Gout

Question 1

What is gout

Answer 1

Persistent raised plasma uric acid (urate) concentrations this leads to uric acid crystal formation - painful inflammation within joints (big toe)

Question 2

How does gout occur

Answer 2

Monosodium urate crystals (MSU) deposit in cartilage in the joint space resulting from sustained hyperuriaemia (high levels of uric acid) this leads to an inflammatory response

Question 3

What are the symptoms of gout

Answer 3

Rapid onset (hrs/days)
Severe pain
Swelling
Redness and warmth
Tenderness in joint

Question 4

Risk factors of gout

Answer 4

Age
Male
Obesity
Purine rich diet (red meat, seafood, alc)
Renal impairment (CKD)
Hypertension
Drugs (beta blockers, diuretics, ACEi)
Family history of gout

Question 5

Diagnosis of gout

Answer 5

Gold standard
MSU urate crystal detection in fluid from joint
Observation, X-ray, ultrasound
Lab - serum Uric acid (SuA), CPRC and ESR

Question 6

When to refer someone with gout to secondary care

Answer 6

URGENT ASAP - septic arthritis - generally unwell, painful hot swollen joint
- Unresponsive to uric acid lowering
- Persistent SE despite Max NSAID
- Gout complications e.g neuropathy
- Gout persists despite uric acid levels being lowered
- young onset ( below 30yrs)
- pregnancy

Question 7

Gout acute management

Answer 7

Start ASAP for 1-2 weeks and R.I.C.E

1st line NSAIDS + PPI
2nd line colchicine
3rd line corticosteroid

If poor response can combine

Question 8

Gout chronic management

Answer 8

DONT START during an attack (1-2 weeks after) BUT CONTINUE if already on drugs and a attack occurs

1st line allopurinol
2nd line febuxostat
3rd line benzbromarone

Question 9

When is long term treatment (chronic) needed for gout

Answer 9

2 + attacks in year
Tophi
Young
CKD And gout
Continuing diuretics (HF) and gout
Uric acid renal stones

Question 10

Allopurinol MOA

Answer 10

Lowers serum uric acid
Inhibits xanthine oxidase
Deposition of urate crystals in tissue (Tophi) is reversed

Question 11

Uricosuric drugs (benzbromarone) MOA

Answer 11

Inhibits renal tubules from reabsorbing uric acid
Increase renal excretion and decrease urate levels in serum

Question 12

Metabolism of purines to uric acid

Answer 12

Uric acid is the end product of purine nucleic acid degradation
1. Adenine and guanine are metabolised through the same pathway
2. Deamination occurs of adenine
3. Ribose-5-P removal
4. BOTH are converted to xanthine
5. Converted to uric acid
6. Uric acid is renally excreted

Question 13

Colchicine SERIOUS SE

Answer 13

STOP severe nausea and vomiting

SAME day assessment If take too much (even if no SE)

Question 14

Colchicine Ci and cautions

Answer 14

CI HF
Caution/ low dose - fluoxetine, erythromycin
Renal impairment and statin and elderly

Question 15

Allopurinol SERIOUS SE

Answer 15

STOP if rash but if mild and resolves can continue if rash again DISCONTINUE

Question 16

Allopurinol CI and cautions

Answer 16

AVOID azathioprine (inhibits metabolism of azathioprine - accumulation of toxic metabolites)

Dose adjustments in renal impairment

Don’t start during an attack (1-2 weeks after) but if already taking continue

Question 17

Febuxostat SERIOUS SE

Answer 17

STOP if hypersensitivity
DISCONTINUE do not restart

Question 18

Febuxostat CI and cautions

Answer 18

AVOID azathioprine
CI - liver impairment, HF, thyroid