binge drinking, especially beers and spirits
• Avoid dehydration and encourage patients to drink at least 2 litres of water a day.
• Take regular exercise, avoiding intense muscular exercise and trauma to joints.

Drug treatment

Urate-lowering therapy (ULT) should be discussed and offered to all people with a diagnosis of gout.

Asymptomatic hyperuricaemia alone is not an indication to institute preventative therapy.

In particular, it is important to advise the use of ULT to people with:

• Two or more attacks of acute gout in 12 months
• Tophi
• Chronic gouty arthritis
• Joint damage
• Renal impairment (eGFR less than 60 ml/min)
• A history of urinary stones
• Diuretic use
• Young age of onset of primary gout

Consider ULT initiation at acute attack follow-up (normally 4-6 weeks). Do not initiate ULT until at least 1-2 weeks after an acute attack has settled.

Allopurinol

• Start at a low dose (100mg daily) and titrate upwards in 100mg increments approximately every 4 weeks until the serum uric acid (SUA) target (see below) has been achieved (maximum dose 900mg in divided doses)
• In patients with renal impairment smaller increments should be used. Maximum dose will be lower but target urate levels should be the same.

Febuxostat

• Can be used as an alternative first-line agent only for patients who are intolerant of allopurinol or for whom allopurinol is contraindicated
• Start with a dose of 80mg daily and, if necessary, increase after 2-4 weeks to 120mg daily, if uric acid levels greater than 6mg/100ml, to achieve therapeutic target
• Rare but serious hypersensitivity reactions have been reported with febuxostat. Refer to MHRA (June 2012) for further details

Consider prescribing colchicine (500 micrograms once or twice daily) or a low-dose NSAID when initiating or increasing the dose of a ULT as prophylaxis against acute attacks secondary to ULT. For allopurinol this will be until at least one month after hyperuricaemia is corrected (normally 3 months) and for febuxostat continue for at least 6 months after initiation.

Follow up

If taking urate-lowering therapy (allopurinol or febuxostat), check the SUA level and renal function every 4 weeks until SUA is in target range, then annually thereafter, and aim for a SUA level below 300 micromol/L.

• Titrate the dose of ULT if appropriate and SUA target is not reached
• If taking febuxostat, monitor liver function tests periodically, where clinically indicated.
• If the person is still having frequent attacks of gout despite ULT:
  • Assess compliance with prophylactic medication or increase the dose if appropriate.
  • Review any trigger factors such as medication (for example diuretics), trauma, diet, weight gain, and excess alcohol consumption.
  • Consider providing an advance prescription for future attacks of gout, e.g. NSAID or colchicine
  • Consider referral to secondary care. 
    • North Devon Referral Guideline: Gout

After some years of treatment, once SUA target is reached and clinical 'cure' has been achieved (acute attacks have stopped and tophi have resolved), consider reducing the dose of ULT to maintain the SUA level between 300-360 micromol/L.