Gout

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.

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.

• 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.

Although the diagnosis of acute gout is usually made clinically, all patients with a suspected first attack should be investigated to:

1. look for underlying causes
2. identify associated co-morbidities
3. 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

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 Criteria

Consider referral to secondary care if:

1. Tophaceous gout, progressive despite treatment.
2. Refractory gout, after 3 attacks whilst on adequate treatment.
3. Patient suffers complications relating to gout e.g., arthropathy, neuropathy.
4. Gout persists despite serum uric acid (SUA) lower than 300 micromol/L.
5. The SUA is unresponsive to treatment.
6. Patient requires intra-articular therapy and primary care are not able to provide.
7. Relative contraindication to urate-lowering therapy (ULT)
8. 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

Patient Information

MyHealth Devon - Gout

Evidence

The Lancet - gout article

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: January 2023