The video version of this podcast can be found here:

·      https://youtu.be/xJwdGqR9Rt0

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.

NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through the NICE guideline on “Gout: diagnosis and management” or NG219, focusing on what is relevant in Primary Care only.

I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

 

Disclaimer:

The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.

In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.

 

There is a podcast version of this and other videos that you can access here:

 

Primary Care guidelines podcast:

 

·      Redcircle: https://redcircle.com/shows/primary-care-guidelines

·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148


There is a YouTube version of this and other videos that you can access here: 

  • The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk


The Full NICE guideline on Gout: diagnosis and management can be found here:


·      https://www.nice.org.uk/guidance/ng219


Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

 

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I am Fernando, a GP in the UK. Today, we are looking at the NICE guideline on gout, or NG219, focusing on what is relevant in Primary Care only.

Right, without further ado, let’s jump into it.

Looking at the clinical presentation, we will suspect gout if there is either

  • the patient has tophi or
  • there is rapid onset (often overnight) of severe pain together with redness and swelling, in 1 or both first metatarsophalangeal (MTP) joints, although we will bear in mind that gout can affect other joints.

Other differential diagnoses that we have to consider in people presenting with a painful, red, swollen joint are:

·      Septic arthritis, and let’s remember that septic arthritis is a medical emergency, and in most cases, the patient should be sent to the emergency department immediately. This is because of the risk of rapid joint destruction, systemic spread and because the delay in treatment worsens outcomes.

·      We should also consider other inflammatory arthritis as well as

·      Calcium pyrophosphate crystal deposition. And let’s stop here for a moment. What is Calcium pyrophosphate crystal deposition? It is often referred to as pseudogout because it can cause acute joint inflammation, mimicking the symptoms of gout. However, it is caused by Calcium pyrophosphate crystals rather than uric acid crystals. Diagnosis is confirmed by synovial fluid analysis although it can be suspected if chondrocalcinosis is seen on x-ray.

Now, going back to gout, if instead of presenting with a painful, red, swollen joint, they present with chronic inflammatory joint pain, we should also consider chronic gouty arthritis

In terms of making a diagnosis of gout, as always, we will start with a detailed history and examination.

We will then check urate and confirm the clinical diagnosis is the serum urate level is 360 micromol/litre [6 mg/dl] or more). If the serum urate level is below this threshold during a flare and gout is strongly suspected, we will repeat it at least 2 weeks after the flare has settled. This is because during a gout flare, the serum urate level can be temporarily low due to the inflammatory response and redistribution of urate into the tissues. This means that a single low urate measurement during a flare does not rule out gout.

If the diagnosis remains uncertain or unconfirmed, other tests may be considered, such as joint aspiration and microscopy of synovial fluid or CT imaging or the affected joints, although normally this would be in secondary care.

As treatment of gout flares, we will offer a non-steroidal anti-inflammatory drug, colchicine or a short course of an oral corticosteroid for first-line treatment, taking into account the patient’s individual circumstances. When giving a NSAID or oral steroid, we will consider adding a proton pump inhibitor for gastric protection.

We will also explain that applying ice packs to the affected joint may also help.

If NSAIDs and colchicine are contraindicated, not tolerated or ineffective we can consider an intra-articular or intramuscular corticosteroid injection.

However, at the moment, this is an off-label use of steroids.

We should not offer an interleukin-1 (IL-1) inhibitor in Primary care but we will refer to a rheumatology service instead.

And, What is an Interleukin-1 (IL-1) Inhibitor?

It is a type of biologic drug that blocks the activity of interleukin-1, a key pro-inflammatory cytokine involved in the body's immune response in conditions like gout and rheumatoid arthritis. They are particularly useful in cases where NSAIDs, steroids, or colchicine are not effective or cannot be used due to side effects or contraindications.

After a gout flare, we will arrange follow up to:

  • check the serum urate level
  • provide information and assess comorbidities
  • review medications
  • discuss long-term Urate lowering therapy and
  • Discuss lifestyle. In this respect, we will explain that there is not enough evidence to show that any specific diet prevents flares or lowers serum urate and we will just advise a healthy, balanced diet. However, we will explain that excess body weight, or excessive alcohol consumption, may exacerbate gout flares and symptoms.

We will also explain that the disease progresses without intervention and that gout is a lifelong condition that benefits from long-term urate-lowering therapy to prevent flares, shrink tophi and prevent long-term joint damage.

Now that we have had a look at the management of an acute flare, let’s look at the long-term management, which involves urate-lowering therapies. Anyone with the diagnosis of gout is likely to benefit, but it is particularly important for those who:

  • Have multiple or troublesome flares
  • take diuretic therapy
  • have developed tophi or
  • chronic gouty arthritis and finally anyone with
  • CKD stages 3 to 5, that is, anyone with an eGFR less than 60.

However, as explained, we should discuss therapy with everyone with a gout diagnosis, as they are likely to benefit long term.

Normally, we will start urate lowering therapy at least 2 to 4 weeks after a gout flare has settled. However, if flares are more frequent, it can be started during a flare.

In order to prevent gout flares when starting or titrating urate-lowering therapy we can offer colchicine while the target serum urate level is being reached. If colchicine is contraindicated, not tolerated or ineffective, we can use a low-dose NSAID or low-dose oral corticosteroid, and for both a proton pump inhibitor can be given for gastric protection.

How do we prescribe urate lowering therapy?

Well, we will follow a treat-to-target strategy, where we start with a low dose of urate lowering therapy and use monthly serum urate levels to guide dose increases, as tolerated, until the target serum urate level is reached.

We will aim for a target urate below 360 micromol/litre (6 mg/dl) but we will go for a lower target of below 300 micromol/litre (5 mg/dl) if they:

  • have tophi or chronic gouty arthritis
  • continue to have flares despite having a level below 360 micromol/litre (6 mg/dl).

We will explain that urate lowering therapy is usually continued after the target serum urate level is reached, and is typically a lifelong treatment.

What are the recommended drugs?

We can offer either allopurinol or febuxostat as first-line treatment. If the target urate level is not reached with the first drug or if it is not tolerated, we will consider switching to the second drug.

For patients with major cardiovascular disease, we will go for allopurinol first line. This is because studies suggest that allopurinol may reduce cardiovascular events in those with pre-existing CVD, whereas, conversely, febuxostat has been associated with an increased cardiovascular risk.

Once the target has been reached, we will monitor urate levels annually.

Finally, we will consider referring to rheumatology if:

  • the diagnosis is uncertain
  • treatment is contraindicated, not tolerated or ineffective
  • they have CKD stages 3b to 5, that is, they have an eGFR below 45 or
  • they have had an organ transplant.

And that is it, a review of the diagnosis and management of gout in Primary Care.

We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

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