Gout

Investigations

• FBC
• ESR/PV
• RENAL PROFILE (P5)
• Serum Urate (between attacks - the serum uric acid may fall to normal during the acute phase.)
• Xray of target joint
• Synovial fluid analysis - send to Histopathology for cytology

Preventing attacks

Indications: Recurrent acute gout, >3 attacks per year.

Tophaceous gout with renal impairment (inc. late onset female).

NB - Only start prophylaxis after acute attack has been settled >= 2 weeks.

Note that patients may continue to have acute attacks of gout for at least 6 months after prophylaxis is started. If podagra occurs whilst on prophylaxis then continue with the prophylaxis and add an NSAID or colchicine as above.

Do not stop prophylaxis if an acute attack occurs!

Special Points

1. Continue first line treatment for about six weeks after starting allopurinol.
2. Acute attacks of podagra may occur for many months after starting allopurinol. Reintroduce first line treatment but CONTINUE allopurinol.
3. Up to 30% of patients with gout have polyarthritis.

When to Refer

1. Unsure of diagnosis. differential = chondrocalcinosis monoarticular inflammatory arthritis septic arthritis traumatic osteoarthritis
2. Failure of first line management.
3. Renal impairment. urea > 10 or creatinine > 150
4. Allergy to Allopurinol.
5. Secondary gout.
6. Patient on Azathioprin or 6 Mercaptopurine.
   Rheumatology Referral

First Line Management

Managing acute attacks

Either NSAID or Colchicine until the attack resolves.
NSAID: e.g. Naproxen 500 mg statim then 250 mg tds.
Colchicine: 1 mg followed by 500 mcg 4 hours later.

Then 500 mcg qds until attack resolves.

Starting prophylaxis

1. To prevent an acute exacerbation on introduction of allopurinol or probenecid you should co-prescribe an NSAID or colchicine for the first two months.

Suggest: Naproxen 500 mg bd for OR Colchicine 500 mcg tds - for 2 months

Either

2a. Allopurinol

week 1 - 100 mg od
week 2 - 200 mg od
week 3 - 300 mg od
week 6- Recheck serum urate and adjust allopurinol dose.
You might need to lower the dose in renal failure.
Maintenance dose 200 - 600 mg od.
week 9 - Stop co-prescribed NSAID or colchicine.

or

2b. Probenecid

week 1- 250 mg bd with food
week 2- 500 mg bd with food
week 6- Recheck serum urate and adjust allopurinol dose.
Maintenance dose 2g per day in 2-4 divided doses.
week 9- Stop co-prescribed NSAID or colchicine.

Document Information
Expiry Date : 11/04/04
Author : Kennedy Tom Dr
Organisation : Arrowe Park Hospital