Gota

Key NICE recommendations on management

Please be aware that some of the following indications for medications may not be licensed by the manufacturer (i.e., the use of the medication is ‘off-label’). Refer to the full NICE guideline and your local drug formulary for further information when prescribing.

Advise people with gout to follow a healthy, balanced diet. Advise that excess body weight, obesity or excessive alcohol consumption may exacerbate gout flares and symptoms.

Treatment of gout flares

Offer a non-steroidal anti-inflammatory drug (NSAID), colchicine or a short course of an oral corticosteroid as first-line treatment for a gout flare, considering the person's comorbidities, concurrent medication and preferences.

• Consider adding a proton-pump inhibitor if treating with an NSAID.

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

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

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

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

• Measure the serum urate level

• Advise about how to self-manage and reduce the risk of future flares

• Review medications and discuss the risks and benefits of long-term urate-lowering therapy (ULT)

• Assess lifestyle and comorbidities (including cardiovascular risk factors and chronic kidney disease).

Long-term management of gout with urate-lowering therapies (ULT)

Offer ULT to people with gout who have multiple or troublesome flares, chronic kidney disease stages 3 to 5, diuretic therapy, tophi, or chronic gouty arthritis. For people not within these groups, but who have had a first or subsequent gout flare, discuss the option of ULT.

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

• Start ULT at least 2 to 4 weeks after a flare has settled. If flares are more frequent, ULT can be started during a flare.

• Use a treat-to-target strategy: 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.

• Aim for a target serum urate level below 360 micromol/litre (6 mg/dl). Consider a lower target below 300 micromol/litre (5 mg/dl) if the person has tophi or chronic gouty arthritis, or if they continue to have ongoing frequent flares despite having a serum urate level below 360 micromol/litre (6 mg/dl).

Offer either allopurinol or febuxostat as first-line ULT treatment, considering the person's comorbidities and preferences.

• If the person has major cardiovascular disease (e.g., previous myocardial infarction or stroke, or unstable angina), offer allopurinol as first-line treatment.

• Consider switching to second-line treatment with allopurinol or febuxostat (where suitable) if the target serum urate level is not reached or first-line treatment is not tolerated.

Preventing gout flares when starting or titrating urate-lowering therapy (ULT)

Discuss the benefits and risks of taking medicines to prevent gout flares when starting or titrating ULT. For people who choose to take medicines to prevent 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

• Consider adding a proton-pump inhibitor (based on individual risk factors) if an NSAID or corticosteroid is used.

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

Follow-up and referral

Consider annual serum urate level monitoring for people with gout who are continuing urate-lowering therapy (ULT) after reaching their target serum urate level.

Consider referring a person with gout to rheumatology if:

• The diagnosis is uncertain

• Treatment is contraindicated, not tolerated or ineffective

• They have chronic kidney disease stages 3b to 5

• They have had an organ transplant.

© NICE (2022) All rights reserved. Subject to Notice of rights NICE guidance is prepared for the National Health Service in England https://www.nice.org.uk/terms-and-conditions#notice-of-rights . All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.