Gout remains one of the most common inflammatory joint diseases seen in Malaysian primary care, yet it is frequently undertreated or managed inconsistently. To support doctors in making fast, evidence-based decisions, the Malaysia Clinical Practice Guidelines (CPG) provide clear recommendations on diagnosis, acute flare management, urate-lowering therapy, and long-term targets. This article presents a concise and practical summary tailored for busy clinicians, focusing on the essentials you need during consultations. Whether you are managing a first-episode flare or chronic tophaceous gout, this SetelDoc guide helps streamline your approach while staying aligned with national standards.
Serum Urate (SU) = Uric Acid
Definition
A disease caused by monosodium urate (MSU) crystal deposition with gout flare OR chronic gouty arthritis OR subcutaneous tophus.
Diagnosis
Demonstration of MSU crystals in synovial fluid (SF) or tophus aspirate OR by clinical, laboratory parameters and imaging.
Hyperuricemia
Men: SU >420 µmol/L
Women: SU >360 µmol/L
Hyperuricaemia ≠ gout
A normal or low SU during flare does not exclude gout due to urate shifting into tissues. Repeat SU 2 weeks after flare.
Gout Flare
Symptoms of acute arthritis with joint pain, swelling, warmth, redness and movement difficulty; commonly the first MTP joint, midfoot and ankle.
In gout flare, the following monotherapy may be used:
Colchicine OR
NSAID OR
Corticosteroids
Combination if insufficient monotherapy response.
Colchicine
Colchicine reduces the inflammation caused by the crystals of uric acid
Gout flare
Initial dose: 1 mg, then 0.5 mg after 1 hour then TDS after 12 hours.
Stop when symptoms are relieved or SE (toxicity).
MAX dose: 6 mg (12 tablets).
Another course should not be started for at least 3 days.
Flare prophylaxis
0.5 mg OD or BD for 3 to 6 months of ULT therapy.
Do not exceed 1 mg at the first sign of flare during prophylaxis.
Prednisolone is alternative to Colchicine if CrCl <30 ml/min. Dose: 30 to 40 mg/day OD or two divided doses for 5 days. If a longer duration is needed for more severe flare, a gradual taper over 7 to 10 day.
Urate Lowering Therapy (ULT)
Indications
- Recurrent gout flares (≥2 flares in 12 months) OR
- Presence of ≥1 tophi OR
- Presence of radiographic damage attributable to gout
Aim
- Serum urate of <360 μmol/L
- If severe or tophi <300 μmol/L
- Not <180 μmol/L
Urate is protective against neurodegenerative diseases
Allopurinol remains as the first line for ULT.
Following the CARES trial, febuxostat has since carried a black box warning issued by FDA regarding the increased rate of CV death in gout patients with established CV disease.
When allopurinol is contraindicated or not tolerated, febuxostat or uricosuric agents may be considered.
Follow Ups
Key parameters
- Serum urate SU (treatment target)
- Renal profile (renal dose)
Every 4 weeks until SU <360 µmol/L then every 6 months
Diet
Plant-based purine-rich foods & nuts are not associated with increased risk of gout.
Avoid
- Animal-based purine-rich (meat extract, internal organs)
- Seafood
- Goose
- Red meat
- Fructose especially sweet drinks, desserts, fruit jam
- Alcohol
According to CPG Malaysia, anchovies (ikan bilis), sardine, and mackerel do not raise uric acid. However, some patients might still get gout attack from these foods.
Referral
- Women with onset before menopause
- Men with early onset at age <30 years without predisposing risk factors
- Treatment failure after 3 months
- Tophaceous gout with progressive joint damage
- Gout in pregnancy
- Surgical management of tophi: Uncontrolled infection, Entrapment neuropathy, Risk of permanent joint damage
- Gout with urolithiasis should be assessed by a urologist.
Source: Gout CPG Malaysia
🔗 Popular SetelDoc Links