An acute attack of gout can be treated with paracetamol or  NSAIDs, or colchicine if NSAIDs are unsuitable. Long-term management is usually with allopurinol to lower blood urate levels.  Pain relief and prophylaxis may be started together for an acute attack.

Dosage regimen

 * If prophylaxis is already established, acute medication is taken until 48 hours after the attack has subsided.  Colchicine should be started within the first few hours of an attack, when it will result in a response in about 90 per cent of patients; the later into an attack it is started, the less likely it will bring pain relief.

 * Prophylaxis should not be started with an acute attack as it can prolong the episode.  Allopurinol can be started one to two weeks after the attack has resolved.  Meanwhile paracetamol, NSAIDs or colchicine should be taken to relieve pain.  However, if prophylaxis is already being used, this should be continued with additional pain-relief as needed.

 * Pain relief is started at the same time as allopurinol for prophylaxis as the changes to uric acid levels can trigger an attack. The two are then taken together for about three months.  Check how long the patient has been taking the two together.

 * Check the patient knows how and when to take any medication: 

Allopurinol – taken after food once daily, unless over 300mg daily.  Doses of 300-900mg daily should be divided to help reduce side-effects.

Colchicine
 – acute attack: 1mg initially, then increasing by 0.5mcg every two to three hours until pain is relieved or vomiting or diarrhoea are experienced.  Maximum dose 6mg per course.  This should not be repeated within three days.
 - Prophylaxis: 500mcg two to three times daily.

 NSAIDs – should be taken with or after food. For an acute attack they are best started within the first 24 hours.  If taken when starting allopurinol prophylaxis, they should be continued for three months.

Paracetamol – 1g four times daily regularly.

Corticosteroids – can be used if other options are contra-indicated and taken first thing in the morning with breakfast.  Intra-articular steroids are also used.

Probenecid – used less often and on a named-patient basis.  Starting dose 250mg twice daily for one week, with usual maintenance 500mg twice daily.  Once uric acid levels have been corrected and stabilised, the dose can be reduced to the minimum effective dose.

Sulphinpyrazone – used rarely. Starting dose 100-200mg twice daily, increasing to up to 600mg daily.  Can then be reduced to a maintenance dose once uric acid levels have been corrected.  Take with food or milk.

 * Does the patient have a supply of medication at home in case of acute attacks – diclofenac, naproxen and indometacin are preferred.

Patient's knowledge of the medicine's use

 * Check understanding of the use of different medications at different times.  When starting prophylaxis, additional pain relief is also given as acute attacks are likely at this time because of changes in uric acid levels.  Does the patient know how long to take analgesics for acute onset?

 * Ensure that they understand the need to continue prophylaxis even though they may feel it is not needed.  However, reduction of higher doses may be possible with no adverse consequences.  If there have been more than two attacks in one year, prophylaxis will have been started as it is likely that further ones will occur.  Reduction of uric acid levels will prevent complications such as movement difficulty, joint deformity and hyperuricaemic renal disease.

 * Does the patient understand the reasons for any medication given to prevent side-effects, such as H2-antagonists or PPIs with NSAIDs?

Is the medication working?

 * How often are attacks occurring? Check that prophylaxis is being taken appropriately and advise on diet and lifestyle.

 * Have other underlying causes been investigated and ruled out, such as kidney uric acid stones (five to10 per cent of all kidney stones in the UK result from high blood uric acid); chronic urate nephropathy; infections; severe degenerative arthritis.

 * Have other contributing factors been investigated:

• Concurrent medication may be causing hyperuricaemia, such as thiazide and loop diuretics, ciclosporin, nicotinic acid, aspirin
•  
• Renal function

• Hyperlipidaemia
• Diabetes
• Vascular disease.

Side-effects

 * Rash occurs in about 10 per cent of patients on allopurinol.  If so it should be stopped immediately and referred back to the GP.

 * Diarrhoea can occur with higher colchicine doses and can be one of the first signs of toxicity, together with vomiting and muscle weakness.  The toxic and therapeutic doses are close.

 * NSAIDs – indigestion and ulceration.

Monitoring

 * Allopurinol – SUA (serum uric acid) and renal function should be checked every three months for one year, then annually, aiming for below 300 micromoles/l.