Diagnosis Flashcards
(15 cards)
Gout
Arthritis caused by monosodium urate crystals forming inside and around joints, resulting in sudden flares of severe pain, heat and swelling. More common in men
Diagnosis of Gout
1 .Serum urate levels of 360micromol/litre (6mg/dl) or more. If low during acute flare then repeat after 2 weeks the flare has settled.
2. Consider joint aspiration and microscopy if uncertain (Gold standard)
3. If aspiration cannot be carried out or uncertain–> imaging with x-ray, USG or dua-energy CT
Risk factors
Genetics
Excess body weight
Medicines (Aspirin, ciclosporin, tacrolimus, or pyrazinamide can raise serum uric acid level by increasing uric acid re-absorption)
Thiazide and loop diuretics
Comorbs =ckd, htn
Treatment gout 1
1st line: Nsaids (avoid ckd or cvs disease), colchicine or course of oral corticosteroids
Consider adding PPI with Nsaids
2nd line: Consider IA or IM corticosteorid injextioj to treat flare if Nsaids and colchicine CI
Treatment gout cont
Do not offer IL1 inhibitors to treat flare unless Nsaids, colchicine and corticosteroids are CI, not tolerated or ineffective . Refer to rheumatology before prescribing
Diet and lifestyle
Not enough evidence to show that any specific diet prevents flares or lowers serum urate levels. Advise them to follow a healthy, balanced diet.
Advise that excess body weight, or excessive alcohol consumption, may exacerbate gout flares and symptoms
Long-term management of gout
Offer ULT, using a treat-to-target strategy, to people with gout who have
- Multiple or troublesome flares
- CKD stages 3 to 5 (glomerular filtration rate [GFR] categories G3 to G5)
- Diuretic therapy
- Tophi
- Chronic gouty arthritis.
Discuss with people who have had a first or subsequent gout flare who are not within the groups
Discuss lifelong treatment
When to start ULT.
Start at least 2 to 4 weeks after a gout flare has settled.
If flares are more frequent, ULT can be started during a flare
Treat to targer strategy
Start with a low dose of ULT and use monthly serum urate levels to guide dose increases, as tolerated, until the target serum urate level is reached.
Target serum urate level
Aim for a target serum urate level < 360 micromol/litre (6 mg/dl).
Consider a lower target serum urate level below 300 micromol/litre (5 mg/dl) for people with gout who:
1. have tophi or chronic gouty arthritis
2. continue to have ongoing frequent flares despite having a serum urate level below 360 micromol/litre (6 mg/dl).
Urate-lowering therapies
Offer either allopurinol or febuxostat as first-line
Consider switching to second-line treatment with allopurinol or febuxostat if the target serum urate level is not reached or first-line treatment is not tolerated
Allourinol as 1st line
Offer allopurinol as first-line treatment to people with gout who have major cardiovascular disease (for example, previous myocardial infarction or stroke, or unstable angina).
Preventing gout flares when starting or titrating urate-lowering therapy
For people who choose to have treatment to prevent gout flares when starting or titrating ULT, offer colchicine while the target serum urate level is being reached.
If colchicine is contraindicated, not tolerated or ineffective, consider a low-dose NSAID or low-dose oral corticosteroid.
Monitoring serum urate level
Consider annual monitoring of serum urate level in people with gout who are continuing ULT after reaching their target serum urate level.
Referral to specialist services gout
- the diagnosis of gout is uncertain
- treatment is contraindicated, not tolerated or ineffective
- they have CKD stages 3b to 5 (GFR categories G3b to G5)
4 had an organ transplant.
