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Gout Management

Guidelines for Management of Gout

Acute Gout treatment

1. Rest affected joints

2. NSAIDs (if no CI) +/- PPI cover

3. If renal impairment consider Colchicine 500mcg bd-qds

4. If not on Allopurinol do not initiate during an acute flare (see below)

5. Opiates analgesia can be used alongside above treatment for pain relieve

6. If able intra articular steroid injection can be considered (if no risk of septic arthritis).  PO or IM steroids can also be considered if NSAID or Colchicine CI/side effects

Start treatment if has any of the below:

¢ After 2nd attack

¢ >1 attack per year

¢ Presence of uric acid stones

¢ Presence of tophi

¢ Patients who need to continue with diuretics

What to start: 1st line

1. Allopurinol 50-100mg as starting dose, increasing by 50-100mg per month dependent on urate levels

2. Start 2 weeks after acute Gout flare has settled

3. Aiming for serum urate level to be in the lower half of the normal range

4. Max Allopurinol dose 900mg. Rheumatology referral to be considered if insufficient response with Allopurinol 600mg.

5. When adjusting Allopurinol take into account renal function, as renal impairment can increase risk of toxity and Allopurinol dose may be limited in patients with renal impairment because of this.

6. When initiating treatment use appropriate prophylatic cover

        i) Cochicine 500micrograms bd for upto 6 months (if no contraindications) or

        ii) NSAID or Coxib can be used if no contraindications but for a max of 6 weeks with appropriate PPI cover as necessary or

        iii) 120mg IM Depomedrone (max every 8-12 weeks usually only 2 needed)

7. Patient should be warned that there is a possibility of flare of Gout when initiating treatment and to continue Allopurinol and treat any flares

Once Allopurinol initiated and target serum urate level achieved:

1. Monitor serum urate level twice a year aiming to maintain serum urate level

2. If has Gout flares, DO NOT stop the allopurinol and treat symptomatically with

    i) Colchicine (if no contraindication) 500 micrograms bd-qds (max qds “ often will cause diarrhoea at this frequency, usually tds         tolerated)

    ii) NSAID/Coxib (if no contraindication)

    iii) PO steroids/intra-articular steroid or IM steroid

    iv) Septic arthritis remains important differential of acute monoarthritis

If unable to achieve target serum urate level with Allopurinol alone:

1. Uricosuric agents may need to considered and can be used alone or added to Allopurinol - will need specialist input

2. Febuxustat -

        i) metabolised by the liver so no dose adjustments in renal impairment

        ii) NICE recommends its use for those patients who are intolerant to Allopurinol or when Allopurinol contraindicated

        iii) The most common side effects are diarrhoea, nausea, headache, liver function test abnormalities and rash

        iv) Not recommended in IHD or congestive heart failure

        v) Starting dose 80mg, increasing as necessary to 120mg od after 1 month, aiming for serum urate level in lower half of the normal             range

        vi) prophylactic treatment with Colchicine (for at least 6 months) or NSAIDs/Coxibs (6 weeks) or IM depo as above

Other pharmaceutical considerations

¢ Analgesic doses of Aspirin (600-2400mg) interferes with uric acid excretion, low dose aspirin considered ok

¢ Losartan produces a uricosuric effect typically decreasing serum uric acid levels by 20% to 25% so should be considered in those patients who have Gout and where an antihypertensive required

¢ Amlodipine also has uricosuric properties to be considered where antihypertensive required

¢ If raised cholesterol add in Fenofibrates, which again have uricosuric properties

¢ Stopping diuretic treatment where able

Lifestyle modifications

¢ Reducing and managing cardiovascular risk factors: as Gout is part of the metabolic syndrome

¢ Maintaining hydration particularly in those patients with hx of renal stones

¢ Advice regarding alcohol Beer>Spirits>Port>Wine (14 units maximum recommended amount per week)

¢ Weight loss

¢ Low purine, increase low fat dairy

Patient education is essential

¢ Advice on lifestyle changes

¢ Usually lifelong treatment

¢ Do not to stop treatment if flares

In refractory Gout we (rheumatology service) would be very happy to see the patient for further assessment and management.

PMR Guidelines

 PMR Guidelines

Hot Swollen Joint Guidelines

Hot Swollen Joint Guidelines

DMARD/Biologic Monitoring Guidelines

DMARD / Biologic Monitoring Guidelines - click on link below


Getting here and contacting us

For those with complex disease or who are more unwell, we can offer assessment as an inpatient, this is usually on Ward 6 at Bradford Royal Infirmary.

There is also a 12-bed day case unit in the Horton Wing at St Luke's Hospital.

Key contacts are:

Pauline Oldfield            Secretary to Dr Helliwell and Dr Zayat; (01274 365227)
Linda Harris                  Secretary to Dr Shingler, Dr Ash and Dr Nadesalingam / Aslam; (01274 365389
Jennifer Rushton          Support Secretary       
Kathy Evans                 Support Secretary
Nazma Iqbal                 Support Secretary
Beverley Loryman        Support Secretary

There is also a telephone advice line service for patients already under our care.  This is 01274 274274.Advice is available regarding the patient's rheumatological condition and associated medications.  If necessary, an appointment to see a member of the Rheumatology team can be arranged.GPs are encouraged to use the advise service via SystmOne.  

For existing patients please send us a task and for new patients please use the e-consult pathway via system one.Booking a rheumatology advice line call back is not appropriate for:        
    1. A request to change your appointments (please discuss this directly on 01274 274274).        
    2. A request for a repeat prescription (if you need a repeat prescription or more blood forms please ring 01274 365779).


Please view a location for further information, including opening and visiting times.

Horton Wing Ward 6