• Treat as early as possible
• Patient education
• NSAID (or coxib) plus PPI

or

• Colchicine 500microg bd-qds.  [An alternative approach is as per EULAR guidance - loading dose Colchicine 1mg within 12hrs of onset followed 1hr later by 0.5mg, +/- NSAID, Prednisolone 30-35mg for 5 days or intra-articular steroid]

or

• Corticosteroid (i.a., oral, i.m., i.v.)
• Consider adjunctive non-pharmacological treatment (e.g. topical ice, rest)

• Assess lifestyle factors (diet, exercise, alcohol, sugary drinks)
• Assess cardiovascular risk factors (obesity, hypertension, lipids, diabetes mellitus)
• Review prescribed medication (diuretics)
• Perform sUA, renal function

• Patient education
• Optimise weight (where relevant)
• Modify diet (where relevant)
• Reduce alcohol intake (where relevant)
• Discontinue diuretic (where relevant/possible)
• Treat underlying cardiovascular risk factors
• Discuss ULT with patient

• First-line ULT: allopurinol
• Start at low dose 50-100mg daily
• Titrate allopurinol dose in 50-100 mg increments every 4 weeks dependent on sUA
• Target sUA: <300micromol/L
• Maximum dose 900mg daily (dependent on renal function)
• Consider prophylaxis (colchicine 500microg od-bd or NSAID/coxib + PPI)
• Do not stop allopurinol during acute attacks

• Consider switch to febuxostat 80mg od
• Increase febuxostat dose to 120mg od after 4 weeks if target sUA not reached

• Consider switch to febuxostat 80mg/120mg od

or

• Consider switch to or addition of:
  • Sulfinpyrazone or probenecid or benzbromarone
  • Titrate dose every 4 weeks dependent on sUA

Consider switch to:

• Sulfinpyrazone or probenecid or benzbromarone
• Titrate dose every 4 weeks dependent on sUA

• Consider reducing ULT dose to maintain sUA between 300micromol/L and 360micromol/L
• Check ULT annually to ensure target still maintained (otherwise adjust ULT dose)
• Continue ULT lifelong unless modifiable risk factors successfully addressed and clinical 'cure' achieved

• Patient education paramount for optimal control (high non-adherence with ULT)
• Early treatment of acute attacks
• Choice of treatment dependant on co-morbidities and patient informed preference
• Avoid Colchicine and NSAIDs in severe renal impairment
• Avoid Colchicine in those receiving (or recently prescribed if renal impairment)
• strong P-glycoprotein or CYP3A4 inhibitors eg cyclosporin or clarithromycin
• Co-prescribe PPI with NSAID as per NICE guidance
• Consider urate lowering therapy (ULT) for all 4-6 weeks after first diagnosed attack
• Consider prophylaxis with NSAID or colchicine for first 6 months of ULT, weighing up
• risks and patient preference on individual basis
• Aim for target serum uric acid (SUA) < 0.30mmol/l
• Once target achieved plus resolution of tophi, reduce ULT to maintain SUA 0.30 – 0.36mmol/l
• Annual review of SUA and ULT
• Continue ULT lifelong unless modifiable risk factors successfully addressed and clinical cure achieved
• Cardiovascular risk factor screening and management for all including annual monitoring of risks

• Continue ULT during acute attack if already taking
• If on diuretic for treatment of hypertension consider change to alternative hypertensive
• Losartan and Fenofibrate have modest urate lowering effect therefore consider as first line for hypertension and hyperlipidaemia on those with gout
• See allopurinol dose titration for renal impairment in full BSR guidance below

In Dumfries and Galloway

Refer to rheumatology clinic if:

1. Diagnosis uncertain
2. Resistant disease - new treatment options are available by IPTR for acute attacks and prophylaxis

For individual patient advice:

Refer via Sci-gateway advice