Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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A hot joint may be septic
Gout and septic arthritis can present identically and can coexist; fever may be absent, crystals do not sterilise a joint and treatment delay risks cartilage destruction, bacteraemia and death.
Action: Refer immediately through the local hot-joint pathway when infection is plausible, aspirate for cell count, Gram stain, culture and crystal analysis before antibiotics when clinically safe, obtain blood cultures if systemically unwell, and never delay sepsis treatment for a serum urate result.
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.
Key red flags
Fever, rigors, hypotension, delirium, rapidly spreading erythema or systemic toxicity requires immediate septic-arthritis and sepsis assessment.
Septic overlap
Fever, prosthesis, recent joint procedure, skin breach, immunosuppression or bacteraemia increases infection risk, but sepsis can occur without any of these.
Investigation priorities
01
Reference synovial-fluid microscopyFirst step
Confirm monosodium urate crystals when the diagnosis is uncertain.
02
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.
NICE first-line treatmentChoose one safe anti-inflammatory
Gout is secure or likely and septic arthritis has been reasonably excluded.
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.
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.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.