Gout

Question 1

What are the differentials of a hot, swollen joint?

Answer 1

• Septic arthritis
• Gout
• Pseudogout
• Haemarthrosis
• Psoriatic arthritis
• Reactive arthritis

Question 2

What are the risk factors for gout?

Answer 2

• Male
• Alcohol intake
• High purine intake: steak, oily fish etc
• Diuretics
• Overweight
• Other features of metabolic syndrome: diabetes and HTN

Question 3

What is the gold standard investigation for gout?

Answer 3

Joint aspiration and synovial fluid microscopy to identify MSU (urate) crystals or calcium pyrophosphate.

Question 4

What would serum urate be used for measuring?

Answer 4

Can be normal/low during an acute attack as majority of uric acid has precipitated to the joint. A normal/low urate would not rule out gout. If it is normal/low then advised to repeat urate a couple weeks after the attack has settled.

Question 5

What is the 1st line management of gout?

Answer 5

NSAIDs or colchicine - the max dose of NSAID should be prescribed until 1-2 days after symptoms have settled (PPI can be added). Colchicine is ideally started within 12 hours of flare onset e.g. 500 micrograms bd-tds.
- Allopurinol should be continued if the patient is already taking it.

Question 6

What can be used if 1st line agents are contraindicated?

Answer 6

Oral steroids, prednisolone 15mg/day - can also have intra-articular steroid injection.

Question 7

What are the indications for urate-lowering therapy (ULT)?

Answer 7

• Guidelines recommend offering to all patients now after their 1st attack of gout
• Recurring attacks (>2 attacks in 12 months)
• Tophi
• Chronic gouty arthritis
• Joint damage
• Renal impairment (eGFR <60ml/min)
• Hx of urolithiasis
• Prophylaxis for cytotoxics or diuretics
• Primary gout starting at a young age

Question 8

What is the aim of ULT?

Answer 8

To maintain a lower serum uric acid (SUA) <300 micromoles/l. The lower the SUA the more chances of dissolution of tophi.

Question 9

What is 1st line for ULT?

Answer 9

Allopurinol should started 2-4 weeks after an acute attack. Aim to start at 100mg daily (with CKD stage 4, start at 50mg/day). Titrate every 2-5 weeks.
Max dose should not exceed 900mg/day (renal impairment 300mg).

Question 10

What medication should be taken alongside allopurinol?

Answer 10

Colchicine or NSAIDs 2 weeks prior as ULT can precipitate gout in the first 6 months of therapy leading to non-adherence.

Question 11

What is 2nd line for ULT?

Answer 11

If allopurinol is not tolerated or ineffective then febuxostat is used.

Question 12

What other medications can be good for ULT?

Answer 12

• Losartan for HTN (specific uricosuric action)
• Fibrates for hyperlipidaemia
• If gout occurs in patients receiving loop or thiazide diuretic, substitute if possible.
• Increase vit C uptake (supplements or diet)

Question 13

What lifestyle modifications are recommended for gout?

Answer 13

• Reduce alcohol intake and avoid during acute attack
• Lose weight
• Avoid food high in purines e.g. liver, kidneys, seafood, oily fish (mackerel and sardines) and yeast products
• Regular exercise