Scope:
- Diagnosis of gout in adults within primary care
Consider referral to secondary care if:
- Tophaceous gout, progressive despite treatment.
- Refractory gout, after 3 attacks whilst on adequate treatment.
- Patient suffers complications relating to gout e.g., arthropathy, neuropathy.
- Gout persists despite serum uric acid (SUA) lower than 300 micromol/L.
- The SUA is unresponsive to treatment.
- Patient requires intra-articular therapy and primary care are not able to provide.
- Relative contraindication to urate-lowering therapy (ULT)
- There is diagnostic uncertainty.
Out of scope:
- Diagnosis and management of differential diagnoses
Assessment
Gout classically presents in first MTP. In any presentation of a hot joint (especially first presentation), septic arthritis should always be considered.
Gout is usually a clinical diagnosis.
Differential Diagnoses
Important differential diagnoses include:
- Septic arthritis – consider in monoarthritis (especially if first presentation or not a classical presentation) and systemic evidence of sepsis.
- Rheumatoid arthritis – symmetrical polyarthritis with morning stiffness. Usually affects MCPJ first.
- Connective Tissue Disorders – often accompanied by other systemic features.
- Enteropathic Inflammatory Arthritis – history of IBD. Consider checking HLA-B27 status.
- Psoriatic Arthritis – history of psoriasis.
- Pseudo-gout – usually affects larger joints.
Red Flags
- Septic arthritis – consider in monoarthritis (especially if first presentation or not a classical presentation) and systemic evidence of sepsis
- Prosthesis in-situ.
- Gout is rare in premenopausal women and men under 30 years of age – consider alternative diagnoses (including inherited metabolic disorders)
Please refer suspected septic joints to the on-call orthopaedic team for joint aspiration.
Investigations
Although the diagnosis of acute gout is usually made clinically, all patients with a suspected first attack should be investigated to:
- look for underlying causes
- identify associated co-morbidities
- obtain evidence to support the diagnosis
1.Underlying causes:
- Assess lifestyle factors (diet, exercise, alcohol, fluid intake).
- Consider drug induced gout: - diuretics, betablockers, ACE inhibitors, ARBs.
2. Associated co-morbidities:
Associated co-morbidities include:
- dyslipidaemia, hypertension, renal impairment, diabetes, myeloproliferative disease, severe psoriasis
Check:
- Blood pressure
- HbA1c
- Renal function
- Blood Lipids
3. Evidence to support the diagnosis:
- Serum urate:
- Is not diagnostic and may be falsely normal in an acute attack
- Serum urate levels should be checked 4-6 weeks after an acute attack
- The main use of urate is in titrating prophylactic treatments e.g., allopurinol
- Joint aspiration:
- can demonstrate urate crystals in the synovial fluid (please note that aspirates need to be tested ASAP – ideally within 1 hour, otherwise can give inconclusive falsely negative results)
- usually reserved for when the diagnosis is uncertain
Consider the following investigations for the diagnosis of chronic or recurrent gout:
- X-ray:
- useful in chronic gout to distinguish between osteoarthritis and rheumatoid arthritis changes.
- destructive changes may be an indication for urate lowering therapy
- demonstrates characteristic changes including the presence of:
- subcortical cysts without erosions
- geodes - punched-out type erosions with sclerotic margins and overhanging edges
Management
For detailed advice on the management, please follow the link
Target
NICE guidance advises a target serum uric acid (SUA) of 360micromol/L to be satisfactory if symptoms are controlled.
The target should be lower than 300 micromol/L for patients with:
- tophi
- chronic gouty arthritis
- patients still having flares when treated to SUA lower than 360 micromol/L
SUA should be checked monthly and treatment up-titrated to target
Monitoring once at Target
Once stable, check a SUA level annually (increases with age)
Acute attacks of gout can still occur for up to 2 years or longer and should be managed in the usual way - the frequency and intensity of attacks should gradually diminish and cease altogether.
Consider annual monitoring for co-morbidities (e.g. renal function, HbA1c, Lipids, BP)
Referral
Referral Criteria
Consider referral to secondary care if:
- Tophaceous gout, progressive despite treatment.
- Refractory gout, after 3 attacks whilst on adequate treatment.
- Patient suffers complications relating to gout e.g., arthropathy, neuropathy.
- Gout persists despite serum uric acid (SUA) lower than 300 micromol/L.
- The SUA is unresponsive to treatment.
- Patient requires intra-articular therapy and primary care are not able to provide.
- Relative contraindication to urate-lowering therapy (ULT)
- There is diagnostic uncertainty.
Referral Instructions
Refer to Rheumatology via the e-Referral Service:
Specialty: Rheumatology
Clinic Type: Musculoskeletal
Service: DRSS-Eastern and Northern-Rheumatology- Devon ICB -15N
Referral Forms
DRSS referral form
Home >
Referral >
Northern locality >
Rheumatology >
Gout
- First line
- Second line
- Specialist
- Hospital