Recommendations | Gout: diagnosis and management | Guidance

1.1 Diagnosis and assessment

Symptoms and signs

1.1.1

Suspect gout in people presenting with any of the following:

rapid onset (often overnight) of severe pain together with redness and swelling, in 1 or both first metatarsophalangeal (MTP) joints
tophi.

1.1.2

Consider gout in people presenting with rapid onset (often overnight) of severe pain, redness or swelling in joints other than the first MTP joints (for example, midfoot, ankle, knee, hand, wrist, elbow).

1.1.3

Assess the possibility of septic arthritis, calcium pyrophosphate crystal deposition and inflammatory arthritis in people presenting with a painful, red, swollen joint.

1.1.4

If septic arthritis is suspected, refer immediately according to the local care pathway.

1.1.5

Consider chronic gouty arthritis in people presenting with chronic inflammatory joint pain.

1.1.6

In people with suspected gout, take a detailed history and carry out a physical examination to assess the symptoms and signs (see recommendations 1.1.1 and 1.1.2).

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on symptoms and signs of gout.

Full details of the evidence and the committee's discussion are in evidence review B: what signs and symptoms indicate gout as a possible diagnosis?

Diagnosis

1.1.7

Measure the serum urate level in people with symptoms and signs of gout (see recommendations 1.1.1 and 1.1.2) to confirm the clinical diagnosis (serum urate level of 360 micromol/litre [6 mg/dl] or more). If serum urate level is below 360 micromol/litre (6 mg/dl) during a flare and gout is strongly suspected, repeat the serum urate level measurement at least 2 weeks after the flare has settled.

1.1.8

Consider joint aspiration and microscopy of synovial fluid if a diagnosis of gout remains uncertain or unconfirmed.

1.1.9

If joint aspiration cannot be carried out or the diagnosis of gout remains uncertain, consider imaging the affected joints with X-ray, ultrasound or dual-energy CT.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on diagnosis.

Full details of the evidence and the committee's discussion are in evidence review C: what are the most accurate and cost-effective approaches to diagnosing gout, in particular serum urate level compared with joint aspiration?

1.2 Information and support

1.2.1

Provide tailored information to people with gout and their family members or carers (as appropriate) at the time of diagnosis and during subsequent follow-up appointments. Explain:

the symptoms and signs of gout
the causes of gout
that the disease progresses without intervention because high levels of urate in the blood lead to the formation of new urate crystals
any risk factors for gout they have, including genetics, excess body weight or obesity, medicines they are taking, and comorbidities such as chronic kidney disease (CKD) or hypertension
how to manage gout flares and the treatment options available
that gout is a lifelong condition that benefits from long-term urate-lowering therapy (ULT) to eliminate urate crystals and prevent flares, shrink tophi and prevent long-term joint damage
where to find other sources of information and support such as local support groups, online forums and national charities.

See also the recommendations on diet and lifestyle.

1.2.2

Follow the recommendations in NICE's guidelines on patient experience in adult NHS services and shared decision making.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on information and support.

Full details of the evidence and the committee's discussion are in evidence review A: patient information.

1.3 Managing gout flares

Treatment for gout flares

1.3.1

Offer a non-steroidal anti-inflammatory drug (NSAID), colchicine or a short course of an oral corticosteroid for first-line treatment of a gout flare, taking into account the person's comorbidities, co-prescriptions and preferences.

In June 2022, this was an off-label use of oral corticosteroids. See NICE's information on prescribing medicines.

1.3.2

Consider adding a proton pump inhibitor for people with gout who are taking an NSAID to treat a gout flare.

1.3.3

Consider an intra-articular or intramuscular corticosteroid injection to treat a gout flare if NSAIDs and colchicine are contraindicated, not tolerated or ineffective.

In June 2022, this was an off-label use of corticosteroid injections. See NICE's information on prescribing medicines.

1.3.4

Do not offer an interleukin-1 (IL-1) inhibitor to treat a gout flare unless NSAIDs, colchicine and corticosteroids are contraindicated, not tolerated or ineffective. Refer the person to a rheumatology service before prescribing an IL-1 inhibitor.

1.3.5

Advise people with gout that applying ice packs to the affected joint (cold therapy) in addition to taking prescribed medicine may help alleviate pain.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on managing gout flares.

Full details of the evidence and the committee's discussion are in evidence review D: pharmacological and non-pharmacological interventions for managing gout flares.

Follow-up after a gout flare

1.3.6

Consider a follow-up appointment after a gout flare has settled to:

measure the serum urate level
provide information about gout and how to self-manage and reduce the risk of future flares (see the section on information and support)
assess lifestyle and comorbidities (including cardiovascular risk factors and CKD)
review medications and discuss the risks and benefits of long-term ULT.

For guidance on adherence to medicines, see NICE's guideline on medicines adherence. For guidance on investigations for CKD, see NICE's guideline on chronic kidney disease. For guidance on cardiovascular risk factors, see NICE's guideline on cardiovascular disease. For guidance on shared decision making, see NICE's guideline on shared decision making.

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on follow-up after a gout flare.

Full details of the evidence and the committee's discussion are in evidence review M: follow-up for people with gout after a gout flare.

1.4 Diet and lifestyle

1.4.1

Explain to people with gout that there is not enough evidence to show that any specific diet prevents flares or lowers serum urate levels. Advise them to follow a healthy, balanced diet.

1.4.2

Advise people with gout that excess body weight or obesity, or excessive alcohol consumption, may exacerbate gout flares and symptoms.

For guidance on maintaining a healthy weight see NICE's guidelines on preventing excess weight gain and obesity: identification, assessment and management.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on diet and lifestyle.

Full details of the evidence and the committee's discussion are in evidence review I: diet and lifestyle modifications for managing gout.

1.5 Long-term management of gout

Management of gout with urate-lowering therapies

1.5.1

Offer ULT, using a treat-to-target strategy, to people with gout who have:

multiple or troublesome flares
CKD stages 3 to 5 (glomerular filtration rate [GFR] categories G3 to G5)
diuretic therapy
tophi
chronic gouty arthritis.

1.5.2

Discuss the option of ULT, using a treat-to-target strategy, with people who have had a first or subsequent gout flare who are not within the groups listed in recommendation 1.5.1 (see recommendation 1.5.4 on when to start ULT).

1.5.3

Ensure people understand that ULT is usually continued after the target serum urate level is reached, and is typically a lifelong treatment.

1.5.4

Start ULT at least 2 to 4 weeks after a gout flare has settled. If flares are more frequent, ULT can be started during a flare (see the section on preventing flares when starting or titrating ULT).

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on management of gout with urate-lowering therapies.

Full details of the evidence and the committee's discussion are in:

Treat-to-target strategy

1.5.5

Start with a low dose of ULT and use monthly serum urate levels to guide dose increases, as tolerated, until the target serum urate level is reached.

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on treat-to-target strategy.

Full details of the evidence and the committee's discussion are in evidence review J: treat-to-target management.

Target serum urate level

1.5.6

Aim for a target serum urate level below 360 micromol/litre (6 mg/dl).

1.5.7

Consider a lower target serum urate level below 300 micromol/litre (5 mg/dl) for people with gout who:

have tophi or chronic gouty arthritis
continue to have ongoing frequent flares despite having a serum urate level below 360 micromol/litre (6 mg/dl).

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on target serum urate level.

Full details of the evidence and the committee's discussion are in evidence review K: best serum urate level target to use when treating-to-target in gout?.

Urate-lowering therapies

1.5.8

Offer either allopurinol or febuxostat as first-line treatment when starting treat-to-target ULT, taking into account the person's comorbidities and preferences.

1.5.9

Offer allopurinol as first-line treatment to people with gout who have major cardiovascular disease (for example, previous myocardial infarction or stroke, or unstable angina).

1.5.10

Consider switching to second-line treatment with allopurinol or febuxostat if the target serum urate level is not reached or first-line treatment is not tolerated, taking into account the person's comorbidities and preferences. See recommendation 1.5.5 for guidance on treat-to-target strategy.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on urate-lowering therapies.

Full details of the evidence and the committee's discussion are in evidence review G: urate-lowering therapies for the long-term management of gout.

Preventing gout flares when starting or titrating urate-lowering therapy

1.5.11

Discuss with the person the benefits and risks of taking medicines to prevent gout flares when starting or titrating ULT.

1.5.12

For people who choose to have treatment to prevent gout flares when starting or titrating ULT, offer colchicine while the target serum urate level is being reached. If colchicine is contraindicated, not tolerated or ineffective, consider a low-dose NSAID or low-dose oral corticosteroid.

In June 2022, this was an off-label use of NSAIDs and oral corticosteroids. See NICE's information on prescribing medicines.

1.5.13

Consider adding a proton pump inhibitor for people with gout who are taking an NSAID or a corticosteroid to prevent gout flares when starting or titrating ULT. Take into account the person's individual risk factors for adverse events.

In June 2022, this was an off-label use of NSAIDs and corticosteroids. See NICE's information on prescribing medicines.

1.5.14

Do not offer an IL-1 inhibitor when starting or titrating ULT to prevent gout flares unless colchicine, NSAIDs and corticosteroids are contraindicated, not tolerated or ineffective. Refer the person to a rheumatology service before prescribing an IL-1 inhibitor.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on preventing gout flares when starting or titrating ULT.

Full details of the evidence and the committee's discussion are in evidence review H: colchicine, NSAIDs, corticosteroids and IL-1 inhibitors for the prevention of gout flares during the initiation or titration of urate-lowering therapy.

Monitoring serum urate level

1.5.15

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

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on monitoring serum urate level.

Full details of the evidence and the committee's discussion are in evidence review L: optimum frequency of monitoring.

1.6 Referral to specialist services

1.6.1

Consider referring a person with gout to a rheumatology service if:

the diagnosis of gout is uncertain
treatment is contraindicated, not tolerated or ineffective
they have CKD stages 3b to 5 (GFR categories G3b to G5)
they have had an organ transplant.

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on referral to specialist services.

Full details of the evidence and the committee's discussion are in: