NICE Guidelines on Gout Diagnosis and Management Save

NICE (UK) has systematically reviewed current medical evidence and delivered a set of recommendations with consideration of cost effectiveness.

Key Tenets:

• Urate lowering therapy (ULT) should be given using a treat-to-target management strategy (aiming for a serum urate level <360 μmol/L (6 mg/dL)) to provide therapeutic cure
• People without a major cardiovascular disease can be offered either allopurinol or febuxostat as first line treatment.
• When prescribing ULT, it is important to explain to people that treatment is lifelong
• Consider annual monitoring of serum urate level in people with gout who are continuing ULT after reaching their target serum urate level

This review summarises the recommendations from the new National Institute for Health and Care Excellence (NICE) guideline on gout, focusing on the diagnosis and management. Below are a few select recommendations from the NICE guidance (read full report for more information).

The Diagnosis 

• 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).
• Assess the possibility of septic arthritis, calcium pyrophosphate crystal deposition, and inflammatory arthritis.
• Measure the serum urate level to confirm the clinical diagnosis (serum urate level ≥360 μmol/L (6 mg/dL)). If serum urate level is <360 μmol/L during a flare and gout is strongly suspected, repeat the serum urate level measurement at least two weeks after the flare has settled.
• Consider joint aspiration and microscopy of synovial fluid if a diagnosis of gout remains uncertain or unconfirmed.
• If joint aspiration cannot be carried out or the diagnosis of gout remains uncertain, consider imaging the affected joints with x ray, ultrasound scanning, or dual-energy computed tomography (CT).

Treatment of Gout Flares

• Offer a non-steroidal anti-inflammatory drug (NSAID), colchicine, or a short course of an oral corticosteroid for first line treatment 
• Consider adding a proton pump inhibitor for people with gout who are taking an NSAID to treat a gout flare.
• Consider an intra-articular or intramuscular corticosteroid injection to treat a gout flare if NSAIDs and colchicine are contraindicated, not tolerated, or ineffective.

Diet and Lifestyle

• There is no standardised advice for diet and lifestyle modification in gout, and the current evidence base to support specific dietary interventions is limited.
• 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.
• Advise people with gout that excess body weight or obesity, or excessive alcohol consumption, may exacerbate gout flares and symptoms.

Gout and Urate Lowering Therapies

• Treatment with urate lowering therapy (ULT) for gout is suboptimal, with only around a third of people with gout receiving ULT.
• Treat-to-target with ULTs is considered best practice, compared with only treating symptoms. 
• Febuxostat was found to be more effective than allopurinol at reducing flares and lowering serum urate, but allopurinol was found to have fewer adverse events.
• A costefficacy analysis showed minimal cost differences in the first year of treatment between allopurinol and febuxostat when following a treat-to-target management strategy. 
• Offer ULT, using a treat-to-target strategy, to people with gout who have:
  • Multiple or troublesome flares, CKD - stages 3 to 5
  • Diuretic therapy
  • Tophi
  • Chronic gouty arthritis
• Offer either allopurinol or febuxostat as first line treatment when starting treat-to-target ULT, taking into account the person’s comorbidities and preferences.
• 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)
• Aim for a target serum urate level <360 μmol/L (6 mg/dL)
• 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.
• Start ULT at least two to four weeks after a gout flare has settled. If flares are more frequent, ULT can be started during a flare.
• Consider annual monitoring of serum urate level in people with gout who are continuing ULT after reaching their target serum urate level.
• 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 a low dose oral corticosteroid.

Rheumatology Referral

• 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.