Pre- referral Checklists

GOUT

General points

  • Gout usually starts as an acute onset lower limb monoarthritis with pain that is EXTREMELY severe “the worst pain I’ve ever had – 11/10 severity”
  • Pain often maximizes in first 6-12 hours and resolves in 3-10 days
  • Attacks recur at intervals- between attacks the joint is initially normal
  • Joint is hot, red, swollen, tender – 1stMTP joint involved in 50% first attacks and 90% of patients within 12 months. If not 1stMTP then first attack usually midtarsal or ankle.
  • Gout is usually a clinical diagnosis
  • Associations with:
  • metabolic syndrome,
  • Non Alcoholic Fatty Liver Disease (NAFLD)
  • Diabetes Mellitus type 2
  • Increased risk of cardiovascular disease
  • Gout is very rare in premenopausal women or men under 30yrs
  • USUALLY MEN> 40y or women > 70y(where associated with CCF, diuretic use)

Have DIFFERENTIAL DIAGNOSES BEEN CONSIDERED? e.g.
  • septic arthritis
  • gout usually presents in MTP joint – if first episode not in MTP joint then joint needs aspirating
  • systemic features of sepsis
  • septic joints get worse rather than better
  • prosthesis in-situ
  • Psoriatic arthritis(as often lower limb onset)-this is the main differential- URATE OFTEN RAISED: psoriatic attacks may persist or not settle completely
/ y/n
Have Investigations been performed?
Urate-Is not diagnostic and may be falsely normal in an acute attack
The main use of urate is in titrating prophylactic urate lowering treatments such as allopurinol
Consider FBC, ESR, CRP if appropriate / y/n
TREATMENT IN PRIMARY CARE
acute attack – prompt treatment works best
options:
  • NSAIDs until 2 days after symptoms settle, consider gastroprotection +/- PPI or
  • Colchicine 500mcgs 2-4 daily
  • Prednisolone 20mg-40 mgs od for 5 days
  • Consider precipitating drugs e.g. diuretics / aspirin / salicylates
Recurrent gout
  • Lifestyle modifications
  • Reconsider precipitating drugs e.g. diuretics / aspirin / salicylates
  • STOP THIAZIDES ( considering implications)
  • ConsiderURATE LOWERING TREATMENT: (see appendix1)
  • Allopurinol- first line
  • Febuxostat - second line
IF
  • 2 or more attacks per year
  • renal impairment (lowering urate is renoprotective)
  • urate stones
  • tophi
  • erosions on xray
  • need to continue loop diuretic therapy
  • start urate lowering therapy when disease in remission
(If never in remission then start but warn about allopurinol flare and ensure cover with NSAIDS/ colchicine / steroids)
  • Give low dose NSAIDs (+/- PPI) or colchicine (0.5mg per day) for a week before and the first 3-6 months of allopurinol/febuxostatto prevent a flare
OR
  • Low dose prednisolone 5-10mgs 4-12 weeks ( may be safer better tolerated alternative prophylactic agent) issue ‘steroid’ card for treatment exceeding 3 weeks
Note-a frequent cause of relapse is inadequate prophylactic cover
  • Consider Bone protection(separate guideline)
  • Explain this treatment is lifelong and may initially precipitate flares – continue the treatment
  • Treat acute flares as above
  • Try not to discontinue urate lowering therapy if flare develops on treatment, unless the patient has only just started; in patients established on allopurinol treat flare and continue therapy
  • allopurinol hypersensitivity is rare but can be very dangerous.
  • Features include renal or hepatocellular injury, rash , fever,
  • Risk is increased in renal impairment, the elderly and those on baseline thiazide therapy.
  • Stop treatment if any rash develops and liaise with rheumatology
  • ‘apparent’ hypersensitivity may actually be dosage problems ( over-rapid escalation), lack of prophylactic cover, use with thiazide etc

Consider REFERRALif:
  • Diagnostic uncertainty
  • Complex medical comorbidities
  • Refractory cases
  • For issues around possible Hypersensitivity to allopurinol-consider d/w rheumatology or try febuxostat
  • For these discussions include details of Initial allopurinol dose, speed of escalation, urate level and reason for treatment failure
/ y/n
References:

Patient information
Thanks to Dr Matthew Grove, Dr Les Ashton, November 2015
APPENDIX 1
COLCHICINE TREATMENT REGIME for acute gout
500micrograms (1 tablet) , two to four times a day, until relief of pain is achieved, or diarrhoea or vomiting occurs
  • In people with moderate renal impairment, a low starting dose of 500 micrograms twice a day should be considered
  • oThe licensed daily dose of colchicine (1mg followed by 500micrograms every 2–3 hours, up to a maximum of 6mg has been found to commonly cause gastrointestinal adverse effects although there may be a faster clinical response than with the dose recommended by the BSR
ALLUPURINOL TREATMENT REGIME
  • typical starting dose = 100mg – increase by 100mg every 2w until urate < 300-330umol/l , usual dose 300mg OD can be increased to maximum dose 900mg / day (doses >300mg should be taken in divided doses)
  • check serum uric acid (SUA) level and renal function at 3 months.
  • reduce initial dose in renal impairment – 50mg (half a tablet check tablets are scored) - and slow cautious dose increases – see BNF
FEBUXOSTAT TREATMENT REGIME
  • recommended as a possible treatment for chronic hyperuricaemia in people with gout ONLY if:
  • allopurinol contraindicated
  • allopurinol not tolerated
  • true allopurinol hypersensitivity
  • starting dose of 80 mg once daily. If the serum uric acid (SUA) level is greater than 6 mg/dl (360 micromol/L) after 2–4 weeks, increase the dose of febuxostat to 120 mg once daily, aiming for a therapeutic target SUA level of below 6 mg/dl (360 micromol/L).
  • In people with mild hepatic impairment, febuxostat 80 mg is recommended. There is limited information regarding the use of febuxostat in people with more severe hepatic impairment.
  • No dose adjustment is needed for the elderly, or those with mild or moderate renal impairment. Febuxostat has not been fully evaluated in people with severe renal impairment (creatinine clearance less than 30 ml/min).

1