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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- Acute gout: exquisitely painful, red, hot, swollen joint — classically 1st MTP (podagra) but can affect any joint
- Gold standard diagnosis: negatively birefringent needle-shaped crystals on polarised light microscopy of joint aspirate
- Acute flare: NSAID (naproxen 500 mg BD) OR colchicine 500 mcg BD–TDS — NOT allopurinol (can worsen flare)
- Urate-lowering therapy (ULT): allopurinol 100 mg OD titrated to target serum urate <300 µmol/L (or <360 µmol/L)
- Do NOT start allopurinol during an acute flare — wait 2–4 weeks. Once started, continue during future flares
Overview
Gout is the most common inflammatory arthritis, caused by deposition of monosodium urate (MSU) crystals in joints and soft tissues due to chronic hyperuricaemia. Hyperuricaemia results from overproduction of urate (purine-rich diet, high cell turnover) or underexcretion of urate (renal impairment, diuretics, alcohol). Acute gout flares involve intense neutrophilic inflammation triggered by crystal shedding into the joint space. Chronic untreated gout leads to tophaceous disease (urate deposits in skin, tendons, joints) and joint destruction.
Epidemiology
Gout affects approximately 2.5% of the UK adult population (~1.5 million people). It is more common in men (3:1) and prevalence increases with age. Risk factors include obesity, high purine diet (red meat, shellfish), alcohol (especially beer), fructose-rich drinks, chronic kidney disease, diuretics (thiazides, loop), organ transplant (ciclosporin), and conditions with high cell turnover (myeloproliferative disorders, psoriasis). It is associated with metabolic syndrome and cardiovascular disease.
Clinical Features
Symptoms
Acute onset of severe joint pain — often wakes from sleep, peaks within 12–24 hours
First MTP joint (podagra) in ~70% of first attacks — also ankle, knee, wrist, fingers
Exquisite tenderness — even bedsheets touching the joint causes severe pain
Attacks typically self-resolve within 1–2 weeks without treatment
Fever and malaise may accompany severe attacks
Chronic tophaceous gout: painless lumps (tophi) on ears, elbows, fingers, Achilles tendon
Signs
Acutely swollen, red, hot, tender joint (mimics septic arthritis — must exclude)
Overlying skin may be shiny, taut, and desquamating
Tophi: firm, white/yellow subcutaneous nodules (chronic gout)
If septic arthritis cannot be excluded clinically: aspirate joint urgently
Investigations
First-line
Joint aspiration and microscopyGold standard. Negatively birefringent needle-shaped crystals under polarised light microscopy. Also excludes septic arthritis (Gram stain and culture)
Serum urateSupports diagnosis but may be NORMAL during an acute attack (urate drops during inflammation). Recheck 2–4 weeks after flare settles. Target <300 µmol/L on ULT (NICE NG219)
Second-line
BloodsFBC, CRP/ESR (raised in acute flare), U&Es (renal function — affects ULT choice), glucose/HbA1c (metabolic syndrome)
X-rayUsually normal in early gout. Chronic: well-defined "punched-out" erosions with overhanging edges ("rat-bite" erosions), preserved joint space (initially), soft tissue tophi
Specialist
Dual-energy CT (DECT)Can demonstrate urate crystal deposits — useful for atypical presentations or diagnostic uncertainty without aspiration
1
Acute flare treatment
- First-line: NSAID (naproxen 500 mg BD) at full dose for the shortest time + PPI if risk factors
- OR colchicine 500 mcg BD–TDS (lower dose than historically used — fewer GI side effects)
- OR short course prednisolone 30–40 mg/day for 5 days (if NSAID and colchicine contraindicated — e.g. CKD)
- Rest, ice, elevate affected joint
- Do NOT start or stop allopurinol during an acute flare
2
Urate-lowering therapy (NICE NG219)
- Discuss ULT with ALL patients after their first gout flare (NICE NG219 — changed from previous guidance)
- First-line: allopurinol — start 100 mg OD (50 mg if eGFR <30), titrate slowly every 4 weeks to target serum urate <360 µmol/L (or <300 µmol/L if tophi or frequent flares)
- Provide anti-inflammatory cover (NSAID or colchicine) for first 6 months of ULT to prevent flares
- Second-line: febuxostat 80 mg OD — if allopurinol not tolerated or contraindicated
- Once started, ULT is typically lifelong. Do NOT stop during acute flares
3
Lifestyle advice
- Weight loss if overweight
- Reduce alcohol intake (especially beer)
- Reduce purine-rich foods: red meat, offal, shellfish, yeast extract
- Avoid sugar-sweetened and fructose-rich drinks
- Stay well hydrated
- Review medications: stop thiazide diuretics if possible (switch antihypertensive)
Complications
- Chronic tophaceous gout: Urate deposits causing joint destruction and deformity — preventable with ULT
- Renal stones: Urate nephrolithiasis in ~10–25%
- Chronic kidney disease: Urate nephropathy — screen renal function
- Cardiovascular disease: Gout is independently associated with CVD — assess and manage cardiovascular risk
- Joint destruction: Chronic erosive disease mimicking RA if untreated
UKMLA Exam Tips
- 1Acute hot red swollen 1st MTP = gout (podagra). But MUST exclude septic arthritis — aspirate if any doubt
- 2Negatively birefringent NEEDLE-shaped crystals = gout. Positively birefringent RHOMBOID crystals = pseudogout (CPPD)
- 3Serum urate may be NORMAL during an acute flare — recheck 2–4 weeks later
- 4Do NOT start allopurinol during an acute flare — it can worsen the attack
- 5NICE NG219: discuss ULT after FIRST flare (not just recurrent — this is new guidance)
- 6Allopurinol: start low (100 mg), go slow (titrate every 4 weeks), target urate <360 µmol/L
- 7Thiazide diuretics cause hyperuricaemia — switch if possible (consider losartan which is uricosuric)
practicetest your knowledge on goutApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — musculoskeletal and beyond.
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