Vaccination Referrals from ED Paediatric Antimicrobial Guidance Children’s Services Resolution and Escalation Protocol Blunt Chest Wall Trauma/Rib Fractures Information for Parents Carers of Children Having Investigations in Relation to Unexplained Injuries + Consent form Bruising and Injuries in Babies and Children – Parents Leaflet Multi-Agency Protocol for Injuries to Non-Mobile Children Flowchart for children attending Galloway Community Hospital (GCH) for NAI Follow Up Skeletal Survey Flowchart for children attending DGRI for NAI Follow-Up Skeletal Survey Cognitive Function Conscious Level Kidney Biopsy Complications Parenteral Iron for Non-HD CKD Patients Fracture Management Guidelines (Paediatric) Fracture Management Guidelines (Adult) Management of Hypertension in Acute Stroke Prescribing for CAU Patients Still in ED Hypothermia Deactivation of Implantable Cardioverter Defibrillator Myeloma Croup Care Of Burns In Scotland (COBIS) Paediatric Guidance Management of Epistaxis Sore Throat Differential Diagnosis Dizziness Differential Diagnosis Peritonsillar Abscess/Quinsy Acute Tonsillitis Acute Mastoiditis Otitis Media Otitis Externa Extravasation of IV Amiodarone WoS Paediatric Drooling and Aspiration Guideline Palliative Care – How to Refer Eating Disorders Stroke Care Warfarin Anticoagulation for AF, DVT and PE Molnupiravir MyPsych Foundation Doctors Toolkit Paediatric Febrile Neutropenia Guidance PAEDIATRIC HYPOGLYCAEMIA MANAGEMENT in NON DIABETIC CHILDREN   Paediatric Diabetic Ketoacidosis (DKA) Guideline Child Protection Policies and Procedures (D&G) Management of Acute Behavioural Challenges in Adolescents and Young People presenting to Secondary Care Cancer of Unknown Primary Patients Returning from Interventional Cardiac Procedure Treatment of Malaria Discharging Patients on High Dose Steroids Sotrovimab Paediatric Ketone Correction Guideline Insulin Correction Factor Table (Paediatrics) Management of uncomplicated Henoch-Schonlein Purpura (HSP) in under 16s Management of Hypoglycaemia in Children with Type 1 Diabetes Newly diagnosed diabetic – not in DKA (Walking wounded) Proton Pump Inhibitor Guideline for Neonatal and Paediatrics Stroke – Post Thrombolysis Neonatal Guidelines Gentamicin Prescribing (Paediatrics) Management of Anaphylaxis (Paediatrics) Management of Prolonged Seizures (Convulsive Status Epilepticus) in Children Bronchiolitis Acute Wheeze or Asthma in Paediatrics Conscious Proning Covid-19 Basics Remdesivir Thromboprophylaxis Identifying Patients in the Highest Risk Groups Steroids for Patients with Covid-19 Infection IL-6 Inhibitors – Tocilizumab or Sarilumab Baricitinib Paxlovid (Nirmatrelvir/Ritonavir) Influenza A Inhalers for Adults with Asthma Standard Operating Procedure for AMU Trigger Finger/Thumb Osteoarthritis of the Hand/Thumb Mallet Finger Ganglion Dupuytren’s Contracture De Quervain’s Tenosynovitis Carpal Tunnel Syndrome Prescribing Advice on Admission – Clozapine Prescribing Advice on Admission – 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Coeliac diagnosis pathway (Adults) Voice clinic Ear Wax Dermatology Squamous Cell Carcinoma (SCC) Malignant Melanoma Basal Cell Carcinoma (BCC) Nipple Discharge Early Cancer Diagnostic Clinic (ECDC) Genetics Referrals Breast Infections Breast Pain Primary Care Prescribing Guidelines Emergency Department Anaesthetics and Chronic Pain Team Respiratory Referrals Chronic Cough Pathway GP Clinical Handbook Test Paediatric Bronchiolitis Early Cancer Diagnosis Clinic (ECDC) Obstetrics & Gynaecology/Medicine Admission Agreement Idiopathic Intrancranial Hypertension Urology Out of Hours Urology Out of Hours Sengstaken/Minnesota Tube for Bleeding Varices Eradication of Helicobacter pylori Transfer from Galloway Community Hospital Repatriation of Patients from Tertiary Hospitals THROMBOPROPHYLAXIS IN PREGNANCY – Appendix 1, Risk factors THROMBOPROPHYLAXIS IN PREGNANCY – Appendix 3, Postnatal assessment & management THROMBOPROPHYLAXIS IN PREGNANCY – Appendix 4 THROMBOPROPHYLAXIS IN PREGNANCY – Appendix 2, Management of women with previous VTE THROMBOPROPHYLAXIS IN PREGNANCY, LABOUR AND THE PUERPERIUM Orthopaedic VTE Risk Assessment Sodium Glucose Transporter 2 Inhibitors (SGLT2i) Cardiology Referrals Vascular Referrals ‘Watershed’ Conditions Myasthenia Gravis Gentamicin in Renal Replacement Therapy Vancomycin in Renal Replacement Therapy REDMAP Poster Realistic Conversations Summary Plan for Deteriorating Health Treatment Escalation Plans Ambulatory Care for Blood and/or Iron Infusion Principles for Light Touch Patients – B2 Clostridiodes difficile Infection Post Astra Zeneca Vaccine Headache Blood Culture Rhabdomyolysis Analgesia Acute Appendicitis Small Bowel Obstruction Elective Admission – Colorectal Surgery Trauma Admissions Post-operative Care Gallstone Disease Vasopressors and Inotropes/Chronotropes Shock Elective Admission – ERCP Elective Admission – Orthopaedics Laxatives Fat Embolism Compartment Syndrome Surgical Post-operative Complications Stoma Diverticular Disease High Dose Steroid Pre-Treatment Checklist Acute Surgical Admissions Level 1 CCU Medical Area Acute Oncology STEMI Thrombolysis Protocol Haemolytic Anaemia Conversion Charts Anticipatory ‘As Required’ Medications Syringe Driver Chart Scottish Palliative Care Guidelines Covid-19 Sick Day Rules for Patients with Primary Adrenal Insufficiency Diabetic Retinopathy Coming Off Benzodiazepines and “Z” Drugs Dental Abscess Facial Trauma – Mandibular Fractures Facial Trauma – Orbital Fractures Facial Trauma – Zygoma Platelet Transfusion Death Certification Parenteral Iron in Adults >18 Years OPAT SBAR (Complex Infections) Mental Health Liaison Team Referrals STEMI Admitting Patients with Tracheostomy/Laryngectomy to DGRI Emergency Laryngectomy Management Emergency Tracheostomy Management Safe Transfer of Patients with Tracheostomy/Laryngectomy within DGRI Other Tracheostomy Documents Systemic Anticancer Therapy Toxicity Haemodialysis Medication Prescribing Breaking Bad News by Telephone End of Life Diabetes Care Adrenal Insufficiency Serotonin Syndrome DGRI Referrals Confirmation of Death Neuroleptic Malignant Syndrome Pulmonary Embolism Deep Vein Thrombosis of Lower Extremities Exacerbation of COPD Contrast Associated AKI Acute Kidney Injury – Introduction Paracetamol Hypertensive Emergencies Staphylococcus aureus Bacteraemia (SAB) Rate Control in AF Common Scenarios Acute Severe Ulcerative Colitis IV Fluid Prescription in Adults Chronic Obstructive Pulmonary Disease Legionnaires Disease Septic Arthritis Guillain-Barré Syndrome Back Pain Anaesthetics – Unscheduled Procedures Requests Hyperglycaemia & Steroids Variable Rate Insulin Infusion Decompensated Liver Disease Fast Atrial Fibrillation – ACP Hyperkalaemia Contraindications to MRI Magnetic Resonance Imaging Bleeding with Other Antithrombotics In-patient Hyperglycaemia Management Anaemia (Management) – ACP Suspected NSTEMI – ACP Guidance on Chaperones Compulsory Admission and Treatment Radiology Immediate Discharge Letter Alcohol Withdrawal Fentanyl Patches in the Last Days of Life Care in the Last Days of Life Low Molecular Weight Heparin Interstitial Lung Disease Haematinic Testing Thromboprophylaxis for Non-Covid Patients Lung Cancer Osteoporosis Heart Failure Fluid Replacement in AKI Death & The Procurator Fiscal Thrombophilia Screening Neutropenic Sepsis Acute Vertigo Aortic Dissection Antithrombotics in Hip Fracture Transient Global Amnesia Hypomagnesaemia Hypophosphataemia Oxygen Therapy Falls – ACP Falls Acute Asthma Oncology Contact Details & General Advice Reversal of Warfarin Lumbar Puncture, Antiplatelet & Anticoagulant Drugs Antithrombotics & Surgery Non ST Elevation MI (NSTEMI) Suspected Acute Coronary Syndrome Antibiotics and the Kidney Acute Upper GI Bleeding (AUGIB) Pericardiocentesis Pleural Effusion Spontaneous Pneumothorax Acute Diarrhoea Iron Deficiency Anaemia Hyperthyroidism Gout Giant Cell Arteritis Pacemakers Clinical Suspicion PE – ACP Community Acquired Pneumonia (CAP) Management of Urinary Symptoms Management of Acute Kidney Injury SSRI Poisoning Immobility Autopsies Indications for Echocardiography Bradycardia Suspected Meningitis Hypernatraemia Diarrhoea – ACP Suspected Meningitis – ACP Blood Transfusion Brain Tumours Newer Antidiabetic Drugs Parkinson’s Disease Major Haemorrhage Protocols (DGRI & GCH) Major Haemorrhage Stroke Thrombolysis Heart Failure – ACP Suspected Anaphylaxis Anaphylaxis – ACP The AMB Score – ACP Transient Loss of Consciousness (TLOC) – ACP Bell’s Palsy – ACP Suspected Sepsis Lumbar Puncture Hypokalaemia Gentamicin Dosing Transient Loss of Consciousness Urinary Tract Infection Urethral Catheterisation Vancomycin Dosing Hyponatraemia Narrow Complex Tachycardia Hypocalcaemia New Onset Type 1 Diabetes – ACP Paracentesis for Tense Ascites – ACP Idiopathic Intracranial Hypertension – ACP Other Funny Turns Hypoglycaemia Hypoglycaemia – ACP Management of Transfusion Reactions Hypercalcaemia Haematemesis – ACP Anti-Platelet Therapy in Coronary Heart Disease Unfractionated Heparin Infusion Anaemia (Investigation) – ACP Delirium Suspected Seizure – ACP Headache – ACP Community Acquired Pneumonia – ACP Cellulitis Dyspepsia Management of Acute AF Rhythm Control in AF Atrial Fibrillation Renal Transplants Massive Pulmonary Embolism Head and Neck Injury Diabetic Ketoacidosis Switching from VRII Insulin Pumps Diabetes Mellitus Aspirin Digoxin Poisoning Tricyclic Antidepressants Opiates Benzodiazepines Gut Decontamination Deliberate Self Harm Acute Liver Failure Asymptomatic Raised Transaminases (ALT & AST) Nutritional Support in Adults Refeeding Syndrome Parenteral Nutrition Crohn’s Disease Acute Pancreatitis Abdominal Aortic Aneurysms Malignant Spinal Cord Compression Post Splenectomy Sepsis Ascites in Cirrhosis Alcohol Related Liver Disease Hepatitis C Symptom Control Suspected Variceal Bleeding Severe Headache Status Epilepsy in Adults Lower Gastrointestinal Bleeding Functional & Social 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Last updated 11th April 2024


  1. Use the EULAR/ACR Classification criteria for gout. There are several on-line calculators: a score of 8 or more is gout Gout Classification Calculator


  1. Under secretion of urate is most common – thiazides, alcohol, impaired renal function.
  2. Over production of urate – myeloproliferative disorders especially when treated, psoriasis.

Triggers of Acute Attack

  1. Acute attacks often triggered by sudden changes in serum urate, which can be up or down
  2. Common triggers are dehydration, trauma, surgical operations, initiation of allopurinol, alcohol, stopping or starting diuretics.

Differential Diagnosis

  1. Pseudogout – often presents as hot swollen knee in elderly with OA. Chondrocalcinosis on X-ray & rhomboid crystals of calcium pyrophosphate in synovial fluid.
  2. Septic arthritis – note leucocytosis & fever may also occur in gout.

Management of Acute Attack

  1. Treat as soon as possible with NSAIDs or Colchicine or steroids.
  2. Allopurinol should not be commenced during an acute attack but in patients already established on allopurinol, it should be continued and the acute attack treated conventionally
  3. Opiate analgesics can be used as adjuncts
  4. Rest, cold packs and splintage can be helpful

When to Consider Prophylaxis

  1. In uncomplicated gout if second or further attacks within 1 year
  2. With visible gouty tophi
  3. With renal insufficiency – eGFR <60ml/min
  4. With uric acid stones

How to do Prophylaxis

  1. Allopurinol is the first choice urate lowering drug, Febuxostat and the Uricosuric agents, covered by NSAID +/- PPI for 6 weeks or Colchicine for up to 6 months – in practice most patients choose to take NSAIDs/Colchicine if/when an acute attack occurs
  2. Aim to maintain serum urate <0.36 mmol/l, or below 0.30 mmol/l if tophi present
  3. Delay starting uric acid-lowering drug therapy until 1-2 weeks after inflammation has settled
  4. Follow up by rheumatology recommended


  1. First line therapy for acute attack unless contraindicated because of renal failure, heart failure, active peptic ulcer or known NSAID intolerance.
  2. Use fast acting NSAID at maximum dose eg ibuprofen 400-600mg tds or Etoricoxib 120mg od.
  3. Coprescription of PPI should follow standard advice for use of NSAIDs and Coxibs in patients with increased risk of peptic ulcers, bleeds and perforations


  1. Used both in treatment of acute gout and for prevention. Frequently given for up to 6 months to prevent acute attacks during initiation of urate lowering therapy
  2. Starting dose in acute gout is 1mg stat then 0.5mg tds until attack resolves or patient develops side effects.
  3. Prophylactic dose is 0.5mg bd for patients with normal renal function
  4. Lower prophylactic doses should be given to patients with renal failure eg 0.5mg od or every other day if eGFR 30-59ml/min and 0.5mg every 2-3 days if eGFR <30ml/min.
  5. Common side effects are vomiting and diarrhoea which are dose related and resolve with dose reduction.
  6. Important drug interaction with CYP450 3A4 inhibitors esp clarithromycin, simvastatin/atorvastatin, protease inhibitors and azole antifungals which can lead to life threatening neutropenia


  1. Consider Prednisolone 30mg od orally for the duration of an acute attack in patients who cannot take NSAIDs or Colchicine. Rx for maximum 7 days. Most need 3-5 days only. The drug should be stopped and not tapered
  2. Intra-articular steroid highly effective in acute gouty monarthritis


  1. Xanthine oxidase inhibitor – inhibits production of uric acid.
  2. First line therapy for prevention of recurrent gout.
  3. Has no place in management of acute gout and may even trigger an acute attack if given alone so is usually co-prescribed initially with NSAID or colchicine
  4. Starting dose is 100mg daily
  5. Dose should be titrated by increments of 100mg every 2-3 weeks to max of 900mg daily if necessary and if tolerated in order to achieve serum uric acid <0.36mmol/l
  6. Most important side effect is a skin rash that may vary in severity from mild and remitting with reduction in dose to severe and life threatening including toxic epidermal necrolysis and Stevens-Johnson syndrome.
  7. Important drug interaction with azathioprine that can lead to life threatening neutropenia. Options are to reduce dose of Azathioprine by 75% or switch to mycophenolate which does not interact with allopurinol


  1. Another xanthine oxidase inhibitor
  2. Second line therapy for prevention of recurrent gout in patients unable to tolerate allopurinol
  3. Starting dose 80mg daily, maximum 120 mg daily
  4. Side effects and drug interactions as per allopurinol

Uricosuric Agents

  1. Uricosuric agents are now rarely used


  1. Aspirin 75-150mg daily has no anti-inflammatory effect and no effect on serum urate.
  2. Aspirin in analgesic doses of 600-2400mg/day has paradoxical effects on serum urate – raises it at lower doses and uricosuric at higher doses – and should be avoided

Lifestyle advice for all patients

  1. Aim for ideal body weight
  2. Encourage moderate physical exercise
  3. Restrict alcohol intake <14 units, with at least 3 alcohol free days each week
  4. Drink at least 2 litres of fluid per day

Role of Low Purine Diet

  1. Some restriction of purine intake is helpful in many patients and especially in patients with renal insufficiency.
  2. Purine contents of various foods can be found online eg
  3. In practice a total daily purine intake of around 200mg can usually be achieved by avoiding foods with very high purine content and moderating intake of foods with relatively high purine content


Content Updated by Dr Lucy Moran