Gout

Question 1

Who is most likely to get gout?

Answer 1

*men 50-60 years
*post menopausal women

Question 2

What is gout?

Answer 2

*acute inflammatory arthritis
*induced by deposition of URIC ACID crystals in joints
*from increased uric acid production
OR
*decreased uric acid excretion

Question 3

What are the risk factors for gout?

Answer 3

*obesity
*drug therapy
*high alcohol consumption
*genetics

Question 4

What are the risk factors for decreased uric acid excretion?

Answer 4

*increased age
*gender
*hypertension
*alcohol
*renal dysfunction

Question 5

What joints are affected by gout?

Answer 5

*end of limbs usually
*foot
*ankle
*knees
*fingers
*elbows
*toes

Question 6

What are symptoms of an acute gout attack?

Answer 6

*hot VERY painful joint
*red dry skin
*crystals in synovial fluid
*raised white cell count
*low grade fever

Question 7

What do NICE guidelines consider to be apparent symptoms and signs of gout?

Answer 7

SUSPECT GOUT-
*rapid onset of SEVERE pain, with redness AND swelling in ONE or BOTH 1st MTP joints
*tophi- uric acid crystals
CONSIDER GOUT
*rapid onset of severe pain, redness OR swelling in joints other than 1st MTP joints
(Midfoot, ankle, knee, hand, wrist, elbow)

Question 8

How is gout diagnosed?

Answer 8

*measure serum urate level- >360micromol/l
*microscopy of synovial fluid
*consider x-ray or ultrasound of joint

Question 9

How is gout treated?

Answer 9

*NSAIDs- Indometacin 50mg TDS onset 24-48hours complete relief after 5 days
*colchicine- when NSAIDs contraindicated. 500mcg BD-QDS until total of 3 days reached or GI side effects occur (80% of patients)
*intraarficular (joint) or oral corticosteroids-colchicine or NSAIDS contraindicated/partial effective. IA- one or two joints. Oral-prednisolone 30-40mg for 7 days
*opioid analgesics- NSAIDS not effective for 24 hours. Colchicine not effective for 6-12hours

Question 10

What is first line for treatment of gout?

Answer 10

*NSAIDS (indometacin) or colchicine or short term course corticosteroids oral
*consided PPI for NSAID

Question 11

What is long term management of gout?

Answer 11

URATE LOWERING THERAPIES
*for people who- have multiple/troublesome flares
*CKD (chronic renal insufficiency) stage 3
*tophi
*chronic gouty arthritis
*NB; continued after uric serum levels reached, lifelong, start 2-4 weeks after gout flare settled

Question 12

What is the target for urate lowering therapy?

Answer 12

<360micromol/L serum urate levels
(Consider <300micromol/L if patient has tophi, chronic gouty arthritis or ongoing frequent flares after <360)

Question 13

What are examples of drugs used in long term management of gout?

Answer 13

*Allopurinol- used for increased uric acid levels/decreased clearance
MOA: xanthine oxidase inhibitor
100-300 mg at night, max 900mg daily. >300mg taken in divided doses
SE- rare, hypersensitivity
OFFERED TO PEOPLE WITH CV DISEASE- PREVIOUS STROKE, MYOCARDIAL INFARCTION, UNSTABLE ANGINA
*Febuxostat- used for increased uric levels
80mg once daily or increase to 120mg daily after 2-4 weeks if uric acid levels still >360micromol/L
SE- GI, rash