1. Why this matters for MRCGP

Gout is a common AKT topic because it tests pattern recognition, serum urate interpretation, acute flare prescribing and long-term urate-lowering therapy decisions. In SCA, it appears as a painful swollen joint, a request for “strong painkillers”, recurrent attacks, or reluctance to take lifelong treatment. The key GP risk is missing septic arthritis or giving unsafe medicines, especially colchicine, non-steroidal anti-inflammatory drugs or urate-lowering therapy without monitoring. Practical use matters because patients need clear flare treatment, self-care, safety-netting and long-term adherence advice.

2. GP Bottom Line

Think gout with rapid overnight severe pain, redness and swelling in the big toe joint, other distal joints, or with tophi. The dangerous miss is septic arthritis: if suspected, refer immediately according to the local care pathway. Treat flares promptly with a non-steroidal anti-inflammatory drug, colchicine or short-course oral corticosteroid, chosen around comorbidities and co-prescriptions. Do not diagnose gout from high serum urate alone, and do not stop established allopurinol or febuxostat during a flare.

3. 60 Second Exam Snapshot

• Serum urate ≥360 micromol/L (6 mg/dL) supports confirmation, but gout can occur with normal urate.
• If urate is below 360 during a flare but gout is still likely, repeat after the flare has settled.
• First-line flare options: non-steroidal anti-inflammatory drug, colchicine or oral corticosteroid.
• Offer urate-lowering therapy to patients with multiple/troublesome flares, chronic kidney disease stages 3–5, diuretic therapy, tophi or chronic gouty arthritis.
• Urate-lowering therapy is treat to target: start low, check serum urate monthly, target below 360 micromol/L; consider below 300 micromol/L with tophi/chronic gouty arthritis or ongoing frequent flares. Up-titrate urate-lowering therapy monthly until target reached.
• Allopurinol or febuxostat are first-line urate-lowering options; allopurinol is first-line with major cardiovascular disease.
• Colchicine overdose is dangerous: strict dose limits and urgent assessment if overdose occurs.

4. Recognition and Diagnosis

Gout is caused by monosodium urate crystals forming in and around joints, causing sudden flares of severe pain, heat and swelling. Suspect gout when there is rapid onset, often overnight, of severe pain with redness and swelling in one or both first metatarsophalangeal joints (big toe joint). Also suspect gout if tophi are present: firm nodules of urate crystals, often around extensor joint surfaces, Achilles tendon, hands, feet or ears. Consider gout in rapid-onset painful red swollen joints elsewhere, including midfoot, ankle, knee, hand, wrist or elbow. Consider chronic gouty arthritis in chronic inflammatory joint pain. Risk factors that support the diagnosis include increasing age, male sex, family history, genetics, excess body weight or obesity, excess alcohol, sugary drinks, meat or seafood, menopause status, diuretics, low-dose aspirin, ciclosporin, chronic kidney disease, hypertension and diabetes. Assess for mimics: septic arthritis, calcium pyrophosphate crystal deposition, inflammatory arthritis, cellulitis, bursitis, tenosynovitis, osteoarthritis, psoriatic arthritis, reactive arthritis, rheumatoid arthritis, haemochromatosis and trauma. Measure serum urate, but remember the trap: hyperuricaemia alone is not gout, and gout can occur without hyperuricaemia.

5. AKT Essentials: What Changes the Answer

Diagnosis / recognition

• First big toe joint + sudden severe red swollen painful flare = classic.
• Tophi suggest longstanding untreated gout.
• Prior self-limiting attacks lasting 7–14 days support the diagnosis.

Investigation / interpretation

• Measure serum urate in suspected gout.
• Serum urate ≥360 micromol/L (6 mg/dL) confirms the diagnosis.
• If serum urate is below 360 during a flare but suspicion remains high, repeat after the flare has settled: NICE says at least 2 weeks; CKS says 2–4 weeks.
• If uncertain or unconfirmed, consider joint aspiration and microscopy of synovial fluid; if aspiration cannot be done or diagnosis remains uncertain, consider X-ray, ultrasound or dual-energy CT.

Management / next best step

• Treat acute episodes as soon as possible.
• Choose non-steroidal anti-inflammatory drug, colchicine or short-course oral corticosteroid according to preference, comorbidity and concurrent medication.
• CKS gives prednisolone 30–35 mg once daily for 3–5 days as an oral corticosteroid example (off label use).
• Naproxen acute gout dose is supplied: 750 mg once, then 250 mg every 8 hours until the attack has passed.
• Aspirin is not indicated for gout.

Long-term prevention

• Offer urate-lowering therapy using a treat-to-target strategy for multiple/troublesome flares, chronic kidney disease stages 3–5, diuretic therapy, tophi or chronic gouty arthritis.
• Discuss urate-lowering therapy with all others after a first or subsequent flare.
• Start urate-lowering therapy at least 2–4 weeks after a flare has settled; if flares are frequent, it can be started during a flare.
• Use monthly serum urate to guide dose increases until target is reached.

Special groups

• Seek specialist advice or refer if gout occurs during pregnancy or in a young person under 30.
• Chronic kidney disease stages 3b–5 and organ transplant history support rheumatology referral.

6. SCA Consultation Essentials

The consultation task is usually: “Is this gout, infection, or something else — and what can I safely give today?” Ask about onset, joint affected, severity, warmth/redness/swelling, previous attacks, duration, medicines already tried, diet, alcohol, family history, renal disease, hypertension, diabetes, mobility and work impact. Explain gout without jargon: uric acid can form crystals around joints, causing sudden painful inflammation. Then pivot to safety: a hot swollen joint can also be infection, so systemic illness or worsening pain changes urgency. For acute care, explain the chosen medicine and self-care clearly. For recurrent gout, move the conversation from “painkiller only” to prevention: long-term urate-lowering therapy can reduce urate crystals, prevent flares, shrink tophi and reduce long-term joint damage. Use shared decision-making around flare treatment and urate-lowering therapy, but not where safety is at stake: suspected septic arthritis, colchicine overdose, serious rash or serious hypersensitivity needs urgent action.

7. Red Flags / Escalation / Referral

Refer immediately according to the local care pathway if septic arthritis is suspected. Treat septic arthritis as a key possibility in any person who is systemically unwell, with or without fever, and has an acutely painful, hot, swollen joint. NHS.UK urgent-help features include sudden joint pain and swelling plus worsening pain, very high temperature or feeling hot/cold/shivery, feeling sick, or being unable to eat.

Refer or seek specialist advice if:

• gout occurs during pregnancy
• gout occurs in a young person under 30
• underlying systemic illness is suspected
• complications are present
• the person is at risk of adverse effects from drug treatment
• intra-articular steroid injection is indicated but primary care facilities or expertise are unavailable

Consider rheumatology referral if diagnosis is uncertain, response is inadequate, treatment is not tolerated or contraindicated, chronic kidney disease stages 3b–5 are present, or the patient has had an organ transplant.

8. What the GP Should Do Today

• Assess: clarify onset, joint pattern, previous attacks, medicines, comorbidities, renal/hepatic disease, cardiovascular disease, pregnancy possibility, and impact on function.
• Examine: look for warm red swollen joints, tenderness, limited range of movement and tophi. Assess whether septic arthritis is possible.
• Investigate: measure serum urate. If low during the flare but gout remains likely, repeat after the flare settles. If diagnosis remains uncertain, secondary-care aspiration or imaging may be needed.
• Treat: offer one of a non-steroidal anti-inflammatory drug, colchicine or oral corticosteroid. Consider a proton pump inhibitor with a non-steroidal anti-inflammatory drug.
• Advise: rest and elevate the limb, keep the joint exposed and cool, use an ice pack, and avoid pressure on the joint.
• Review: consider follow-up 4–6 weeks after the flare has settled to measure serum urate, assess lifestyle/comorbidities, review medicines and discuss urate-lowering therapy.
• Safety-net: return if symptoms worsen or there is no improvement after 1–2 days.

9. Practical Use in GP: How to Apply This Topic

Before prescribing flare treatment:

• Check comorbidities, co-prescriptions, renal/hepatic impairment, cardiovascular disease and pregnancy.
• Do not use aspirin as gout treatment.
• For suspected septic arthritis, do not manage routinely as gout. Refer immediately according to the local care pathway for emergency assessment, including joint aspiration and culture where indicated.

Patient self-care:

• Take prescribed flare treatment as soon as possible.
• Rest and raise the limb.
• Keep the joint cool; NHS.UK supports an ice pack or frozen peas wrapped in a towel for up to 20 minutes at a time.
• Drink plenty of water unless advised not to.
• Keep bedclothes off the joint at night if helpful.
• Avoid putting pressure on the affected joint.

Urate-lowering therapy:

• Explain that it is usually lifelong and continued after target urate is reached.
• Continue allopurinol or febuxostat during a flare if already taking it.
• Discuss flare-prevention treatment when starting or titrating urate-lowering therapy.

10. Medicines, Investigations and Intervention Safety

Non-steroidal anti-inflammatory drugs (NSAIDs)

Used for acute flares. Naproxen is an example. Consider gastric protection with a proton pump inhibitor. NSAID risks include gastrointestinal toxicity, renal risk, asthma worsening, cardiovascular thrombotic events, elderly prescribing risk and alcohol-related gastrointestinal haemorrhage risk. Systemic NSAIDs are contraindicated after 28 weeks of pregnancy and should be avoided from week 20 unless clinically required.

Colchicine

Dose for acute gout: 500 micrograms 2–4 times daily until symptoms are relieved, maximum 6 mg per course, and do not repeat within 3 days / 72 hours. Prophylaxis during urate-lowering therapy initiation: 500 micrograms twice daily. It has a narrow therapeutic window; overdose can be fatal and needs immediate assessment even without early symptoms. Avoid grapefruit juice. Toxicity risk rises with renal/hepatic impairment and interacting medicines such as P-glycoprotein inhibitors, strong CYP3A4 inhibitors, ciclosporin, macrolides, ritonavir and verapamil. Do not prescribe colchicine in blood disorders, severe renal impairment or severe hepatic impairment. If eGFR is 10–50 mL/minute/1.73 m², reduce the dose or increase the dosing interval; colchicine is contraindicated if eGFR is below 10 mL/minute/1.73 m².

Oral corticosteroid

Prednisolone 30–35 mg once daily for 3–5 days is an acute flare option. Oral corticosteroid use for gout flare is off-label.

Allopurinol

A xanthine-oxidase inhibitor for urate lowering. Start 100 mg or less once daily, preferably after food, and adjust in 100 mg increments every 4 weeks by serum/plasma urate. Use lower/reduced dosing in elderly, renal impairment and hepatic impairment. Allopurinol is not a treatment for acute symptom relief; if already prescribed, continue it during a flare and treat the flare separately. Rash requires stopping and prompt medical advice. Consider HLA-B5801 screening before treatment in high-prevalence groups such as Han Chinese, Thai and Korean populations. If the HLA-B5801 allele is known to be present, do not start allopurinol unless there is no reasonable alternative and the benefits are judged to outweigh the risks. Important interactions include azathioprine/6-mercaptopurine, ACE inhibitors, aluminium hydroxide, diuretics and warfarin/coumarins. Avoid allopurinol with azathioprine or 6-mercaptopurine where possible; if co-administration is clinically needed, reduce azathioprine/6-mercaptopurine to one-quarter of the usual dose, monitor full blood count and advise the person to report unexplained bruising, bleeding, sore throat or fever.

Febuxostat

A xanthine-oxidase inhibitor. Dose supplied: 80 mg once daily, increasing if needed to 120 mg once daily after 2–4 weeks if serum uric acid remains above 6 mg/100 mL. Check liver function before starting and monitor periodically. Use cautiously in pre-existing major cardiovascular disease; allopurinol is first-line in major cardiovascular disease. Stop immediately for serious hypersensitivity; do not restart after hypersensitivity. Febuxostat with azathioprine or mercaptopurine is not recommended; if unavoidable, reduce azathioprine/mercaptopurine to 20% or less of the previous dose and monitor closely.

Interleukin-1 inhibitor

Do not offer or prescribe an interleukin-1 inhibitor directly in primary care. If non-steroidal anti-inflammatory drugs, colchicine and corticosteroids are contraindicated, not tolerated or ineffective, refer to rheumatology for consideration of an interleukin-1 inhibitor.

Pregnancy/breastfeeding

For gout in pregnancy, specialist advice or referral is required.

11. How to Explain It to the Patient

“Gout happens when uric acid forms tiny crystals around a joint, which can cause sudden severe pain, swelling and heat.”

“A hot swollen joint can sometimes be caused by infection, so if you feel very unwell, feverish, sick, or the pain is getting worse, you need urgent medical help.”

“For this flare, we can choose from an anti-inflammatory medicine, colchicine or a short steroid course, but the safest option depends on your other conditions and medicines.”

“If you are already taking allopurinol or febuxostat, keep taking it during a flare and treat the flare separately.”

“Long-term urate-lowering treatment is usually continued even when you feel well, because the aim is to prevent future flares and joint damage.”

“With colchicine, do not take more than prescribed; even a little extra can be serious.”

12. When the Plan Changes

• If: the patient is systemically unwell with an acutely painful hot swollen joint.
  • Why this changes the plan: septic arthritis is a dangerous alternative diagnosis.
  • What the GP does now: arrange immediate referral according to the local care pathway for emergency hospital assessment.
• If: serum urate is below 360 micromol/L during a flare but gout still fits clinically.
  • Why this changes the plan: gout can occur without hyperuricaemia during a flare.
  • What the GP does now: repeat serum urate after the flare has settled.
• If: the patient has multiple or troublesome flares, chronic kidney disease stages 3–5, diuretic therapy, tophi or chronic gouty arthritis.
  • Why this changes the plan: urate-lowering therapy should be offered.
  • What the GP does now: discuss treat-to-target treatment and monitoring.
• If: the patient has major cardiovascular disease.
  • Why this changes the plan: febuxostat needs caution and allopurinol is first-line.
  • What the GP does now: favour allopurinol if starting urate-lowering therapy.
• If: colchicine overdose or toxicity symptoms occur.
  • Why this changes the plan: toxicity can be delayed and serious.
  • What the GP does now: arrange immediate medical assessment.

13. Common AKT / SCA Traps

• Diagnosing gout from high urate alone.
• Excluding gout because serum urate is normal during the flare.
• Missing septic arthritis in a hot swollen joint.
• Stopping established allopurinol or febuxostat during a flare.
• Starting urate-lowering therapy without monthly serum urate monitoring to target.
• Giving unsupported NSAID doses.
• Forgetting colchicine maximum course dose and 3 day repeat interval.

14. Common Exam Angles

• Angle: First painful red swollen big toe.
  • Hidden challenge: gout versus septic arthritis.
  • What the candidate must not miss: systemic illness or suspected infection means arrange immediate referral according to the local care pathway for emergency hospital assessment.
• Angle: Recurrent gout asking only for painkillers.
  • Hidden challenge: prevention, not just flare treatment.
  • What the candidate must not miss: offer or discuss urate-lowering therapy according to criteria.
• Angle: Patient on allopurinol develops a flare.
  • Hidden challenge: whether to stop urate-lowering therapy.
  • What the candidate must not miss: continue allopurinol and treat the flare separately.
• Angle: Colchicine prescription request.
  • Hidden challenge: toxicity and interactions.
  • What the candidate must not miss: strict dose limit, no repeat within 3 days, urgent action for overdose.

15. 90 Second Audio Summary Script

Gout is a sudden inflammatory arthritis caused by urate crystals. In exams, recognise the rapid overnight painful red swollen big toe joint, but remember it can affect other joints too. Tophi point towards longstanding gout.

The key danger is septic arthritis. If the patient is systemically unwell or you suspect infection in a hot swollen joint, arrange immediate referral according to the local care pathway for emergency hospital assessment.

Measure serum urate. A level of 360 micromol per litre or more supports confirmation, but do not diagnose gout from urate alone. If the level is low during a flare and gout still seems likely, repeat after the flare settles.

Treat acute flares promptly with a non-steroidal anti-inflammatory drug, colchicine or a short course of oral corticosteroid, chosen around comorbidities and other medicines. Naproxen and prednisolone are the named examples with supplied doses. Colchicine is high risk: 500 micrograms two to four times daily, maximum 6 milligrams per course, and do not repeat within 3 days.

After the flare settles, review serum urate, lifestyle, comorbidities and medicines. Offer urate-lowering therapy for multiple or troublesome flares, chronic kidney disease stages 3 to 5, diuretic therapy, tophi or chronic gouty arthritis, and discuss it with others. Start low, titrate monthly to target, and continue established allopurinol or febuxostat during flares.

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