Gout

Description

General Measures

Medicine Treatment

Referral

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ICD-10 Code: M10.90-99

DESCRIPTION

A metabolic disease in which uric acid crystal deposition occurs in joints and other tissues.

Gout is managed in the following three stages:

1. Treating the acute attacks;
2. Prevention of acute flares;
3. Lowering excessive uric acid to prevent flares and tissue deposition of urate crystals. 

LoE:III¹⁶

Acute gout:

Joint involvement is characterized by recurrent attacks of acute arthritis, which usually affects one joint, and is accompanied by extreme pain and tenderness, swelling, redness, and local heat.

• The inflammation may extend beyond the joint.
• In many patients the first metatarsophalangeal joint is initially involved.
• The instep, ankle, heel, and knee are also commonly involved.
• Bursae (such as the olecranon) may be involved.

Chronic gout:

Gout with one or more of the following:

• uric acid deposits in and around joints, bursae and cartilages of the extremities (tophi)
• initial involvement of the first metatarsalphalangeal joint in most patients
• involvement of the instep, ankle, heel and knee
• involvement of bursae (such as the olecranon)
• significant periarticular inflammation
• bone destruction
• prolongation of attacks, often with reduction in pain severity
• incomplete resolution between attacks

GENERAL MEASURES

Acute gout

• Rest and immobilisation.

Chronic gout

• Lifestyle modification, including high fluid intake.
• Avoid alcohol intake.
• If possible, avoid diuretics, or use the lowest dose possible.

MEDICINE TREATMENT

Acute gout

Initiate treatment as early as possible in an acute attack:

• NSAID e.g.:
  • Ibuprofen, oral, 400 mg 8 hourly with meals.

LoE:I¹⁷

In high-risk patients: >65 years of age; history of peptic ulcer disease; on concomitant warfarin, aspirin, or corticosteroids:

LoE:II¹⁸

ADD

• PPI, e.g.:
  • Lansoprazole, oral, 30 mg daily while on an NSAID.

If NSAIDs are contraindicated, e.g. warfarin therapy and renal dysfunction:

• Corticosteroids  (intermediate-acting) e.g.:
  • Prednisone, oral, 40 mg daily for 5 days.

Chronic gout

• If possible, avoid known precipitants and medicines that increase uric acid, including:
  • low dose aspirin,
  • ethambutol,
  • pyrazinamide, and
  • thiazide and loop diuretics.
• If diagnosis is uncertain, joint aspiration with microscopy for crystal analysis is recommended.
• Investigate for and treat secondary causes (e.g. haematological malignancies) where clinically indicated.
• Measure serum creatinine and urate.
• Serum urate may be normal during acute attacks.

Urate lowering therapy

Urate lowering therapy is recommended in the following circumstances:

• >2 acute attacks per year
• urate renal stones
• chronic tophaceous gout
• urate nephropathy

When the acute attack has settled, i.e. usually after 2 weeks:

• Allopurinol, oral, 100 mg daily.
  • Increase monthly by 100 mg according to serum urate levels.
  • Titrate dose to reduce serum urate to < 0.35 mmol/L.
  • Allopurinol dosage is dependant on severity of disease and serum urate concentration. Doses in excess of 300 mg should me administered in divided doses.
   LoE:III¹⁹
  • Maximum dose: 900 mg per day.
  • Elderly: start with 50 mg daily.
  • Renal impairment: Adjust dose according to renal function.
    • eGFR 30-60 mL/minute: start with 50 mg daily.
    • eGFR <10 mL/minute: consult a specialist.
   LoE:III²⁰

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Caution in prescribing allopurinol to patients with renal impairment as they have an increased risk of hypersensitivity reaction. Immediate cessation of allopurinol if rash or fever occurs. 

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LoE:III²¹

Prophylaxis to prevent breakthrough gout attacks:

An increase incidence of gout flares is associated with initiation of urate lowering therapy. Thus colchicine or NSAIDs is recommended as anti-inflammatory prophylaxis when initiating allopurinol.

Anti-inflammatory prophylaxis should be discontinued at 6 months provided gout symptoms have resolved. 

LoE:I²²

• NSAID, e.g.:
  • Ibuprofen, oral, 400 mg 8 hourly with meals.
    • Monitor renal function, as clinically indicated

OR

• Colchicine, oral, 0.5 mg 12 hourly for 6 months.
  • eGFR <50 mL/minute: consult a specialist.

LoE:III²³

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CAUTION

Concomitant use of more than one oral NSAID has no additional clinical benefit and only increases toxicity.
Use of all NSAIDs is associated with increased risks of gastrointestinal bleeding, renal dysfunction, and cardiovascular events (stroke and myocardial infarction).
NSAIDs should be used judiciously at the lowest effective dose for the shortest duration. Explore and manage exacerbating factors for pain. See Chronic pain.
Do not use NSAID in pregnancy or while breastfeeding.

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In high-risk patients: i.e. patients > 65 years of age, or with a history of peptic ulcer disease, or on concomitant warfarin, aspirin or corticosteroids:

LoE:II²⁴

ADD

• PPI, e.g.:
  • Lansoprazole, oral, 30 mg daily.

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Do not stop urate lowering drugs during an acute attack.

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REFERRAL

• No response to treatment despite adequate adherence.
• Suspected secondary gout.
• Non-resolving tophaceous gout.

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Adults 2024 Edition