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Guideline for the management of gout

  • This Guidelines for Nurses summary focuses on recommendations for modification of lifestyle and risk factors that would normally be addressed during a nurse consultation. For full details of all recommendations included in the guideline see www.rheumatology.org.uk/Knowledge/Excellence/Guidelines

Background to the disease

  • Gout is the most common cause of inflammatory arthritis worldwide 

  • Clinical manifestations of gout resulting from monosodium urate crystal deposition include tophi, chronic arthritis, urolithiasis and renal disease as well as recurrent acute arthritis, bursitis and cellulitis

  • Gouty arthritis and tophi are associated with chronic disability, impairment of health-related quality of life, increased use of healthcare resources and reduced productivity

  • Gout is also frequently associated with co-morbidities such as obesity, dyslipidaemia, diabetes mellitus, chronic renal insufficiency, hypertension, cardiovascular disease, hypothyroidism, anaemia, psoriasis, chronic pulmonary diseases, depression and osteoarthritis as well as with an increase in all-cause mortality and urogenital malignancy

  • Sustained hyperuricaemia is the single most important risk factor for the development of gout. Hyperuricaemia occurs secondarily to reduced fractional clearance of uric acid in >90% of patients with gout

  • Age, male gender, menopausal status in females, impairment of renal function, hypertension and the co-morbidities that comprise the metabolic syndrome are all risk factors for incident gout associated with decreased excretion of uric acid, as are the use of diuretic and many anti-hypertensive drugs, ciclosporin, low-dose aspirin, alcohol consumption and lead exposure

  • Tophi and chronic arthritis, alcohol consumption and recent use of diuretic drugs are important risk factors for recurring flares 

Algorithm for the management of gout 

algorithm for the management of gout 1280x1776

Recommendations for modification of lifestyle and risk factors

  • If diuretic drugs are being used to treat hypertension rather than heart failure, an alternative anti-hypertensive agent can be considered as long as blood pressure is controlled 

  • All patients with gout should be given verbal and written information about the following: the causes and consequences of gout and hyperuricaemia; how to manage acute attacks; lifestyle advice about diet, alcohol consumption and obesity; and the rationale, aims and use of urate-lowering therapy (ULT) to target urate levels. Management should be individualised and take into account co-morbidities and concurrent medications. Illness perceptions and potential barriers to care should be discussed

  • In overweight patients, dietary modification to achieve a gradual reduction in body weight and subsequent maintenance should be encouraged. Diet and exercise should be discussed with all patients with gout, and a well-balanced diet low in fat and added sugars, and high in vegetables and fibre should be encouraged: sugar-sweetened soft drinks containing fructose should be avoided; excessive intake of alcoholic drinks and high-purine foods should be avoided; inclusion of skimmed milk and/or low fat yoghurt, soy beans and vegetable sources of protein, and cherries in the diet should be encouraged

  • Patients with gout and a history of urolithiasis should be encouraged to drink >2 litres of water daily and avoid dehydration. Alkalinisation of the urine with potassium citrate (60 mEq/day) should be considered in recurrent stone formers

  • Cardiovascular risk factors and co-morbid conditions such as cigarette smoking, hypertension, diabetes mellitus, dyslipidaemia, obesity and renal disease should be screened for in all patients with gout, reviewed at least annually and managed appropriately

full guideline available from…
www.rheumatology.org.uk

British Society for Rheumatology. The British Society for Rheumatology Guideline for the Management of Gout. June 2017

First included: July 2017.