Gout

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Clinical DescriptionMost common form of inflammatory arthritis. Characterized by intermittent painful inflammatory joint attacks in response to crystals formed because of excessive levels of uric acid occurring mostly in a context of decreased renal excretion of uric acid or increased production of uric acid. 

Risk Factors

  • Age, male gender, menopausal status in females, impairment of renal function, hypertension
  • Diets high in red meat or seafood
  • Increased consumption of beer, spirits and fructose or sugar sweetened soft drinks
  • Drugs: thiazides, furosemide, pyrazinamide, low dose aspirin
  • Secondary hyperuricemia can also result from increased cell turnover and destruction

 

ACUTE GOUTY ARTHRITIS

Acute painful joint in patient with Gout arthritis.

Clinical Features 

SIGNS AND SYMPTOMS 

  • Affected joint is painful, tender, warm, swollen and red. Attacks usually last 7 days
  • Typically, monoarticular and occurs in men in most cases. The first metatarsophalangeal (MTP) joint of great toe commonly involved

INVESTIGATIONS

  • Full blood count
  • Serum uric acid
  • Serum urea and creatinine
  • Joint fluid microscopy
  • ESR and CRP

Treatment

General measures

  • Encourage Rest
  • Ensure abundant fluid intake

The main objective of treatment is to decrease pain and swelling, reduce serum uric acid levels

  • Give Ibuprofen 800mg 12 hourly preferably after food in established cases until attack subsides


Alternatively:

  • Give Indomethacin 50-75mg 8 hourly with food or
  • Give Diclofenac Sodium 25-50mg 8 hourly preferably after food and preferably suppositories
  • Give Colchicine 1.0mg followed by 0.5mg no more frequently than 4 hourly until pain is relieved or diarrhoea or vomiting starts. Maximum of 6mg per course; course should not be repeated within 3 days
  • Give Prednisolone 30 - 50mg daily for 5 -7 days

Prevention of Attacks

  • Encourage physical exercise
  • Encourage reduction in dietary protein (if intake is high)
  • Avoid alcohol <14 units/week
  • encourage to drink >2 litres of water daily
  • Only indicated in recurrent gout attacks.
  • Allopurinol 100 mg daily after food is the first line Urate lowering therapy
  • Maintenance dose: Up to 200 -600mg daily; dosage >300 mg to be given in divided doses; may be required life long
  • Gradually increase over 1-3 weeks to 300 mg daily, according to plasma or urinary uric acid concentration
  • Do not start this treatment until an acute attack has completely subsided

Complications

Chronic recurrent gout 

  • Frequent polyarticular arthritic attacks with bony deformities

Tophaceous Gout 

  • Solid, chalky white masses of uric acid commonly around joints and soft tissues
  • Predilection - extensor surfaces of elbows, distal Achilles tendon, finger proximal interphalangeal (PIP), cartilaginous portion of ears

Renal impairment (due to hyperuricemia and NSAIDS chronic use)

 

REFERRAL CRITERIA

  • Not responding to first line ULT (Allopurinol)
  • Presence of comorbid conditions