• Confirm gout and exclude alternative diagnoses, especially septic arthritis.
• Assess the severity of the attack (number of joints affected, the person's ability to mobilize, impact on work and functioning).
• Ask about previous attacks and which drugs (if any) the person is taking or has tried.
• Assess risk factors such as medication (e.g. diuretics), alcohol, diet, and obesity.
• Identify any associated conditions (e.g. hypertension, diabetes, cardiovascular disease).
• Measure the person's serum uric acid level 4–6 weeks after the acute attack.

In depth

• Prescribe a nonsteroidal anti-inflammatory drug (NSAID) such as diclofenac, indometacin, or naproxen as soon as possible, and continue the treatment until 48 hours after the attack has resolved.
• If NSAIDs are contraindicated, not tolerated, or have been ineffective in previous attacks, prescribe oral colchicine 500 micrograms, two to four times a day, until relief of pain is achieved, or diarrhoea or vomiting occurs.
• If NSAIDs and colchicine are contraindicated, consider systemic corticosteroids.
• Use paracetamol, with or without codeine, in addition to other drug treatment, or alone, if NSAIDs, colchicine, and corticosteroids are all contraindicated.
• Do not stop allopurinol or febuxostat during an acute attack of gout.

In depth

• Advise the person to rest, elevate the limb, and avoid trauma to the affected joint.
• Keep the joint in a cool environment by avoiding clothing and using an ice pack.
• Offer lifestyle advice.

In depth

• Aim for an ideal body weight — but avoid crash dieting and high protein/low carbohydrate diets.
• Eat sensibly — by restricting the amount of red meat and avoiding a high protein intake. Avoid foods rich in purines such as liver, kidneys, and seafood.
• Drink alcohol sensibly — by avoiding binge drinking and restricting alcohol consumption to 21 units per week for men and 14 units per week for women.
• Avoid dehydration by drinking water (up to 2 litres/day unless there is a medical contraindication).
• Take regular exercise — but avoid intense muscular exercise and trauma to joints.
• Stop smoking.
• Provide written information and patient support via the UK Gout Society. For more information, see www.ukgoutsociety.org.

In depth

• If there is no improvement in symptoms after 2–3 days:
• Review the diagnosis, check compliance with medication, and encourage self-care strategies.
• Increase the dose of medication to maximum and add paracetamol, with or without codeine.
• If there is still no improvement in symptoms, try an alternative drug or consider combining treatment, or seek specialist advice.

In depth

• Follow up the person 4–6 weeks after an acute attack of gout has resolved, and:
• Check the serum uric acid level.
• Measure their blood pressure and take blood for fasting glucose, renal function, and lipid profile.
• Identify underlying conditions such as hypertension, diabetes, or renal impairment, and assess the person's overall cardiovascular risk.
• Provide advice on risk factors such as obesity, diet, excessive alcohol consumption, and exercise.
• Consider prophylactic medication if a person is having two or more attacks of gout in a year. See Recurrent attacks of gout for more information.
• Consider providing an advance prescription of effective treatment for future attacks of gout.

In depth

• Admit the person if septic arthritis is suspected.
• Seek specialist advice when:
• The diagnosis is uncertain, there is a suspicion of an underlying systemic illness (e.g. rheumatoid arthritis or connective tissue disorder), or gout occurs during pregnancy or in a young person (under 25 years of age).
• Allopurinol or febuxostat is at maximum dose but a person is still having recurrent attacks of gout.
• A person has 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.
• Complications are present, including urate kidney stones, urate nephropathy, or troublesome tophi.

In depth