Gout (Crystal Arthropathy)

Overview

Gout is a disorder of purine metabolism characterized by a raised uric acid level in the blood (hyperuricaemia) and the deposition of urate crystals in joints and other tissues, such as soft connective tissues or the urinary tract.

Gouty arthritis is arthritis due to urate crystals in joints.

The natural history of gout can occur in three distinct phases:

• A long period of asymptomatic hyperuricaemia.
• A period during which acute attacks of gouty arthritis are followed by variable intervals (months to years) when there are no symptoms.
• The final period of chronic tophaceous gout, where people have nodules affecting joints.

Gout may present without hyperuricaemia, and hyperuricaemia may occur without gout.(1)

(1) CKS on Gout

Diagnosis and Who to Refer

The majority of patients with gout can be managed in primary care and there is advice on diagnosis and management in CKS.

If presentation is not typical then consider what else it might be (see also red flag section below).

Dr Paul Creamer, Consultant Rheumatologist at NBT advises the following approach:

First MTP joint -  in general an acute hot 1st MTP is very likely to be gout. Urate should be checked, but it is reasonable to treat as gout pending results. Don’t try to aspirate. Consider it might NOT be gout if atypical patient – e.g. young, female, no risk factors.

Other joints - diagnosis in other joints is less clear and do not assume a swollen knee/ankle is gout unless you have evidence to support that –i.e. raised uric acid, crystals on aspirate.  Consider alternatives. Try to get fluid especially if from the knee (getting fluid from other joints is very tricky and should normally be avoided in primary care).Beware septic arthritis  - particularly if unwell, febrile, risk factors for sepsis etc (see Red Flags section below).

Urate Levels and gout - A normal urate does not exclude gout, however several uric acid levels in low normal range effectively does exclude gout. If you suspect gout (as above) and uric acid is normal, don’t let that put you off treating – but repeat it later.

CPPD (pseudogout) - Don’t assume it is CPPD just because uric acid is repeatedly normal. There are other causes. A patient with an unexplained persistent swollen joint should be referred – if you suspect sepsis (unlikely if long term) send to orthopaedics, otherwise to rheumatology. 

Consider requesting rheumatology advice and guidance or contacting your local rheumatology on call team in the following circumstances:

• Diagnosis is uncertain, there is a suspicion of an underlying systemic illness (for example rheumatoid arthritis or connective tissue disorder), or gout occurs during pregnancy or in a young person (under 30 years of age).
• Persistent symptoms during an acute attack despite maximum doses of anti-inflammatory medication (alone or in combination).
• An intra-articular steroid injection is indicated but the facilities or expertise are not available.
• The patient requires urate-lowering treatment and:
  • Allopurinol and febuxostat are not tolerated or contraindicated.
  • Allopurinol or febuxostat is at maximum dose but there is failure to reach urate level target or the patient is still having recurrent attacks of gout.
  • Complications are present, including urate kidney stones, urate nephropathy, recurrent urinary tract infection, joint damage or troublesome tophi.
  • The patient is at risk of adverse effects of drug treatment. 

Red Flags

Septic arthritis requires an urgent referral or aspiration of the affected joint with urgent microscopy and culture.

Septic arthritis must be considered in any person who is systemically unwell (with or without a temperature) and an acutely painful, hot, swollen joint. It is important to diagnose septic arthritis promptly, as late recognition can be fatal (1).

For suspected septic arthritis refer to A&E/discuss urgent assessment with the orthopaedic team on call.

Treatment and Management

Acute Gout

 Acute attacks should be treated as early as possible (as soon as an attack occurs).

Information about treatment can be found in the CKS link above or there are further guidelines on management of acute gout and gout prevention from The British Society for Rheumatology below:

The British Society for Rheumatology Guideline for the Management of Gout 

Prescribing information can be found on the Adult Joint Formulary.

Self-care

Advise the person to:

• Rest and elevate the limb.
• Avoid trauma to the affected joint.
• Keep the joint exposed and in a cool environment.
• Consider the use of an ice pack or bed-cage.

Discuss lifestyle issues such as weight loss, exercise, diet, alcohol consumption, and fluid intake. 

Assess CVD Risk in all patients with hyperuricaemia

Most patients with asymptomatic hyperuricaemia do not require treatment.  However, there is evidence that it may contribute to the development of hypertension − therefore consider the following in a patient with hyperuricaemia:

• assess cardiovascular disease risk
• provide lifestyle advice to prevent development of cardiovascular disease

Review cardiovascular risk factors and provide ongoing lifestyle advice: 

• in a person with hypertension, stop diuretics during an acute attack and change to an alternative antihypertensive
• in a person with heart failure, continue diuretics during an acute attack − if using a non-steroidal anti-inflammatory drug (NSAID) for pain relief, monitor renal function closely

Screen for co-morbidities associated with gout using the following investigations:

• blood pressure
• cholesterol
• blood sugar 

Allopurionol

Dr Paul Creamer, Consultant Radiologist at NBT advises the following approach to prevention of attacks:

Both UK and European guidelines recommend treating to target. Start allopurinol low dose – 100 mg daily (50 mg daily in elderly, reduced eGFR etc – or even 50 mg alt days) and increase every 6 weeks checking uric acid before. Aim to get uric acid levels to low normal (i.e. < 320 but be aware this a guideline – 340, 360 may be OK). Cover for 6 weeks after starting and after increasing dose  - with low dose NSAID, colchicine or steroids (depends on patient).

Almost all patients who “can’t take” allopurinol actually can if introduced slowly, with cover and alternatives are rarely required.

Services

If after following the management guidance above, a referral is still being considered, please see the following options:

• If advice is required then consider Rheumatology Advice and Guidance via eRS.
• If referral to outpatients is required then consider a Rheumatology referral via eRS.
• If the differential diagnosis includes early inflammatory arthritis and criteria for referral are met, then consider referral to EIA clinic via eRS.

Resources

Our thanks to Dr Paul Creamer, Consultant Rheumatologist, NBT for his input into development of this page.

Gout on Patient UK

Gout on Versus arthritis 

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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