rheumatology

Acute Gout

Any acute hot joint is septic arthritis until proven otherwise — aspirate before treating. Gout: needle-shaped, negatively birefringent crystals; serum urate may be normal acutely. Treatment chosen by comorbidity: NSAIDs, colchicine, or steroids…

Hot Joint / Crystal Arthropathy Pathway

The pathway

1 · Aspirate first

Synovial fluid: Gram stain, culture, polarised microscopy
Gout: needle-shaped, negatively birefringent
CPPD: rhomboid, positively birefringent
Infection and crystals can coexist

2 · Exclude sepsis

Positive Gram/organisms → treat as septic arthritis: IV flucloxacillin + orthopaedic washout
Fever occurs in gout too — don't rely on it

3 · Choose treatment by comorbidity

No contraindication → NSAID + PPI
CKD/HF/ulcer → prednisolone 30–35mg × 5 days or intra-articular steroid
Colchicine 500mcg BD (dose-reduce in CKD; diarrhoea limits)

4 · Remove triggers

Rehydrate
Review thiazides, low-dose aspirin, alcohol
Post-op attacks are common — anticipate

5 · Established ULT continues

Continue allopurinol through attacks
Never start it during one

6 · Prevent recurrence

Start allopurinol 100mg (50mg in CKD) 2–4 weeks after settling
Titrate to urate <360 µmol/L (<300 if tophi)
Colchicine cover up to 6 months

Drugs

Drug	Dose	Route	Notes
Naproxen	750mg then 250mg TDS	PO	If no CKD/HF/ulcer. Add PPI.
Colchicine	500mcg BD–QDS	PO	Reduce in CKD. Stop if diarrhoea. Many interactions (statins, clarithromycin).
Prednisolone	30–35mg OD × 5 days	PO	First choice with CKD or NSAID contraindication.
Allopurinol	Start 100mg OD (50mg CKD)	PO	Start 2–4 weeks post-attack; titrate monthly to urate <360. HLA-B*58:01 in at-risk ethnicities.

When to escalate

Any suspicion of septic arthritis — aspirate + orthopaedics urgently,Polyarticular gout with systemic upset,Recurrent attacks despite ULT — rheumatology,Tophaceous gout with ulceration or infection

Reference: BSR Gout Guidelines 2017 / NICE NG219 / EULAR 2020

This page is the reference half

The app adds what a web page cannot: a VINDICATE differential builder, worked on-call scenarios with full A–E findings, recall practice, and all of it offline.