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Gout

NICE guideline [NG219] Gout: diagnosis and management. Published: Jun 2022.

Disclaimer

Comparing the recommendations:

  • While both guidelines agree on acute flare treatment and ULT dosing strategies, NICE NG219 favours initial serum urate testing over routine joint aspiration and delays ULT until certain clinical thresholds are met. In contrast, the BSR 2017 guideline emphasises early crystal confirmation and advocates initiating ULT after the first flare in most patients, with a longer (6 month) prophylaxis period.
     

Which reflects the most up-to-date evidence?

  • For current UK practice, the NICE guideline is more accurate and evidence-based
  • NICE NG219, last reviewed June 2022, incorporates newer trial data (e.g., on febuxostat’s cardiovascular safety and optimal prophylaxis duration) and pragmatic primary-care pathways.
  • BSR guideline on the other hand is published on July 2017.

Guidelines

1st line test: serum urate level
  • ≥360 μmol/L or 6mg/dL confirms the diagnosis of gout
  • If below the cut off → repeat the test at least 2 weeks after the flare has settled

2nd line:
  • Joint aspiration and microscopy of synovial fluid - gold standard test

3rd line:
  • Imaging of the affected joint(s) with X-ray / ultrasound / dual-energy CT
 

NICE recommends measuring serum urate level as the first test in anyone with a typical acute monoarthritis due to its non-invasive property, high availability, and low cost to be used in primary care. The NICE committee noted that joint aspiration is the 'gold standard' test to diagnose gout when the diagnosis remains uncertain.

Note that synovial fluid microscopy can definitively distinguish gout from septic arthritis (the most important differential diagnosis to exclude in acute monoarthritis) and other causes of arthritis.

Parameter Finding in Gout
Appearance Cloudy, yellow
Viscosity Reduced
WBC count and differential 2,000 - 50,000 (50-90% polymorphs)
Crystals Needle-shaped monosodium urate crystals
Strongly negative birefringence
Gram stain / culture -ve
Glucose Normal

Apply ice packs to the affected joint.

Pharmacological management:
  • 1st line: NSAID / colchicine / oral corticosteroid (short-course)
 
  • 2nd line: intra-articular / intramuscular corticosteroid injection
 

Common reasons to avoid NSAIDs in acute gout flare are:

  • History of peptic ulcer disease or GI bleed
  • Chronic kidney disease
  • Congestive heart failure (NYHA III / IV)

In these patients, colchicine or steroids are preferred.

  • Advise patients to follow a healthy, balanced diet
  • Advise that excess body weight, obesity, excessive alcohol consumption may exacerbate gout flares and symptoms 

ULT should be offered and discussed with ALL patients after a first gout flare.

ULT is indicated in:
  • Multiple or troublesome flares
  • CKD stages 3 to 5 
  • Diuretic therapy
  • Tophi
  • Chronic gouty arthritis

1st line: allopurinol / febuxostat (both xanthine oxidase inhibitors)
  • Febuxostat should be avoided in those with major CVD (e.g. previous MI, stroke, unstable angina)

  • ULT should be started at least 2 to 4 weeks after a gout flare has settled
  • Offer colchicine when starting and titrating ULT 
    • Alternative: low-dose NSAID or low-dose oral corticosteroid

ULT should be offered with a treat-to-target strategy:
  • Start with a low dose of ULT
    • For allopurinol: start at 50-100mg daily, then increase in 100mg increments every ~4 weeks
    • Maximum dose for allopurinol: 900mg
 
  • Then, use monthly serum urate level to guide dose increases until the target serum level is reached
 
  • Target serum urate level:
    • <360 μmol/L / 6 mg/dL for most patients
    • Consider <300 μmol/L / 5 mg/dL for those with tophi / chronic gouty arthritis / continue to have frequent flares despite below the initial target
 

If ULT is started during the acute gout flare, reducing serum urate levels can destabilise monosodium urate crystals in joint tissues, making the flare worse or more prolonged.

Consider annual monitoring of serum urate level in people with gout who are continuing ULT after reaching their target serum urate level.

References

Author: Adams Lau
Reviewer:
Last edited: 28/05/25