Gout Management Guidelines Updated May 2016

SUMMARY
NHS Fife Gout Management Guidelines
Diagnosis of Acute Gout

1. A painful red hot swollen joint develops over 2-3 hours and resolves within 2
weeks.
2. 90% of first gout attacks are mono-articular and most occur in the big toe.
3. Gout attacks may occur when the serum uric acid is normal.
4. For gout diagnosis see Appendix 1. The Nijmegen score.
Management of Acute Gout

1. NSAIDs (+/- PPI) are the treatment of choice when not contraindicated
2. Colchicine is slower to act.
3. Analgesics can be added.
4. Corticosteroids are highly effective and can be substituted for NSAIDS or
added to colchicine.
5. Stop thiazide or loop diuretics unless being used to treat heart failure.
Management of Chronic Gout

1. Urate lowering therapy (ULT) is indicated when patients have clinical
evidence of urate overload e.g. acute arthritis (2 or more attacks in one year),
tophi, renal stones or gout-like erosions on X Ray. It is also indicated in heart
failure patients who need to continue treatment with diuretics.
2. Delay starting urate lowering therapy until 1-2 weeks after the signs of
inflammation have resolved.
3. The goal of ULT is to achieve a uric acid level < 300 µmol/L.
4. Allopurinol can be started at a dose of 100mg daily. Urate should be checked
in 2-4 weeks and if > 300 µmol/L then allopurinol dose should be increased by
100mg. Re-check urate 2-4 weekly and increase allopurinol dose by 100mg
until urate is < 300 µmol/L or a maximum dose of 900mg (severe disease) is
reached. Doses over 300mg daily given in divided doses. 300mg is
considered the minimum therapeutic dose by the rheumatology consultants.
An audit by FRDU has shown 90% of patients will achieve target serum urate
level on allopurinol 600mg daily.
5. Colchicine 500 micrograms twice daily is given for 6-12 months after starting
ULT to reduce the number of acute attacks that are known to occur in the first
year of treatment.
6. Febuxostat can be prescribed by GPs in patients who are intolerant of
allopurinol, where allopurinol is contraindicatied, or in patients where the
Authors: Dr Helen Harris, Consultant Rheumatologist; Stephanie Hart, Rheumatology Pharmacist, May 2016
Approved on behalf of NHS Fife by the Fife Area Drugs & Therapeutics Committee, June 2016 Review: June 2019
maximum tolerated dose of allopurinol has been ineffective. Benzbromarone
is unlicensed and should be initiated in a specialist setting.
Patient Education and Lifestyle Advice All patients should receive education and
lifestyle advice and be encouraged to visit www.arthritisresearchuk.org.
NHS Fife Gout Management Guidelines
Gout Diagnosis Facts
• A typical gout attack is the development of a

painful red hot swollen joint over a 2-3 hour
period. Attacks usually resolve within 2 weeks
even when untreated.
• The differential diagnosis includes septic arthritis

• 90% of first gout attacks are monoarticular and
most occur in the big toe.
• The skin around the affected joint may be red and
due to sterile cellulitis caused by gout crystals.
Figure 1. 1st MTP Gout • Gout attacks may occur when the serum uric acid
is normal.
• The Nijmegen score can be used to diagnose gout
in the community (appendix 1).
Management of Acute Gout [1]
1. Affected joint(s) should be rested and anti-inflammatory and analgesic

drug therapy commenced immediately, and continued for 1-2 weeks. Bed
cages and ice packs can be effective adjuncts to therapy.
2. A non-selective oral NSAID e.g. naproxen 500mg twice daily is the drug of
choice when not contraindicated, +/- PPI. Etoricoxib +/-PPI may be
prescribed if at least two non-selective NSAIDs are ineffective or not
tolerated. Treatment should be continued until symptoms have resolved.
3. Co-prescription of a PPI e.g. omeprazole or lansoprazole is appropriate if
the patient is at increased risk of GI adverse effects. Gastrointestinal
effects are dependent upon risk factors, see summary guidance from
NICE for advice on risk factors and when to co-prescribe a PPI [2].
4. Colchicine can be an effective alternative but is slower to work than
NSAIDs. To minimise risk of diarrhoea doses of 500 micrograms two to
four times daily should be used. Treatment should be continued until
symptoms have resolved or diarrhoea or vomiting occurs or maximum of 6
mg is reached per course.
5. Allopurinol is not usually commenced during an acute attack. Allopurinol
should be continued in patients already established on it, and the acute
attack treated as above.
6. Opioid analgesics can be used in addition to or instead of NSAIDs or
colchicines.
7. Intra-articular corticosteroids are highly effective in acute gouty
monoarthritis and can be used in addition to or instead of NSAIDs or
colchicine when these are ineffective or not tolerated.
8. Oral, IM or IV corticosteroids can be used instead of NSAIDs. Oral, IM or
IV corticosteroids can be used in addition to colchicine in those refractory
to treatment. Oral prednisolone 10-30mg /day for five days, or up to two
weeks may be required in severe cases. Depomedrone 120mg IM stat
may be used as an alternative to oral.
9. If thiazide or loop diuretics are being used to treat hypertension, alternative
agents should be considered. In patients with cardiac failure diuretics
should be continued [3].
Table 1.
Management of Acute Gout: Key facts
First line treatment Alternative or additional
treatments
Naproxen +/- PPI Etoricoxib +/- PPI
Colchicine
Prednisolone
Reduce or discontinue loop or thiazide diuretics if possible
Figure 2. Gout crystals Figure 3. Gout Erosions
Management of Chronic Gout [1,4]
1. The therapeutic goal of urate-lowering therapy is to achieve a uric acid

level < 300 µmol/L [1,5]
2. Urate lowering therapy is indicated in patients that have had 2 or more
acute gout attacks, chronic gouty arthritis, tophi or radiographic changes of
gout (Figs. 3 & 4)
3. Commencement of uric acid lowering therapy should be delayed until 1-2
weeks after the signs of inflammation have subsided
4. Allopurinol is usually started at a dose of 100mg daily. Urate should be
checked in 2-4 weeks and if urate remains > 300 µmol/L then allopurinol
dose should be increased by 100mg. Urate should be repeatedly checked
every 2-4 weeks and allopurinol dose increased by 100mg until urate is <
300 µmol/L or a maximum dose of 900mg (severe disease) is reached.
Doses over 300mg daily should be given in divided doses. 300mg is
considered the minimum therapeutic dose by the rheumatology
consultants. An audit by FRDU has shown 90% of patients will achieve
target serum urate level on allopurinol 600mg daily.
5. Febuxostat is a non-purine xanthine oxidase inhibitor that has been shown
to be more effective in reducing serum urate levels than allopurinol 100-
300mg daily. The effect of febuxostat has not been compared with higher
doses of allopurinol. Febuxostat is more costly than allopurinol and is
therefore used second line when allopurinol is not effective or not
tolerated. [6,7].
6. Febuxostat has a different structure to Allopurinol and can be used in
patients with allopurinol hypersensitivity including rashes.
7. Uricosuric agents such as sulfinpyrazone (200-800mg/day) can be used
in patients with normal renal function but are not used in patients with
urolithiasis. Sulfinpyrazone should be initiated by a specialist.
8. Benzbromarone (50-300mg/day available on a named patient basis) is an
unlicensed uricosuric agent that can be used in patients with reduced
creatinine clearance (CrCl 30-60 ml/min). It is ineffective when the eGFR
is less than 15mL/min.
9. During the first 6-12 months of urate-lowering therapy patients are at
increased risk of acute gout attacks [3]. Prophylaxis of acute attacks can
be achieved using colchicine 500 micrograms twice daily [8].
10. The recommended duration of prophylactic colchicine or NSAIDs during
the initiation of uric acid lowering therapy varies with the clinical setting:
• Patients with normal renal function can be prescribed colchicine 500
micrograms twice daily for up to 6 months [5].
• Patients without tophi may only need 3 months of prophylactic
colchicine
• The optimal duration of prophylactic therapy for patients with tophi is
uncertain. Colchicine should be continued for a maximum of one year
or it is clear that topaceous deposits will not resolve despite persistent
normouricemia [6]
11. An NSAID with PPI can be used instead of colchicine or in addition to
colchicine for prophylaxis of acute attacks. The evidence base for
prophylaxis with colchicine is stronger than that for NSAIDS [4]
12. Aspirin 75-150 mg/day slightly increases plasma urate but should be used
where the benefits outweigh the risks
13. Where thiazide or loop diuretics are being used to treat hypertension in
patients with gout, alternative therapy should be considered instead.
Losartan has a modest uricosuric effect (table 2) [3]
14. Where statins are contraindicated for lowering cholesterol then fenofibrate
could be considered as an alternative lipid lowering agent as it has a
modest uricosuric effect.
Table 2.
Management of Chronic Gout: Key facts

First line treatment Second line treatment
Febuxostat
Allopurinol Sulfinpyrazone – initiated by specialist
Benzbromarone – initiated by specialist
Increase allopurinol by Uricosuric agents should be avoided
100mg every 2-4 weeks until in those with renal stones
target reached
Target uric acid 300 µmol/L. Monitor uric acid every 2-4 weeks
until target reached
Colchicine 500 micrograms twice daily is used for the first 6
months after initiating urate lowering therapy
Uricosuric Drugs – Good for gout
Losartan Atorvastatin
Calcium channel blockers Fenofibrate
Anti-uricosuric Drugs – Not good for gout
diuretics pyrazinamide
high dose aspirin ethambutol
diclofenac
Figure 4. Chronic gouty arthritis and tophi
Acute Gout management in patients with Renal Impairment (table 3).
1. To minimise risk of diarrhoea doses of colchicine 500micrograms two times a

day for 3-6 days or up to four times a day for 1½-3 days depending on eGFR
should be used. Maximum total dose is 3mg if eGFR <10ml/min (off-label) and
6mg if eGFR is 10-50ml/min. Do not repeat course within 3 days [9]
2. Opioid analgesics can be used in addition to colchicine.
3. In practice, eGFR can be considered interchangeable if the patient is of a
normal build and height, and not prescribed a drug with a narrow therapeutic
index.
Chronic Gout management in patients with Renal Impairment (table 3)[9].
1. Allopurinol and its metabolites have a long half life. In renal impairment
allopurinol 100mg/day can be commenced and the dose titrated up until target
urate < 300 µmol/L is achieved. In patients with CKD Stage 3-5 lower
maintenance doses of allopurinol may be required and occasionally doses of
50mg/day or 100mg alternate days may be sufficient (table 3)[9]. The
incidence of a rash is increased in patients with CKD.
2. Febuxostat can be used in renal impairment. No dose adjustment is required
in mild-to moderate renal impairment (CrCl 30–80 ml/min). The safety and
efficacy of febuxostat have not been fully evaluated in patients with creatinine
clearance <30 ml/min [6,7].
3. Benzbromarone (50-200 mg/day available on a named patient basis) is an
unlicensed uricosuric agent that can be used in patients with low CrCl (30-60
ml/min), but is ineffective when the eGFR is less than 15mL/min.
4. During the first 6-12 months of urate-lowering therapy patients are at
increased risk of acute gout attacks [5]. Prophylaxis of acute attacks can be
achieved using colchicine 500 micrograms/day (table 3).
5. The dosage of colchicine should be adjusted in patients with renal
impairment. Duration of colchicine course should be limited to 3 months if
possible. (see Table 3)
6. Adverse effects such as raised liver function tests are most commonly seen in
patients with renal impairment where the duration of colchicine prophylaxis is
greater than 6 months [3].
Table 3. Doses below in keeping with the Renal Drug Database and/or have been agreed with Dr
Doyle, Renal Consultant
Colchicine dose in renal impairment

(Acute Gout treatment – first 2 weeks)
eGFR Colchicine dose
< 10 mL/min 500 mcg bd x 3 days under specialist supervision (off-label)
10-50 mL/min 500 mcg bd x 6 days or
500 mcg qid x 3 days
Do not repeat course within 3 days [9]
Colchicine dose in renal impairment

(Chronic Gout prophylaxis – after initial 2 weeks)
eGFR Colchicine dose
< 10 mL/min 500 mcg 1-2 days per week under specialist supervision
(off-label)
10-50 mL/min 500 mcg daily
> 50 mL/min 500mcg twice daily
Allopurinol dose in renal impairment

eGFR Allopurinol dose
< 10 mL/min 100mg daily or alternate days under specialist supervision
10-20 mL/min 100-200mg daily under specialist supervision
20-50 mL/min 200-300mg daily
> 50 mL/min Up to 900mg daily in divided doses
Febuxostat dose in renal impairment

eGFR Febuxostat dose
< 10-29 mL/min 80mg on alternate days under specialist supervision (off-
label)
> 30 mL/min Up to 120mg daily
Drug Monitoring Guidelines. Table 4
Allopurinol Colchicine Benzbromarone

Febuxostat Sulfinpyrazone
eGFR, U&Es, 6 monthly in the first 3 monthly monthly for 1st 6

LFTs, FBC year then stop. months then every
Continue only if patient 6 months
has CKD 2-4
Uric acid Every 2-4 weeks until urate < 300 µmol/L
Interactions
Allopurinol
• Increases toxicity and effects of azathioprine and 6-mercaptopurine. Reduce
dose of azathioprine and 6-mercaptopurine to one quarter of usual dose
Colchicine
• A reduction in colchicine dosage or interruption of colchicine treatment is
recommended in patients with normal renal or hepatic function if treatment
with a P-glycoprotein inhibitor or a strong CYP3A4 inhibitor is required.
• Toxicity of colchicine increased if co-prescribed with clarithromycin or
erythromycin, avoid concomitant use in renal or hepatic failure.
• Increases plasma concentrations of ciclosporin. Possible increased risk of
nephrotoxicity and myotoxicity
• Possible increased risk of myopathy if co-prescribed a statin.
Febuxostat
• Co-prescription of azathioprine, 6-mercaptopurine or theophylline with
febuxostat is not recommended (Increases toxicity) [6].
Sufinpyrazone
• Increases the anti-coagulant effect of warfarin and apixaban.
• Enhances the hypoglycaemic effect of sulphonylureas.
• Increases plasma concentrations of phenytoin.
• Reduces plasma concentrations of ciclosporin.
Benzbromarone
• Avoid co-prescription of hepatotoxins e.g. isoniazid.
For a complete list of potential drug interactions refer to the BNF or Summary of
Product Characteristics.
Education
Optimal treatment of gout requires both non pharmacologic and pharmacologic

treatment.
• Patient education (ARC leaflet)
• www.arthritisresearchuk.org
• Lifestyle advice: where indicated weight loss, diet and reduced alcohol intake
(especially beer including non-alcoholic beer) are essential
• Co-morbidities such as hypertension, hyperlipidaemia hyperglycaemia and
smoking should be addressed.
Lifestyle Advice [1]
1. In overweight patients dietary modification to achieve ideal body weight

should be attempted but crash dieting and high protein Atkins-type diets
should be avoided
2. Skimmed milk, low fat yoghurt, soy beans, cherries and vegetable sources
of protein should be encouraged in the diet
3. Liver, kidneys, shellfish and yeast extracts should be avoided. Intake of
high purine foods and red meat and overall protein intake should be
restricted
4. Patients with gout and urolithiasis should drink > 2 litres of water per day.
In recurrent stone formers alkalinisation of the urine with potassium citrate
(6.5mg/ day) should be considered
5. Beer, stout, port and fortified wines should be avoided. Alcohol
consumption should be restricted to < 21 units/week (men) and <14
units/week (women). Patients should have at least 3 alcohol free days per
week. Moderate wine consumption does not appear to increase frequency
of gout attacks
6. Patients wishing to try herbal remedies for gout should first discuss them
with their doctor
7. Moderate physical exercise should be encouraged but intense exercise or
trauma to joints should be avoided.
8. Vitamin C intake up to 1400mg / day is recommended. A combination of
supplements and dietary intake is recommended [10-12].
9. Fructose is used as a sweetener in soft drinks (but not diet drinks). Taking
fructose doubled the incidence of gout [3]. Avoid all fructose containing
drinks.
Table 5.
Risk factors for Gout Comment
Raised serum urate The higher the urate level, the

greater the risk of gout.
Genetics Mutations in genes for urate

transporter URAT1 and fructose
transporter GLUT9 are associated
with gout.
Age 2% of 45-64 year old men and 6%
men >75 years old have gout.
Gender Male :Female ratio 3:1 in those > 65

years
Osteoarthritis Gout attacks more likely in joints

affected by OA while Rheumatoid
Arthritis is protective
Diet and alcohol Wine in moderation appears safe
Indications for GP referral of Gout Patients to Rheumatology

1. Acute gout attack that fails to resolve within 14 days when treated as above.
2. Uncontrolled recurrent gout attacks despite use of Allopurinol 900mg daily or
Febuxostat 120mg and guideline advice.
3. Uncontrolled recurrent attacks when serum urate < 300 µmol/L and use of
guideline advice.
4. Intolerance of Allopurinol or Febuxostat
5. Renal impairment, eGFR < 10 mL/min
Patients with urolithiasis should be assessed by a Urologist.
Indications for X-Ray in Gout Patients

An X-Ray of the affected joint should be undertaken in all patients that have had
one or more gout attacks. The presence of an erosion is an indication for urate
lowering therapy. The diagnosis of gout is clinical and X-Rays are often not
useful in making a gout diagnosis.
When Can Urate Lowering Therapy be Reduced?

If serum urate is < 300 µmol/L and there have been no gout attacks for 1 year
Allopurinol can safely be reduced by 100 mg. Serum urate should be re-checked
6 monthly and Allopurinol dose lowered further if urate remains < 300 µmol/L.
The risk of a gout attack rises as serum urate levels rise. Patients that have tophi
are most likely to require lifelong urate lowering therapy.
Gout Management: Key Facts Summary
An NSAID +/- PPI is first line therapy in Colchicine 500 micrograms twice daily is
acute gout used for the first 6 months after initiating
urate lowering therapy.
2 or more gout attacks, tophi or renal Gout therapy should be adjusted in renal
stones are indications for indefinite urate impairment
lowering therapy
Allopurinol dose should be escalated Education and lifestyle advice should be
until uric acid is < 300 µmol/L given to all patients
References
1. British Society for Rheumatology and British Health Professionals in Rheuma-

tology Guideline for the Management of Gout. Jordan KM, Cameron S et al
Rheumatology 2007 1-3
2. NICE Clinical Knowledge Summaries, NSAIDs prescribing issues. July 2015
http://cks.nice.org.uk/nsaids-prescribing-issues#!scenarioclarification
3. Doherty M. New insights into the epidemiology of gout. Rheumatology (Ox-
ford). 2009 May;48 Suppl 2:ii2-ii8.
4. EULAR evidence based recommendations for gout. Zhang W et al. Ann
Rheum Dis 2006 65, 1312-1324
5. Lowering Serum Uric Acid levels: What is the optimal Target for Improving
Clinical Outcomes in Gout? Perez-Ruiz Fernando and Liote F Arthritis and
Rheum 57; 7 1324-1328
6. Edwards NL. Febuxostat: a new treatment for hyperuricaemia in gout. Rheu-
matology (2009) 48(Suppl. 2):ii15–19
7. Becker MA, Schumacher HR, MacDonald PA, Lloyd E, Lademacher C. Clini-
cal efficacy and safety of successful longterm urate lowering with febuxostat
or allopurinol in subjects with gout. J Rheumatol. 2009 Jun;36(6):1273-82.
Epub 2009 Mar 13.
8. Recent developments in crystal-induced inflammation pathogenesis and
management. Liote F and Hang-Korng Ea. Current Rheumatology Reports
2007, 9:243-250
9. The Renal Drug Database. Available online https://renaldrugdatabase.com/
accessed December 2015.
10. Vitamin C intake and serum uric acid concentration in men Gaox, Curhan G,
Forman et al J. Rheum 2008 Sept 35(9) 1853-8
11. A little citrus might go a long way Gelber AC J. Rheum. 2008 35(9) 1692-4
12. Choi HK, Gao X, Curhan G. Vitamin C intake and the risk of gout in men: a
prospective study. Arch Intern Med. 2009 Mar 9;169(5):502-7.
Appendix 1.: Nijmegen score[13]
Gout Diagnosis: The Nijmegen score
Parameter Score
Male gender 2
One or more previous attacks 2
Onset of attack within one day 0.5
Joint redness 1
Joint affected – 1st metatarsalphalangeal joint 2.5
Hypertension or 1 or more cardiovascular 1.5

diseases
Serum uric acid > 0.32 mmol/l 3.5
Score ≥8 80% probability of having gout
Score 4 - 8 30% probability of having gout
Score ≤4 2% probability of having gout

Gout Management Guidelines Updated May 2016

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Gout Management Guidelines Updated May 2016

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SUMMARY

NHS Fife Gout Management Guidelines

Diagnosis of Acute Gout

Management of Acute Gout

Management of Chronic Gout

Gout Diagnosis Facts

• A typical gout attack is the development of a

• The differential diagnosis includes septic arthritis

Management of Acute Gout [1]

1. Affected joint(s) should be rested and anti-inflammatory and analgesic

Figure 2. Gout crystals Figure 3. Gout Erosions

1. The therapeutic goal of urate-lowering therapy is to achieve a uric acid

Management of Chronic Gout: Key facts

Acute Gout management in patients with Renal Impairment (table 3).

1. To minimise risk of diarrhoea doses of colchicine 500micrograms two times a

Chronic Gout management in patients with Renal Impairment (table 3)[9].

Colchicine dose in renal impairment

Colchicine dose in renal impairment

Allopurinol dose in renal impairment

Febuxostat dose in renal impairment

Allopurinol Colchicine Benzbromarone

eGFR, U&Es, 6 monthly in the first 3 monthly monthly for 1st 6

Optimal treatment of gout requires both non pharmacologic and pharmacologic

Lifestyle Advice [1]

1. In overweight patients dietary modification to achieve ideal body weight

Risk factors for Gout Comment

Raised serum urate The higher the urate level, the

Genetics Mutations in genes for urate

Gender Male :Female ratio 3:1 in those > 65

Osteoarthritis Gout attacks more likely in joints

Indications for GP referral of Gout Patients to Rheumatology

Patients with urolithiasis should be assessed by a Urologist.

Indications for X-Ray in Gout Patients

When Can Urate Lowering Therapy be Reduced?

Gout Management: Key Facts Summary

1. British Society for Rheumatology and British Health Professionals in Rheuma-

Gout Diagnosis: The Nijmegen score

One or more previous attacks 2

Onset of attack within one day 0.5

Joint affected – 1st metatarsalphalangeal joint 2.5

Hypertension or 1 or more cardiovascular 1.5

Serum uric acid > 0.32 mmol/l 3.5

Score ≥8 80% probability of having gout

Score 4 - 8 30% probability of having gout

Score ≤4 2% probability of having gout

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