NICE NG219 (2022): Gout diagnosis and management key recommendations

Who it applies to

Adults with gout or suspected gout managed in primary and secondary care.

Key recommendations

• Consider joint fluid aspiration and microscopy for synovial fluid crystal analysis to confirm diagnosis when the diagnosis is uncertain, particularly to rule out septic arthritis.
• Diagnosis can be made clinically in typical presentations (e.g. classic podagra) without further testing if the presentation is characteristic.
• Offer NSAIDs (with gastroprotection if indicated), colchicine, or corticosteroids as first-line options for treating acute gout flares, choosing based on comorbidities, patient preference, and contraindications.
• Do not stop existing urate-lowering therapy during an acute flare.
• Offer urate-lowering therapy to patients with multiple flares, tophi, chronic gouty arthritis, or joint damage, and discuss ULT with all patients after their first flare.
• Either allopurinol or febuxostat can be considered as first-line urate-lowering therapy, started at a low dose and titrated upward with monitoring of serum urate; allopurinol is specifically favoured as first-line in patients with major cardiovascular disease.
• Choice between allopurinol and febuxostat as first-line agents should also take into account tolerability, contraindications, and renal function, rather than treating febuxostat as a strict second-line fallback.
• Target serum urate level below 360 micromol/L (or lower, below 300 micromol/L, for patients with tophi or ongoing flares) using a treat-to-target strategy.
• Consider prophylaxis against flares (such as colchicine or low-dose NSAID) when starting or titrating urate-lowering therapy, due to risk of precipitating flares.
• Advise on lifestyle factors including weight management, reducing alcohol intake, and dietary modification, while recognising these alone are usually insufficient to control gout.
• Review cardiovascular risk and renal function as part of holistic management, since gout is associated with metabolic syndrome and renal impairment.

Practice points for students

• Gout and septic arthritis can coexist or mimic each other, so have a low threshold for joint aspiration if there is diagnostic uncertainty, especially with fever or single hot swollen joint.
• Continuing ULT through a flare (rather than stopping it) is a commonly tested point that differs from older practice.
• Treat-to-target serum urate monitoring is central to long-term management, analogous to treat-to-target approaches in other chronic diseases.
• ULT should generally be started at least 2 to 4 weeks after a flare has settled; starting during a flare is reserved for patients with very frequent flares.

Condition

Other guidelines on this topic

• 2018 updated European League Against Rheumatism evidence-based recommendations for the diagnosis of goutEULAR2020Official guideline
• 2020 American College of Rheumatology Guideline for the Management of GoutACR2020Summary
• Management of Acute and Recurrent Gout: A Clinical Practice Guideline From the American College of PhysiciansACP2017Summary

Independent educational summary written by the WhiteCoat Pro editorial team with AI assistance and checked by a second AI model. It does not reproduce the guideline text, tables or figures, and it is not affiliated with or endorsed by NICE. It is not medical advice: always read the original guideline before applying it to patients.