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GOUT• Gout is a metabolic disease where uric acid crystals are deposited in the joints. It occurs most commonly in men over 40 years and post-menopausal women.• Acute gout tends to affect 1 joint (often big toe, knee or ankle) and to recover completely.• In chronic gout, many joints may be affected and they may not be very painful, but there is incomplete recovery in between.GOUT: ROUTINE CAREAssess the patient with goutAssess When to assess NoteSymptoms Every visit Manage symptoms as per symptom pages.Substance abuse At diagnosis > 21 drinks/week (man) or >14 drinks/week (woman) and/or > 5 drinks/session or misuse of illicit or prescription drugs 83.Medication Acute attacks Hydrochlorothiazide, ethambutol, pyrazinamide and aspirin can all induce acute gout attacks. Discuss with doctor.Joints Every visit • Recognise the acute gout attack: Sudden onset of 1–3 hot, extremely painful, swollen joints with red, shiny overlying skin (often big toe, knee or ankle).• Tophaceous gout appears as painless yellow hard irregular lumps around the joints (picture).CVD risk At diagnosis Assess cardiovascular disease risk 68. If BMI < 25 or < 40 years, refer within 1 month to exclude possible cancer cause for gout.eGFR At diagnosis If eGFR < 50, refer.Urate At diagnosis and with allopurinol Normal is ≤ 0.3. The patient needs allopurinol if urate > 0.5. Adjust allopurinol dose until urate < 0.3.Advise the patient with gout• Help the patient to manage his/her cardiovascular disease risk 69.• Give dietary advice:--Avoid fizzy drinks, alcohol, red meat, liver, kidneys, turkey, crayfish, sardines and anchovy.--Avoid fasting.--Drink at least 2l of fluids a day.• Advise bed rest until the pain subsides.• Advise patient there are drugs that may induce a gout attack, like aspirin and to discuss with doctor when starting any new medication.Treat the patient with goutTreat the patient with an acute gout attack• Give ibuprofen 800mg after food 8 hourly for 1–2 days. Then ibuprofen 400mg 8 hourly until pain and swelling are improved.• If patient has peptic ulcer, asthma, hypertension, heart failure or kidney disease, give prednisone 40mg daily for 3–5 days instead of ibuprofen.• If patient is already using allopurinol, do not stop it during the acute attack.Treat the patient with chronic gout• Patient needs allopurinol if: > 2 attacks per year, chronic tophaceous gout (picture), kidney stones, kidney disease, serum urate > 0.5.• Give allopurinol 100mg once daily. Do not start allopurinol during or for 3 weeks after an acute attack.• Increase by 100mg monthly until serum urate < 0.3 or the maximum dose of 400mg.Refer patient to specialist if no response to treatment or unsure about diagnosis.89