Gout: management

Gout is a form of microcrystal synovitis caused by the deposition of monosodium urate monohydrate in the synovium. It is caused by chronic hyperuricaemia (uric acid > 450 µmol/l)

Acute management

• NSAIDs
• intra-articular steroid injection
• colchicine* has a slower onset of action. The main side-effect is diarrhoea
• oral steroids may be considered if NSAIDs and colchicine are contraindicated. A dose of prednisolone 15mg/day is usually used
• if the patient is already taking allopurinol it should be continued

Allopurinol prophylaxis - see indications below

• allopurinol should not be started until 2 weeks after an acute attack has settled as it may precipitate a further attack if started too early
• initial dose of 100 mg od, with the dose titrated every few weeks to aim for a serum uric acid of < 300 µmol/l
• NSAID or colchicine cover should be used when starting allopurinol

Indications for allopurinol**

• recurrent attacks - the British Society for Rheumatology recommend 'In uncomplicated gout uric acid lowering drug therapy should be started if a second attack, or further attacks occur within 1 year'
• tophi
• renal disease
• uric acid renal stones
• prophylaxis if on cytotoxics or diuretics

Lifestyle modifications

• reduce alcohol intake and avoid during an acute attack
• lose weight if obese
• avoid food high in purines e.g. Liver, kidneys, seafood, oily fish (mackerel, sardines) and yeast products

Other points

• losartan has a specific uricosuric action and may be particularly suitable for the many patients who have coexistant hypertension
• calcium channel blockers also decrease uric acid levels, possibly by a renal vasodilatory effect
• increased vitamin C intake (either supplements or through normal diet) may also decrease serum uric acid levels

*inhibits microtubule polymerization by binding to tubulin, interfering with mitosis. Also inhibits neutrophil motility and activity
**patients with Lesch-Nyhan syndrome often take allopurinol for life