Gout

Gout is a painful and potentially disabling form of inflammatory arthritis that has been recognized since ancient times

It is a disorder of purine metabolism characterized by hyperuricaemia and the deposition of monosodium urate crystals in articular or peri-articular tissues and in the renal tract (1,2).

• uric acid is the breakdown product of purine residues of nucleic acid and two thirds of it are excreted via the kidney; the remainder, via the gut
• the likelihood of crystal formation increases as the level of uric acid increases (most often results from impaired fractional renal clearance of urate rather than from excessive production), and at low temperature. This helps to explain the peripheral distribution of gout (2)
• not all patients with hyperuricaemia have gout

Treatment principles:

• acute flares of gout (3):
  • offer a non-steroidal anti-inflammatory drug (NSAID), colchicine or a short course of an oral corticosteroid for first-line treatment of a gout flare, taking into account the person's comorbidities, co-prescriptions and preferences (In June 2022, this was an off-label use of oral corticosteroids)
  • consider adding a proton pump inhibitor for people with gout who are taking an NSAID to treat a gout flare
  • consider an intra-articular or intramuscular corticosteroid injection to treat a gout flare if NSAIDs and colchicine are contraindicated, not tolerated or ineffective (in June 2022, this was an off-label use of corticosteroid injections)
  • advise people with gout that applying ice packs to the affected joint (cold therapy) in addition to taking prescribed medicine may help alleviate pain
  • follow-up after an acute flare
    • consider a follow-up appointment after a gout flare has settled to:
      • measure the serum urate level
      • provide information about gout and how to self-manage and reduce the risk of future flares
        • explain to people with gout that there is not enough evidence to show that any specific diet prevents flares or lowers serum urate levels
          • advise them to follow a healthy, balanced diet
        • advise people with gout that excess body weight or obesity, or excessive alcohol consumption, may exacerbate gout flares and symptoms
      • assess lifestyle and comorbidities (including cardiovascular risk factors and CKD)
      • review medications and discuss the risks and benefits of long-term ULT (urate lowering therapy)
        
        
• long-term management of gout (3)
  • management of gout with urate-lowering therapies
    • offer ULT, using a treat-to-target strategy, to people who have:
      • multiple or troublesome flares
        • CKD stages 3 to 5 (glomerular filtration rate [GFR] categories G3 to G5)
        • diuretic therapy
        • tophi
        • chronic gouty arthritis
      • treat-to-target strategy
        • start with a low dose of ULT and use monthly serum urate levels to guide dose increases, as tolerated, until the target serum urate level is reached
        • aim for a target serum urate level below 360 micromol/litre (6 mg/dl)
        • consider a lower target serum urate level below 300 micromol/litre (5 mg/dl) for people with gout who:
          • have tophi or chronic gouty arthritis
          • continue to have ongoing frequent flares despite having a serum urate level below 360 micromol/litre (6 mg/dl)
    • discuss the option of ULT, using a treat-to-target strategy, with people who have had a first or subsequent gout flare who are not within the groups listed above
    • ensure people understand that ULT is usually continued after the target serum urate level is reached, and is typically a lifelong treatment
    • start ULT at least 2 to 4 weeks after a gout flare has settled. If flares are more frequent, ULT can be started during a flare*
      
      
  • * preventing gout flares when starting or titrating urate-lowering therapy
    • discuss with the person the benefits and risks of taking medicines to prevent gout flares when starting or titrating ULT
    • for people who choose to have treatment to prevent gout flares when starting or titrating ULT, offer colchicine while the target serum urate level is being reached. If colchicine is contraindicated, not tolerated or ineffective, consider a low-dose NSAID or low-dose oral corticosteroid (in June 2022, this was an off-label use of NSAIDs and oral corticosteroids)
    • consider adding a proton pump inhibitor for people with gout who are taking an NSAID or a corticosteroid to prevent gout flares when starting or titrating ULT. Take into account the person's individual risk factors for adverse events. In June 2022, this was an off-label use of NSAIDs and oral corticosteroids
• consider annual monitoring of serum urate level in people with gout who are continuing ULT after reaching their target serum urate level

Reference:

• (1) Doherty M. New insights into the epidemiology of gout. Rheumatology (Oxford). 2009;48 Suppl 2:ii2-ii8.
• (2) Jordan KM et al. British Society for Rheumatology and British Health Professionals in Rheumatology guideline for the management of gout. Rheumatology (Oxford). 2007;46(8):1372-4
• (3) NICE (June 2022). Gout: diagnosis and management