1. Exclude infection
When a patient presents with suspected acute gout, it is important to exclude other causes of inflammation, such as
sepsis within the joint, especially if gout has not been previously diagnosed.
The clinical presentation of acute monoarticular gout may be identical to that of an acute septic arthritis and occasionally
gout and infection can co-exist. Infection is more likely if the patient is systemically unwell and there is a single,
acutely painful, swollen, hot joint (e.g. knee). Gout is the more likely clinical diagnosis if the patient has a history
of similar attacks, is of male gender, is systemically well and if there is involvement of the first metatarsal phalangeal
joint (MTP). Gout is a more common diagnosis than septic arthritis.1
If after clinical review, infection is suspected, aspiration of synovial fluid from the affected joint, for microbiological
analysis, is recommended where possible, to confirm or exclude sepsis. N.B. This may also confirm the diagnosis of gout
(by the presence of uric acid crystals).
2. Prescribe anti-inflammatory medicine and rest
If gout is the most likely diagnosis, the patient should be advised to rest the affected joint and should be prescribed
an anti-inflammatory treatment.
NSAIDs are first-line
First-line treatment is usually an oral, non steroidal anti-inflammatory drug (NSAID), e.g. naproxen 500 mg, twice daily;
ibuprofen 200-400 mg, four times daily; or diclofenac 75 mg, twice daily. Medicine should be taken until the attack subsides.
Paracetamol can also be used concurrently for pain relief.
Use corticosteroids only if infection is excluded
Corticosteroids may be considered for patients in whom NSAIDs are contraindicated (e.g. peptic ulceration, concurrent
anticoagulant treatment), but only if infection has been excluded. A suggested initial dose is 20-40 mg prednisone daily,
gradually reduced over 10-14 days. Intra-articular corticosteroids (e.g. triamcinolone acetonide - Kenacort-A - up to
10 mg for small joints, up to 40 mg for large joints) can be especially useful if one or two joints are affected as this
reduces the risks of systemic corticosteroids treatment. However, in patients with diabetes, corticosteroids should be
used with caution as doses of insulin or anti-diabetic medicines may need to be adjusted.
Consider colchicine if NSAIDs and corticosteroids contraindicated
When NSAIDs or corticosteroids are contraindicated, low dose colchicine remains an appropriate treatment option. Colchicine
has a slower onset of action than NSAIDs and serious adverse effects can occur if the dose is too high.2 Adverse
effects include: gastrointestinal disturbance, electrolyte imbalance, haematological effects and multi-organ failure.
Colchicine toxicity has also been reported with concomitant use of liver enzyme inhibitors (e.g. erythromycin, ketoconazole,
diltiazem), statins, fibrates and digoxin, daily consumption of grapefruit juice and in patients with hepatic or renal
The recommended dose for colchicine for the treatment of acute gout is 1.0 mg stat, followed by 0.5 mg six hourly, up
to a maximum dose of 2.0 mg per 24 hours on the first day and to a maximum of 1.5 mg on subsequent days.3 Patients
should be advised to contact their doctor if gastrointestinal symptoms occur.
N.B. this is a lower dose than suggested in previous guidance.
The total dose should not exceed 6 mg over four days. In elderly people who weigh <50kg, or people with renal or
hepatic impairment, other treatments should be considered before colchicine but if colchicine is used the maximum cumulative
dose should not exceed 3 mg over four days.4
Combination treatment may be useful for some people
Corticosteroids can be used in combination with NSAIDs or colchicine to provide further relief during acute gout. Colchicine
can be a useful adjunct to NSAIDs in resistant cases, particularly when gouty tophi are present or to prevent flares when
starting allopurinol. Weak opioid analgesics, e.g. codeine, can also be prescribed for further pain relief.2
If there is no response to treatment, the diagnosis should be reconsidered.
Serum urate levels may not be useful for diagnosis of an acute attack of gout
The diagnosis of gout is often made on clinical grounds, but if possible, should be confirmed by the presence of uric
acid crystals on aspiration of the affected joint.
Although serum urate is the most important risk factor for gout, and should be measured in all suspected cases, not
all patients with hyperuricaemia will develop gout. Serum urate levels do not confirm or exclude gout during acute attacks,
as serum levels may be normal during this time. Serum urate should be measured again once the attack has subsided.
Although x-rays may be useful for the differential diagnosis and may show typical features in chronic gout, they are
not useful in confirming the diagnosis of early or acute gout.