• 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

• Start allopurinol after two or more attacks of gout within a year or after the first attack in people at higher risk with one or more tophi, X-ray features of gouty arthritis, renal impairment, known uric acid stones, or on long-term diuretic medication:
• Start allopurinol 1–2 weeks after the inflammation has settled and titrate the dose every few weeks until the serum uric acid level is below 300 micromol/L.
• Co-prescribe a low dose of nonsteroidal anti-inflammatory drugs (NSAIDs) or low-dose colchicine for a minimum of 6 weeks to prevent acute attacks of gout when starting allopurinol. Consider the need for gastroprotective medication when prescribing an NSAID.
• If NSAIDs and colchicine are contraindicated, low-dose oral prednisolone once a day for 4 to 12 weeks is recommended.
• Consider febuxostat as second-line therapy if allopurinol is not tolerated or contraindicated. The dose may be increased after 2–4 weeks if the SUA level remains above 360 micromol/L.
• Co-prescribe a low dose of nonsteroidal anti-inflammatory drugs (NSAIDs) or low-dose colchicine for at least 6 months, to prevent acute attacks of gout when starting febuxostat. Consider the need for gastroprotective medication when prescribing an NSAID.
• If NSAIDs and colchicine are contraindicated or not tolerated, low-dose oral prednisolone once a day for 4 to 12 weeks is recommended.

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

• In most people, allopurinol 100 mg once a day can be started (preferably taken after food) [Jordan et al, 2007]. The dose can then be increased by 50–100 mg increments approximately every 2–3 weeks until a dose of 300 mg is reached, then check the person's serum uric acid (SUA) level and renal function at 3 months.
• Increase doses further to achieve a SUA level below 300 micromol/L. The maintenance dose of allopurinol is often in the region of 300 mg a day but may vary between 100–900 mg.
• Allopurinol is usually given once a day. Doses over 300 mg per day should be taken in divided doses, which will help minimize any gastrointestinal adverse effects.
• Adjust the dose of allopurinol according to:
• SUA levels.
• Renal function.
• Clinical response and how well the allopurinol is tolerated.
• In elderly people, those with frequent attacks, those with renal impairment (glomerular filtration rate less than 60 mL/min), and in those with hepatic impairment, start allopurinol 50 mg once a day. See Managing renal impairment. Note: allopurinol 50 mg tablets are not available, so when providing a 50 mg dose, check that the 100 mg tablets are scored.

In depth

• Treatment with allopurinol or febuxostat is usually lifelong.
• Consider stopping allopurinol or febuxostat in people who have had a normal serum uric acid level for many years with no acute attacks of gout.

In depth

Febuxostat may be used second-line in people with chronic symptomatic gout who are intolerant of allopurinol, or for whom allopurinol is contraindicated. It should not be started until an acute attack of gout has completely subsided, as the drug may precipitate further attacks.

• The recommended oral dose is febuxostat 80 mg once daily. If the serum uric acid (SUA) level is greater than 360 micromol/L after 2–4 weeks, the dose may be increased to 120 mg once daily, aiming for a therapeutic target SUA level of below 360 micromol/L.
• The febuxostat Summary of Product Characteristics recommends gout flare prophylaxis with a nonsteroidal anti-inflammatory drug or colchicine, for at least 6 months. If a gout flare occurs during treatment with febuxostat, it should not be discontinued. See Recurrent gout for more information.
• Febuxostat is not recommended in people with ischaemic heart disease, congestive heart failure, or malignant disease and its treatment.
• 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 < 30 ml/min).
• Liver function tests (LFTs) should be checked before starting febuxostat treatment, as mild liver test abnormalities have been observed. LFTs should be checked periodically thereafter, based on clinical judgement. 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, according to the Summary of Product Characteristics.

In depth

• If taking allopurinol, check the serum uric acid (SUA) level and renal function every 3 months in the first year, then annually, and aim for a SUA level below 300 micromol/L.
• If taking febuxostat, use clinical judgement to decide if liver function tests need to be retested periodically.
• If the person is still having frequent attacks of gout:
• Assess compliance with prophylactic medication or increase the dose if appropriate.
• Review any trigger factors such as medication (e.g. diuretics), trauma, diet, weight gain, and excess alcohol consumption.
• Provide a home supply of medication to use during an acute attack to minimize the impact on the person's functioning.
• Review cardiovascular risk factors and provide ongoing lifestyle advice.
• Consider referral to secondary care, if the person is still having attacks despite all these measures.

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