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Diagnosis and management of gout and pseudogout, in adults within primary care.
Diagnosis and management of septic arthritis.
Gout caused by urate crystals and can occur as acute attack or recurrent attack
Gout usually causes a monoarthritis with pain that is extremely severe "the worst pain I've ever had – 11/10 severity"
Pain often maximizes in first 6-12 hours and resolves in 3-10 days
Usually a monoarthritis which is hot, red, swollen and extremely tender – often 1st MTP joint but can affect any small or large joint
Gout is usually a clinical diagnosis
Associations with metabolic syndrome and increased risk of cardiovascular disease
Age - onset in:
someone less than age 30 years may suggest:
the elderly - disease more likely to be:
Ask about the pain:
location - commonly the first metatarsophalangeal joint, but can also affect joints in the:
precipitating events including:
Accompanying symptoms may occur, such as:
Determine the presence of risk factors which include:
Examine affected joint(s) for the following features:
NB: The extent of the inflammatory response in crystal arthropathy is usually extreme and profound erythema and exquisite tenderness,e.g. inability to tolerate bed clothes on joint, are almost diagnostic features.
For patients with recurrent or chronic gout, examine for tophi:
deposits of urate embedded in a matrix of lipid protein and calcific debris
NB: Inflammation can also affect tendons and soft tissue causing diffuse oedema and cellulitis - this often causes diagnostic confusion and inappropriate antibiotic therapy.
Seek specialist advice when:
Please refer suspected septic joints to the on-call orthopaedic team for joint aspiration.
Although the diagnosis of acute gout is usually made clinically, all patients with a suspected first attack should be investigated to:
NB: If septic arthritis is a differential, make sure to perform blood cultures.
full blood count (FBC):
liver enzymes may reveal:
investigations for the inherited metabolic disorders:
Regarding investigations for the diagnosis of gout: the American College of Rheumatology (ACR) criteria for diagnosing gout is as follows:
NB: X-rays are not useful in the diagnosis of gout
Acute attack – prompt treatment works best
Suppress pain and reduce inflammation until acute flare has subsided.
NSAIDs see section 10.1 Drugs used in rheumatic diseases and gout
Are the drugs of choice in most patients with acute gout who do not have underlying health problems. Avoid NSAIDs in patients who have a history of peptic ulcer or GI bleeding, patients with renal insufficiency, patients with abnormal hepatic function, patients taking warfarin (selective COX-2 inhibitors can be used)
Colchicine see section 10.1 Drugs used in rheumatic diseases and gout
Although colchicine was once the treatment of choice for acute gout, it is now a second-line approach because of its narrow therapeutic window and risk of toxicity. It is contraindicated if GFR less than 30 and if there is active GI bleeding, main side effect (dose related) is diarrhoea
Ask the patient to return for follow-up if there is no resolution of symptoms after 3-4 days and consider:
If there is still no improvement in symptoms:
Lifestyle modifications (see patient information link below)
Reconsider precipitating drugs e.g. diuretics / aspirin / salicylates
Consider urate lowering treatment (e.g. allopurinol) if
Don't start urate lowering therapy until disease in remission
Give NSAIDs (+/- PPI) or colchicine (0.5mg per day) for a week before and the first 3-6 months of allopurinol to prevent a flare – a frequent cause of relapse is inadequate NSAID / colchicine protection
Explain this treatment is life long and may initially precipitate flares – continue the treatment
A recent BMJ article explains that allopurinol is often under-dosed and not given long term
Treat acute flares as above
Febuxostat (see section 10.1 Drugs used in rheumatic diseases and gout for cautions / contraindications)
If allopurinol intolerant or treatment not successful then consider febuxostat see section 10.1 Drugs used in rheumatic diseases and gout
Please contact rheumatology with any clinical concerns
If taking allopurinol, check the serum uric acid level and renal function every 3 months in the first year, then annually, and aim for a serum uric acid level below 300 micromol/L.
If taking febuxostat, use clinical judgement to decide if liver function tests need to be retested periodically.
If the person is still having frequent attacks of gout:
Review cardiovascular risk factors and provide on-going lifestyle advice:
Consider referral to secondary care, if the person is still having attacks despite all these measures.
Consider referral to secondary care, if the person is still having attacks despite the measures taken (see management).
This guideline has been signed off on behalf of the Northern Locality of NEW Devon CCG.
Publication date: July 2017