Acute gout — Rapid | Doctor’s Passport

Synopsis

Recognise an acute monosodium-urate crystal flare, exclude septic arthritis without delay, interpret serum urate correctly, choose safe first-line anti-inflammatory treatment and connect every flare to long-term prevention.

Typical gout is abrupt severe pain, swelling, warmth and erythema reaching maximum intensity within about twenty-four hours, often at the first metatarsophalangeal joint but potentially at any joint or bursa.
Always assess septic arthritis, calcium pyrophosphate disease and inflammatory arthritis; known gout and visible tophi do not remove the possibility of coexisting infection.
Measure serum urate, but a value below 360 micromol/L during a flare does not exclude gout; repeat at least two weeks after the flare resolves when suspicion remains high.
Synovial-fluid identification of needle-shaped, strongly negatively birefringent monosodium urate crystals is the reference confirmation when diagnosis is uncertain; send culture whenever infection remains possible.
NICE offers an NSAID, colchicine or a short oral corticosteroid course as equivalent first-line categories, selected by renal, gastrointestinal, cardiovascular, diabetic, interaction, infection and reproductive safety.
Licensed low-dose colchicine treatment is 1 mg immediately then 500 micrograms one hour later; no further dose for twelve hours, then 500 micrograms up to every eight hours if needed within strict course limits.
Use the lowest effective NSAID dose for the shortest period and add gastroprotection when indicated; avoid NSAIDs in important renal injury, active bleeding and decompensated heart failure.
Aspiration followed by intra-articular corticosteroid is useful for one accessible joint after infection has been reasonably excluded; never inject through cellulitis or into a possibly septic joint.

Key red flags

Fever, rigors, hypotension, delirium, rapidly spreading erythema or systemic toxicity requires immediate septic-arthritis and sepsis assessment.

A prosthetic joint, recent operation or injection, penetrating wound, bacteraemia, immunosuppression or intravenous drug use materially increases infection probability.

Inability to bear weight with a large hip, shoulder or deep-joint effusion requires urgent imaging-guided aspiration and orthopaedic involvement.

Severe pain after trauma, anticoagulation, sickle disease or vascular compromise widens the emergency differential to fracture, haemarthrosis, osteonecrosis or ischaemia.

Acute kidney injury, dehydration, gastrointestinal bleeding, decompensated heart failure or pregnancy changes the safety of NSAID and colchicine treatment.

New gout during chemotherapy or profound systemic illness can accompany tumour lysis and requires metabolic emergency assessment rather than routine flare care.

Septic overlap

Fever, prosthesis, recent joint procedure, skin breach, immunosuppression or bacteraemia increases infection risk, but sepsis can occur without any of these.

Atypical deep-joint attack

Hip, shoulder, sternoclavicular or spinal symptoms require imaging and guided sampling because examination and superficial aspiration cannot secure the diagnosis.

Investigation priorities

Reference synovial-fluid microscopyFirst step

Confirm monosodium urate crystals when the diagnosis is uncertain.

First-line serum urateFirst line

Support diagnosis and establish a future treatment baseline.

Management branches

First diagnostic priorityExclude joint infection

A hot, swollen, very painful joint presents acutely.

Check observations, sepsis, prosthesis, skin breach, recent procedure, immunosuppression, bacteraemia and joint depth before assuming a crystal flare.
Refer immediately and aspirate for culture and crystals when infection is plausible, drawing blood cultures and starting antibiotics according to sepsis timing.
Use imaging-guided aspiration for a deep joint and arrange drainage with orthopaedics when septic arthritis is suspected or confirmed.

NICE first-line treatmentChoose one safe anti-inflammatory

Gout is secure or likely and septic arthritis has been reasonably excluded.

Select colchicine, an NSAID or a short oral corticosteroid course from renal, gastrointestinal, cardiac, diabetic, interaction, infection and patient factors.
Start promptly, add protected ice, rest and elevation and add a proton-pump inhibitor when an NSAID recipient has gastrointestinal risk.
Review response within several days and re-aspirate or revisit infection and CPPD if pain, fever or swelling fails to improve as expected.

Key medicines

Colchicine 500 microgram tabletsTake 1 mg orally at flare onset, then 500 micrograms 1 hour later. Take no more for 12 hours; if needed after that, take 500 micrograms no more often than every 8 hours until relief or a total course dose of 6 mg.Do not repeat a course within 72 hours and stop immediately for diarrhoea or vomiting. Reduce or avoid with renal or hepatic impairment and never combine in high-risk impairment with strong CYP3A4 or P-glycoprotein inhibitors; macrolides, azoles, ciclosporin and statins raise fatal marrow and neuromuscular toxicity risk.

NaproxenFor the licensed acute-gout regimen, take 750 mg orally once, then 250 mg every 8 hours until the attack has passed; use for the shortest necessary period and review if ongoing treatment is needed.Avoid active ulcer or bleeding, severe renal, hepatic or heart failure, NSAID hypersensitivity and concurrent NSAIDs; review anticoagulants, antiplatelets, ACE inhibitors and diuretics. Add gastroprotection when indicated. Avoid from 20 weeks of pregnancy unless essential and use is contraindicated in the final trimester under product advice.

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