GPAtlas
GOUT
gpatlas.co.uk
🔍 When to Suspect
Sudden onset of severe pain, redness, warmth, and swelling in a single joint, most commonly the first MTP joint (big toe), especially with risk factors like diet, alcohol, or diuretic use
🩺 Assessment
- ◉ Symptoms + triggers → Sudden, severe, fluctuating joint pain with redness, swelling, and warmth
- ◉ Risk factors/history → Personal/family history, diet high in purines (red meat, seafood), alcohol (especially beer), obesity, CKD, diuretic use
- ◉ Impact + mimics → Affects ability to walk or wear shoes; key mimic is septic arthritis
- ◉ Exam findings → Erythema, swelling, warmth, and exquisite tenderness of affected joint; check for tophi (on ears, fingers, elbows) in chronic gout
💊 Management
🔸Key tests:
➤ Serum uric acid (check 4-6 weeks after flare settles, target <300 µmol/L), U&Es/eGFR to assess renal function
🔸Lifestyle:
➤ Reduce intake of purine-rich foods and sugary drinks; avoid alcohol during flares; advise weight management and hydration; during a flare: rest, elevate, and use ice packs
🔸Pharmacological:
➤ Acute Flare:
➤ 1st line: High-dose NSAID (e.g. naproxen) with PPI cover, OR Colchicine 500mcg 2-4 times daily (max 6mg per course)
➤ 2nd line: Short course of oral corticosteroid (e.g. prednisolone 30–35mg once daily for 3–5 days)
➤ Continue existing urate-lowering therapy (ULT) throughout a flare
➤ Long-Term (ULT): For ≥2 flares/year, tophi, or joint damage. Start 4-6 weeks after flare resolves
➤ 1st line: Allopurinol, start 100mg daily (50mg in CKD 4/5), titrate up every 4 weeks to target urate <300 µmol/L
➤ 1st line alternative: Febuxostat 80mg daily – equal first-line choice to allopurinol (NICE NG219); MHRA: use with caution in major CVD (allopurinol preferred)
➤ Prophylaxis: Co-prescribe colchicine 500mcg bd for up to 6 months when starting ULT to prevent flares
🔸Exacerbation/emergency:
➤ Urgent hospital admission if septic arthritis is suspected
🔸Follow-up/safety-net:
➤ When starting allopurinol, warn about rare but serious risk of Allopurinol Hypersensitivity Syndrome (rash, fever)
⚠️ Red Flags
• Suspicion of septic arthritis → Fever, systemically unwell, unable to bear weight or actively move the joint
• Severe, uncontrolled pain despite initial treatment
➡️ Referral Criteria
Urgent: Immediate hospital admission if septic arthritis is suspected
Routine: Refer to Rheumatology for diagnostic uncertainty, contraindications to standard treatment, CKD stages 3b–5 (eGFR <45) or organ transplant, or uncontrolled symptoms
📌 GP Tips
🔹Serum uric acid level can be falsely normal during an acute flare-up
🔹Always rule out septic arthritis in a single hot, swollen, painful joint