Acute gout
The hot swollen joint that isn’t septic — and how to be sure.
| If you find… | …then |
|---|---|
| Fever, systemically unwell, or no previous gout | Septic arthritis until proven otherwise — aspirate / ortho |
| Prosthetic joint | Prosthetic joint infection — ortho |
| Several joints, or immunosuppressed | Atypical — senior review |
| Unable to weight-bear with trauma | X-ray for fracture |
- Joint, onset (overnight, peak within 24 h), previous attacks
- Fever, rigors, skin breaks or recent procedures
- Triggers: alcohol, big meals, dehydration, diuretics, recent illness
- Allopurinol / febuxostat use
- PMH: renal function, heart failure, GI bleed, diabetes; anticoagulants
- Obs incl. temperature
- Joint: hot, red, swollen, very tender (first MTP classic)
- Tophi (ears, fingers, elbows)
- Other joints
Gout vs septic arthritis
You can’t reliably tell them apart by looking. Favour gout with previous identical attacks, first MTP, overnight onset, and no fever. If in doubt, the joint needs aspirating before antibiotics.
Colchicine counselling
Low dose works as well as high dose with less diarrhoea. Stop if diarrhoea starts. Check interactions (clarithromycin, statins, some calcium-channel blockers).
Could this be septic?
- Fever or systemically unwell
- First-ever attack in an atypical joint
- Prosthetic joint
- Immunosuppressed
Any present: Septic arthritis not excluded → aspirate / ortho / ED. None present: Typical gout → treat in clinic.
| Investigation | Only if… |
|---|---|
| Joint aspiration (crystals, Gram stain, culture) | If septic arthritis can’t be excluded clinically — before antibiotics |
| Serum urate | Not useful in the attack (can be normal); check 2–4 weeks after |
| U&E | Before NSAIDs/colchicine if renal impairment possible |
Management & advice
- Rest and elevate; ice packs can help
- Continue allopurinol/febuxostat during the attack — don’t stop it
- Treat early; most attacks settle in 5–7 days
- GP: urate-lowering therapy discussion, cardiovascular risk, diuretic review
Refer / follow-up
- Possible septic arthritis → ortho / ED for aspiration
- Recurrent attacks → GP for urate-lowering therapy
| Drug | Dose | Duration / notes |
|---|---|---|
| Naproxen (with a PPI) BNF ↗ | 500 mg twice a day with food | Until settled (usually 5–7 days); avoid in renal impairment, heart failure, GI bleed |
| Colchicine BNF ↗ | 500 micrograms two to four times a day | Until symptoms improve; max 6 mg per course, no repeat course within 3 days; diarrhoea limits dose; reduce in renal impairment |
| Prednisolone (if NSAID/colchicine unsuitable) BNF ↗ | 30–35 mg once a day | 3–5 days |
| Paracetamol BNF ↗ | 1 g every 4–6 hours, max 4 g in 24 h (reduce if under 50 kg or liver risk) | As needed |
This is gout: crystals in the joint causing strong inflammation. It isn’t an infection. The tablets will settle it over the next few days; rest and raise the foot. Keep taking your allopurinol if you’re on it. Come back straight away if you get a fever or feel unwell, because that can mean infection in the joint.
Come back / call 111 — or 999 if severe — if:
- Fever, shivering or feeling unwell
- Joint not improving after 3 days of treatment
- Diarrhoea on colchicine — stop it
Official NHS pages. Ask the patient to scan the code with their phone camera, or tap “Show to patient” to make it full screen.
- Calling septic arthritis gout
- Stopping allopurinol during an attack
- High-dose colchicine causing diarrhoea and dehydration
- NSAIDs in renal impairment
Revision practice. Work through a real or imagined case to rehearse the reasoning. It builds a model note to learn from. It doesn’t replace your judgement, your seniors or local guidance.
✎Blank clinic note template
Acute gout — clinic note
Doses are typical doses drawn from the guidance above. Always confirm in the current BNF/BNFc and your local antimicrobial policy.