The patient may have been prescribed the medicine in the past but stopped taking it, perhaps because of side-effects or not understanding the long-term nature of preventative therapy – so this question enables concerns to be aired and answered

It also provides an opportunity to check that a contraindication or caution with the medication has not been overlooked at the prescribing stage (see Table 1).

Colchicine has specific dosing instructions, usually 500mcg two to four times a day until symptoms are relieved or diarrhoea or vomiting occurs. No more than 6mg per course should be taken and the course should not be repeated within three days. This may be adjusted due to interactions or concurrent conditions 

Allopurinol and febuxostat are usually prescribed on a treat-to-target strategy, starting at a low dose and using monthly serum urate levels to guide dose increases, as tolerated, until target serum urate levels are reached. Getting into a good routine in terms of taking the medicine regularly can be challenging, so suggest putting the tablets near the kettle or bathroom sink to act as a visual prompt to tie in with a daily activity

ULT is usually initiated at least two to four weeks after an acute gout episode and can precipitate a flare, so acute rescue medication such as colchicine or a NSAID may be needed. Ensure the patient knows how and when to use this

If gout flares are more frequent, ULT may be started during an attack along with medication to manage the acute symptoms at the same time.

With colchicine, this teases out whether the patient has a clear understanding of the restrictions around dosing, which they may be tempted to flout if the symptoms of the acute gout attack are severe or prolonged

Ensure that a patient who is experiencing a gout attack understands the need for a follow-up appointment with their GP to discuss measurement of serum urate, future management strategies, and assessment of lifestyle and comorbidities

With allopurinol and febuxostat, the patient may not grasp the lifelong nature of the medication, so asking this question provides an opportunity to emphasise the importance of continuing even when the benefits feel less tangible. Explaining that keeping gout under control means not only fewer attacks, but also shrinkage of tophi and prevention of long-term joint damage, can be a convincing message to get across to the patient

The treat-to-target prescribing strategy for preventative medication means regular blood tests are necessary. Check the patient understands this, and knows how and when to access testing and obtain results (as well as what to do with the information when they receive it).

Draw attention to the patient information leaflet to highlight common side-effects, ensuring the definition of “common” is explained in this context

Colchicine has a narrow therapeutic index and can be extremely toxic in overdose, but use is usually limited by gastrointestinal side-effects such as abdominal pain, nausea and vomiting. There can also be alopecia, blood disorders, myopathy and peripheral neuritis, so patients should be made aware of these symptoms and know to report them promptly

Both allopurinol and febuxostat carry the risk of precipitating an acute attack of gout, so advise patients to continue with the therapy even if this happens. The risk is so significant with febuxostat that the BNF recommends patients are prescribed a NSAID prophylactically or colchicine for at least six months after starting the ULT. 

Rashes are relatively common with both ULT drugs and can occur at any time. Due to the risk of exfoliative rashes such as Stevens-Johnson syndrome or toxic epidermal necrolysis and hypersensitivity, it is prudent to advise anyone who develops a rash to stop the drug and seek prompt medical advice.

There have also been reports of neurological side-effects such as somnolence, dizziness, paraesthesia and ataxia. Caution should be taken with skilled tasks such as driving in the early days of ULT

Allopurinol has a low incidence of adverse effects, but the risk is higher in someone with renal impairment; febuxostat can cause liver abnormalities. Hepatic function tests should be carried out before starting treatment and periodically throughout.

This question offers an opportunity to highlight how drug interactions are possible with a host of other medicines, including OTC products, supplements and alternative remedies (which may be overlooked), along with several food or drink items

Colchicine interacts with drugs that inhibit the cytochrome P450 subtype 3A4 enzyme, which includes clarithromycin, erythromycin, azithromycin, imidazole antifungals, statins, fibrates, ciclosporin, amiodarone, diltiazem, verapamil, cimetidine and many HIV drugs. Dose adjustments should be made in line with manufacturer guidelines. The patient information leaflet also states that grapefruit juice should be avoided

Allopurinol carries with it the risk of haematological and hypersensitivity reactions. The BNF lists several commonly used drugs as potentially increasing these risks, including ACE inhibitors, thiazide diuretics, azathioprine and amoxicillin

Febuxostat has just two interactions according to the BNF, but both are listed as severe:  azathioprine and mercaptopurine.

Acute gout attacks can be made less painful using cold therapy as well as prescribed medication. Resting and elevating the affected limb, avoiding trauma, and the use of a bed-cage can also be advised

Lifestyle changes can make a real difference. Measures include losing weight if necessary, eating a well-balanced diet that is low in fat and sugar, and high in fibre and vegetables. There is not enough evidence to support any specific diet to manage gout but patients may ask about reducing intake of purine-rich foods such as seafood and meat, or increasing foodstuffs such as skimmed milk, low-fat yogurt, soybeans and cherries.