gout

Question 1

what is gout?

Answer 1

inflammatory arthritis related to hyperuricemia

Deposition of monosodium urate (MSU) crystals that accumulate in joints and soft tissues, result in acute and chronic arthritis, soft-tissue masses called tophi, urate nephropathy, and uric acid nephrolithiasis (kidney stones)

Question 2

what joint is most commonly affected at presentation?

Answer 2

1st metatarsophalangeal joint is most commonly involved at presentation (podagra)

other joints can be 
- ankle
- foot
= small joints of hand
- wrist 
- elbow 
- knee

Question 3

what are the non modifiable risk factors for gout?

Answer 3

• age >40

- male

Question 4

what are the modifiable risk factors for gout?

Answer 4

Increased purine uptake (meats and seafood)

Alcohol intake (especially beer) increases urate production

High fructose intake

Obesity

Congestive heart failure

Coronary artery disease

Dyslipidemia

Renal disease ( reduced urate excretion)

Organ transplant

Hypertension

Smoking

Diabetes mellitus

Urate-elevating

medications e.g. diuretics

Question 5

how is gout treated with general prevention?

Answer 5

Maintain optimal weight

Regular exercise

Diet modification (purine-rich foods)

Reduce alcohol consumption (beer and liquor)

Smoking cessation

Maintain fluid intake and avoid dehydration

Question 6

how is gout treated with a specific approach?

Answer 6

First line treatment in acute gout: NSAIDs, oral/IM steroids, colchicine

In chronic cases, commence urate lowering therapy (ULT) after acute attack.

Main ULTs are allopurinol and febuxostat (both are xanthine oxidase inhibitors and reduce urate formation).

Benzbromarone and sulfinpyrazone are used less commonly as more side effects. They act to increase renal excretion of uric acid.

Aim to reduce serum uric acid to <360micromol/L.

Question 7

what investigations are done into gout?

Answer 7

polarised light microscopy of synovial fluid is the test for gout. it will show negatively birefringent crystals.

serum urate is usually raised but may be normal

radiograph will only show soft tissue swelling but may see erosions in juxta articular bone later.

Question 8

what is pseudogout?

Answer 8

Pseudogout is an important differential diagnosis of gout caused by calcium pyrophosphate crystals and mainly occurs in older women with OA.

Question 9

what can precipitate attacks of gout?

Answer 9

trauma, surgery, starvation, infection, diuretics

Question 10

what other diseases is gout associated with?

Answer 10

CVD

hypertension

DM

chronic renal failure

Question 11

what prevention can be done into gout attacks?

Answer 11

lose weight

avoid prolonged fasts, alcohol excess, purine rich meats

Question 12

what can be taken prophylactically?

Answer 12

• allopurinol. It may trigger an attack so wait 3 weeks after acute episode and use NSAIDS
• avoid stopping allopurinol in acute attacks when established
• if this isn’t tolerated, can use Febuxostat