1. Pre-consultation 

Communication issues to bear in mind

Adopting a reassuring tone is key when speaking to someone about their first prescription for gout medication. If suffering from an acute attack, they are likely to be anxious about how soon their symptoms will start to ease and the likelihood of repeat episodes in the future. 

Someone starting preventative medication may be wondering about side-effects and how to fit the regimen into their everyday life, while also being concerned about the potential for long-term complications from the condition such as joint damage and renal stones.

NICE recently published updated guidance on gout diagnosis and management (NG219). In terms of medication:

• For first-line treatment of a gout flare, a NSAID (plus proton pump inhibitor if necessary; note  that aspirin is not recommended), colchicine or a short course of an oral corticosteroid should be offered, although this is an off-licence use of steroids. An intra-articular or intramuscular corticosteroid injection (also off-licence) may be considered if NSAIDs and colchicine are inappropriate or ineffective. An interleukin-1 (IL-1) inhibitor such as canakinumab is rarely used and only then through a rheumatology service.
• Urate-lowering therapy (ULT) should be offered to gout sufferers who have multiple or troublesome flares, chronic kidney disease at stages 3 to 5, diuretic therapy, tophi (visible ‘bumps’ made of urate crystals) or chronic gouty arthritis, and discussed as an option with patients presenting with a first or subsequent gout attack. This type of therapy should be started at least two to four weeks after the flare has settled, although exceptions may be made for frequent sufferers. Usage is typically lifelong. The most commonly prescribed ULT is allopurinol, with patients for whom this is contraindicated or not tolerated prescribed febuxostat (although NICE states that either can be offered first-line). Both inhibit the enzyme xanthine oxidase, thereby reducing the formation of uric acid from purines. Uricosuric drugs such as sulfinpyrazone and benzbromarone, which increase uric acid excretion in the urine, may be used as ULT in patients who are resistant to or intolerant of xanthine oxidase inhibitors, or in combination where monotherapy has proved inadequate. This would only take place under a specialist. An overview of management is also given in the BNF.