The full reasoning pathway — diagnose clinically and confirm with serum urate ≥360, always exclude septic arthritis, treat the flare, then offer urate-lowering therapy treat-to-target, modify the cardiometabolic drivers, and safety-net.StartDecisionInvestigateActionReferStop / Admit
Presentation · NICE NG219Suspected gout
Suspect if rapid-onset (often overnight) severe pain, redness and swelling of one/both 1st MTP joints, or tophi. Consider if the same in other joints, or chronic inflammatory joint pain. Measure serum uric acid (SUA).
Step 1 · Safety — exclude septic arthritisCould this be septic arthritis?
A hot, swollen, painful joint — especially with fever or systemic upset — is septic arthritis until proven otherwise. Pseudogout and other inflammatory arthritis are also differentials.
SUA ≥360 µmol/L confirms the clinical diagnosis. If <360 and gout strongly suspected, repeat ≥2 weeks after the flare settles. Also check U&E, lipids, HbA1c, LFT.
Step 6 · manage the flare
Step 6 · Action · Acute flareTreat early — choose one
Colchicine 500 micrograms 2–4 times daily until the flare settles (BNF; lower frequency/dose in renal impairment or with interacting drugs) OR an NSAID at max anti-inflammatory dose with PPI cover (e.g. naproxen 750 mg once then 250 mg every 8 h, or ibuprofen 400–600 mg every 6–8 h). Or a corticosteroid if both unsuitable (e.g. prednisolone 30–35 mg once daily for 3–5 days, or intra-articular/IM). Choice by comorbidity, other drugs and preference. Continue any established urate-lowering therapy through the flare. Doses per BNF — verify in renal/hepatic impairment.
Step 7 · Action · ULT (treat-to-target)Offer ULT, titrate to a urate target
Offer ULT if: multiple/recurrent flares, CKD 3–5, on a diuretic, tophi, or chronic gouty arthritis. Discuss ULT after a first attack for everyone else. ULT is usually lifelong.
First-line allopurinol if major CVD (previous MI/stroke/unstable angina); otherwise allopurinol or febuxostat by preference/comorbidity. Allopurinol: start 100 mg once daily (50 mg if eGFR <60), titrate by 100 mg every ~4 weeks against monthly SUA, usual max 900 mg/day. Febuxostat: 80 mg once daily, increase to 120 mg once daily if SUA not <360 after 2–4 weeks. Start 2–4 weeks after the flare settles (or during a flare if attacks are frequent), with flare prophylaxis: colchicine 500 micrograms once or twice daily (low-dose NSAID + PPI if colchicine unsuitable) for up to 6 months.
Target SUA ≤360 µmol/L (reduce to ≤300 if tophi, chronic gouty arthritis, or ongoing flares). Check SUA monthly while titrating, then annually once at target.
Step 5 · ReferEscalation
Admit suspected septic arthritis. Rheumatology diagnostic doubt, drugs contraindicated/not tolerated/ineffective, eGFR <45, transplant, or considering an IL-1 inhibitor.
Weight loss, reduce alcohol (especially beer/spirits) and sugar-sweetened/fructose drinks, limit purine-rich foods (red/organ meat, shellfish); encourage dairy & hydration. Review urate-raising drugs — thiazide/loop diuretics (switch where possible), low-dose aspirin, ciclosporin. Gout clusters with hypertension, CKD, T2DM and CVD — screen and treat these.
Step 9 · monitoring & safety-net
Step 9 · Monitoring & safety-netRecheck & when to return
Check SUA monthly while titrating ULT, then annually at target (≤360, or ≤300 with tophi/chronic gout); continue flare prophylaxis up to 6 months. Urgent / same-day if a single hot joint with fever (septic arthritis), or the flare doesn't settle. Provide a rescue plan (kept supply of flare treatment) and reassure that ULT dissolves crystals over months — don't stop it during a flare.
⚠️ Never miss septic arthritis: a hot, swollen, acutely painful joint with fever needs urgent aspiration/admission — do not assume gout. And gout is a lifelong, treatable condition: ULT to dissolve crystals (treat-to-target) is what prevents progression.
1
Safety
Red Flags — Exclude Septic Arthritis
A hot, swollen, acutely painful joint is septic arthritis until proven otherwise — it can destroy a joint within days and can be fatal. Gout and septic arthritis can look identical, and can co-exist.
Hot swollen joint + fever / systemic upset Suspected septic arthritis → admit for urgent joint aspiration before assuming gout, especially if immunosuppressed, diabetic, on a prosthetic joint, or unwell.
Diagnostic uncertainty Aspirate (microscopy: negatively-birefringent monosodium urate crystals confirm gout; positively-birefringent = pseudogout). Consider X-ray, ultrasound or dual-energy CT if aspiration can't be done.
Polyarticular / atypical presentation Consider other inflammatory arthritis (RA, psoriatic, reactive). Refer if the picture is unclear.
Septic arthritis and crystal arthritis share the cardinal features of a hot, red, exquisitely tender joint, and a raised CRP and white count do not distinguish them. The only reliable way to exclude infection in a single hot joint is aspiration and Gram stain/culture, which is why NICE and rheumatology guidance treat the acute monoarthritis as septic until the aspirate proves otherwise.
2
Diagnose
Recognise — Suspect vs Consider
Gout is a clinical diagnosis supported by serum urate. NICE NG219 frames recognition as two tiers:
Suspect gout
Rapid-onset (often overnight) severe pain, redness and swelling in one or both 1st MTP joints, OR the presence of tophi.
Consider gout
Rapid-onset severe pain/redness/swelling in joints other than the 1st MTP (midfoot, ankle, knee, wrist, fingers), OR in someone with chronic inflammatory joint pain.
Typical course
Untreated flares peak within 24 h and self-resolve over 1–2 weeks; recurrent attacks, intercritical periods and tophaceous deposits follow if urate stays high.
A classic podagra presentation (sudden, exquisitely painful, red 1st MTP joint) is specific enough that NICE allows a confident clinical diagnosis without aspiration, reserving crystal confirmation for atypical or uncertain cases. Recognising the "consider" tier matters because gout in the knee, wrist or fingers is frequently mislabelled as cellulitis or osteoarthritis.
3
Diagnose
Confirm — Serum Urate
Measure SUA
Check serum uric acid in anyone you suspect of gout.
Confirms diagnosis
SUA ≥360 µmol/L supports the clinical diagnosis of gout.
If <360 but gout likely
Repeat at least 2 weeks after the flare has settled — urate frequently dips during an acute attack, so a normal value mid-flare does not exclude gout.
Baseline before ULT
Record the pre-treatment urate; it becomes the reference for the treat-to-target titration later.
Serum urate falls during an acute flare (an acute-phase effect), so a value below 360 at presentation in a convincing case is misleading and should be rechecked once settled. Confirming hyperuricaemia underpins the later decision to start urate-lowering therapy and provides the baseline against which treat-to-target dosing is judged.
Check U&E (eGFR), lipids, HbA1c and LFTs if no recent results — gout clusters with CKD, hypertension, T2DM and CVD, and renal function guides drug dosing.
Drug review
Note urate-raising drugs (thiazide/loop diuretics, low-dose aspirin, ciclosporin) for the lifestyle step.
Crystal microscopy is the gold standard and is the way to resolve genuine diagnostic doubt or distinguish gout from pseudogout. The associated bloods are not incidental: eGFR dictates allopurinol starting dose and febuxostat caution, and the lipid/HbA1c profile reflects the cardiometabolic cluster that a gout diagnosis should prompt you to manage.
Diagnostic doubt; ULT contraindicated, not tolerated or ineffective; eGFR <45; transplant recipient; or considering an IL-1 inhibitor.
Reason to escalate
Refractory tophaceous gout, frequent flares despite treat-to-target, or suspected alternative inflammatory arthritis (RA, psoriatic, reactive).
Most gout is managed entirely in primary care; referral is reserved for diagnostic uncertainty, treatment failure or the renal/transplant patient in whom standard urate-lowering therapy is constrained. Flagging septic arthritis first is non-negotiable — a missed septic joint can be destroyed within days.
6
Treat
Acute Flare
First-line (choose one)
Colchicine 500 mcg 2–4× daily OR NSAID
Colchicine until flare settles (reduce in renal impairment/interactions). Or NSAID at max dose + PPI — e.g. naproxen 750 mg stat then 250 mg every 8 h, or ibuprofen 400–600 mg every 6–8 h. Treat early. Doses per BNF.
If neither suitable
Prednisolone 30–35 mg OD, 3–5 days
Oral, or intra-articular/IM corticosteroid (off-label). Useful in CKD or where NSAID/colchicine contraindicated.
Already on ULT
Continue urate-lowering therapy
Do not stop allopurinol/febuxostat during a flare — stopping and restarting can prolong/worsen attacks.
All three flare options work; the choice is driven by safety. NSAIDs are limited by renal impairment, GI and cardiovascular risk; colchicine by diarrhoea and renal/hepatic dosing; corticosteroids are the pragmatic choice in CKD or polypharmacy. Maintaining established urate-lowering therapy through a flare avoids the urate flux that itself triggers attacks.
7
Treat
Urate-Lowering Therapy (ULT) — Treat-to-Target
Offer ULT if
Multiple/recurrent flares, CKD stage 3–5, on diuretic therapy, tophi, or chronic gouty arthritis. Discuss ULT after a first attack for everyone else. Explain it is usually lifelong and works by dissolving urate crystals.
Which drug
Major CVD (previous MI, stroke, unstable angina) → choose allopurinol. No major CVD → allopurinol OR febuxostat by comorbidity/preference. Allopurinol: 100 mg OD start (50 mg if eGFR <60), ↑100 mg every ~4 weeks, max 900 mg/day. Febuxostat: 80 mg OD, ↑120 mg OD if SUA not <360 at 2–4 weeks.
When to start
2–4 weeks after a flare settles (can start during a flare if attacks are frequent). Co-prescribe flare prophylaxis — first-line colchicine 500 micrograms once or twice daily up to 6 months; 2nd-line low-dose NSAID + PPI.
Target SUA
≤360 µmol/L for most; reduce to ≤300 if tophi, chronic gouty arthritis, or continued flares despite SUA <360.
Monitoring
Monthly SUA to guide dose increases until target reached, then annually. Switch agent if target not reached or not tolerated.
Gout is a curable crystal-deposition disease: lowering serum urate below its saturation point (≤360, or ≤300 for heavier crystal load) gradually dissolves the deposits and, over time, stops flares and resolves tophi. The treat-to-target strategy — titrating ULT against monthly urate levels with flare prophylaxis during the early dose-escalation phase — is what delivers that outcome, and is a clear advance over the old symptom-only approach.
8
Lifestyle
Lifestyle & Cardiometabolic Risk
Weight & diet Support weight loss if overweight. Do not recommend a specific "gout diet" — evidence is weak vs ULT — but limit purine-rich red/organ meat, shellfish and beer/spirits.
Alcohol & sugar Reduce alcohol (especially beer and spirits) and sugar-sweetened/fructose drinks; encourage low-fat dairy and good hydration.
Review urate-raising drugs Switch thiazide/loop diuretics where possible; note low-dose aspirin and ciclosporin.
Treat the cluster Gout clusters with hypertension, CKD, T2DM and CVD — screen for and manage these actively.
NICE deliberately avoids prescribing a restrictive "gout diet" because the urate-lowering effect of diet is small next to the proven benefit of ULT; weight, alcohol and sugary drinks are the pragmatic, evidence-supported targets. The bigger prize is the cardiometabolic cluster — a gout consultation is a chance to find and treat undiagnosed hypertension, CKD or diabetes.
9
Follow-up
Monitoring & Safety-net
Urate monitoring
Monthly SUA while titrating ULT, then annually at target (≤360, or ≤300 with tophi/chronic gout). Continue flare prophylaxis up to 6 months.
Rescue plan
Give a kept supply of flare treatment and a written plan to start it at the first twinge.
Reassure on ULT
Explain ULT dissolves crystals over months and must not be stopped during a flare; early flares while titrating are expected, not failure.
Urgent / same-day
Single hot joint with fever (septic arthritis), or a flare that does not settle with treatment.
The commonest reason gout "fails" is that ULT is stopped — during a flare, or once symptoms settle — so the crystal load never clears. Structured monitoring to target plus a rescue plan and clear reassurance about expected early flares is what keeps people on therapy long enough to become flare-free.
Educational use only. Based on NICE NG219 (Gout: diagnosis and management, 2022) as summarised in the GEMS "Gout" guide, and BNF for drug doses (NICE does not specify doses). Always exclude septic arthritis in an acute hot joint, and interpret against the whole clinical picture.