Intended for healthcare professionals

Practice From Drug and Therapeutics Bulletin

Latest guidance on the management of gout

BMJ 2018; 362 doi: (Published 18 July 2018) Cite this as: BMJ 2018;362:k2893
  1. Drug and Therapeutics Bulletin
  1. Drug and Therapeutics Bulletin Editorial Office, London WC1H 9JR, UK
  1. dtb{at}

What you need to know

  • An acute attack of gout is likely to require treatment with a NSAID (with gastroprotection for those at high risk of gastrointestinal complications) or colchicine

  • In general, urate lowering therapy (ULT) is targeted to patients with recurrent attacks, tophi, urate arthropathy, or renal damage and to symptomatic patients with very high serum uric acid levels. Allopurinal is the first line option

  • Shared decision making about ULT should include consideration of harms, benefits, and limitations of ULT, along with patient preferences, comorbidities, and concomitant drug treatments

  • All patients taking ULT require regular monitoring of renal function and serum uric acid level to ensure that the dose is appropriate. For many people, allopurinol 300 mg daily will be insufficient to achieve target serum uric acid reductions.

  • Despite limited evidence, patients should be encouraged to manage their weight, increase exercise, and reduce alcohol consumption

Gout is the most common inflammatory arthritis and its incidence in the UK has steadily increased from 1.5% in 1997 to 2.5% in 2012.12 It is characterised by deposition of monosodium urate crystals in joints and tissues and usually presents with intermittent painful attacks followed by long periods of remission.3 Here, we review the latest guidance on the management of gout and consider the role of long term urate lowering therapy.

What are the main risk factors for gout?

The single most important risk factor is sustained hyperuricaemia, which can be caused by overproduction or underexcretion of urate.23 Pathological hyperuricaemia has been defined as the serum uric acid concentration (408 μmol/L) above which monosodium urate crystals form in vitro at physiological pH and temperature. For most people with gout, underexcretion is the main cause of hyperuricaemia. Other factors associated with the development of gout include drugs (such as diuretics, ciclosporin, and low dose aspirin), renal impairment, excessive consumption of red meat or seafood, fructose-sweetened …

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