Gout
NICE guideline [NG219] Gout: diagnosis and management. Published: Jun 2022.
Disclaimer
NICE vs British Society for Rheumatology Guidelines
Comparing the recommendations:
-
While both guidelines agree on acute flare treatment and ULT dosing strategies, NICE NG219 favours initial serum urate testing over routine joint aspiration and delays ULT until certain clinical thresholds are met. In contrast, the BSR 2017 guideline emphasises early crystal confirmation and advocates initiating ULT after the first flare in most patients, with a longer (6-month) prophylaxis period.
Which reflects the most up-to-date evidence?
- For current UK practice, the NICE guideline is more accurate and evidence-based
- NICE NG219, last reviewed June 2022, incorporates newer trial data (e.g., on febuxostat’s cardiovascular safety and optimal prophylaxis duration) and pragmatic primary-care pathways.
- BSR guideline, on the other hand was published in July 2017.
Guidelines
Investigation and Diagnosis
1st line test: serum urate level (interpreted within the clinical context)
- ≥360 μmol/L or 6mg/dL confirms the diagnosis of gout
- If below the cut off (& gout still suspected) → repeat the test at least 2 weeks after the flare has settled
2nd line:
- Joint aspiration and microscopy of synovial fluid – gold standard test
3rd line:
- Imaging of the affected joint(s) with X-ray / ultrasound / dual-energy CT
NICE recommends measuring serum urate level as the first test in anyone with a typical acute monoarthritis in keeping with gout, due to its non-invasive property, high availability, and low cost. The NICE committee noted that joint aspiration is the ‘gold standard’ test to diagnose gout when the diagnosis remains uncertain.
Note that synovial fluid microscopy can definitively distinguish gout from septic arthritis (the most important differential diagnosis to exclude in acute monoarthritis) and other causes of arthritis.
Synovial Fluid Analysis
| Parameter | Finding in Gout |
|---|---|
| Appearance | Cloudy, yellow |
| Viscosity | Reduced |
| WBC count and differential | 2,000 – 50,000 (50-90% polymorphs) |
| Crystals | Needle-shaped monosodium urate crystals Strongly negative birefringence |
| Gram stain / culture | -ve |
| Glucose | Normal |
Management
Acute Gout Flare
General advise:
- Apply ice packs to the affected joint
- Continue treatment with urate-lowering drugs (allopurinol or febuxostat) if acute episode develops whilst on these drugs
Pharmacological management:
- 1st line: NSAID + PPI (NOT aspirin) / colchicine / oral corticosteroid (short-course)
- NICE committee acknowledges that in practice that NSAIDs / colchicine is typically 1st line, preferred over corticosteroids
- The BSR 2017 guideline also supported this, saying 1st line is NSAID or colchicine
- 2nd line: intra-articular / intramuscular corticosteroid injection
- 3rd line: IL-1 inhibitor (to be prescribed by specialist)
Common reasons to avoid NSAIDs in acute gout flare are:
- History of peptic ulcer disease or GI bleed (inc. risk of GI bleed e.g., due to concurrent use of anticoagulants)
- Chronic kidney disease
- Congestive heart failure and cardiovascular disease
In these patients, colchicine or steroids are preferred.
Long Term Management
Diet and Lifestyle
- Advise patients to follow a healthy, balanced diet
- Advise that excess body weight, obesity, excessive alcohol consumption may exacerbate gout flares and symptoms
Urate-Lowering Therapy (ULT)
Indications
Option of ULT should be discussed with ALL patients after a first gout flare.
ULT is particularly indicated in patients who have:
- Multiple or troublesome flares
- CKD stages 3 to 5
- Diuretic therapy
- Tophi
- Chronic gouty arthritis
Duration: typically lifelong (even if target urate levels are met)
Primary prophylaxis against gout is not standard practice in the UK; urate-lowering therapy is reserved for patients with established disease (secondary prophylaxis/prevention).
Choice of Drug
1st line: allopurinol / febuxostat (both xanthine oxidase inhibitors)
- Febuxostat should be avoided in those with major CVD (e.g. previous MI, stroke, unstable angina)
Initiating ULT
- ULT should be started at least 2 to 4 weeks after a gout flare has settled
- Offer anti-inflammatory prophylaxis when starting and titrating ULT
- 1st line: colchicine
- Alternative: low-dose NSAID or low-dose oral corticosteroid
If ULT is started during the acute gout flare, reducing serum urate levels can destabilise monosodium urate crystals in joint tissues, making the flare worse or prolonged.
ULT Treatment Goal
ULT should be offered with a treat-to-target strategy:
- Start with a low dose of ULT
- For allopurinol: start at 50-100mg daily, then increase in 100mg increments every ~4 weeks
- Maximum dose for allopurinol: 900mg
- Then, use monthly serum urate level to guide dose increases until the target serum level is reached
- Target serum urate level:
- <360 μmol/L / 6 mg/dL for most patients
- Consider <300 μmol/L / 5 mg/dL for those with tophi / chronic gouty arthritis / who continue to have frequent flares despite being below the initial target