Gout:disorder of purine metabolism characterized by a raised uric acid level in the blood (hyperuricaemia) and the deposition of urate crystals in joints and other tissues.
Signs and Symptoms
Investigations
Differentials
Assessment
Management
Possible risk factors - alcohol intake, diet, use of drugs, FHx, Associated comorbidity, more common in men
PMHx arthritis or Trophi (firm, white nodules under translucent skin)
Age of onset- gout in <30 suggests renal or enzymatic disorder. Elderly presents atypically with an insidious onset and polyarticular involvement. Post menopausal women presents in hand small joint tophi
Current and previous attacks - site, symptoms, frequency of attacks, treatment used,affect on mobility
Serum uric acid >380 - measured 4-6 weeks after attack
Joint x-ray
Joint fluid microscopy and culture-not always practical
Screen for CVS and renal disease
Bursitis, cellulitis, tenosynovitis.
Non-urate crystal-induced arthropathy, such as pseudogout
Osteoarthritis
Psoriatic arthritis
Reactive arthritis
Rheumatoid arthritis
Haemochromatosis
Trauma
septic athritis should be considered in anyone systemically unwell
Acute attack
Self care: rest and elevate limb, avoid trauma, expose joint to cool environment, ice pack or bed cage. Lifestyle advice- weight loss, alcohol consumption, fluid intake
NSAIDs max dose continue to 1-2 days after attack (consider PPI cover)
if NSAIDS contraindicated -oral colchicine- 500mcg two to four times a day, until pain relief is achieved or D&V occurs. Do not exceed a total dose of 6 mg of colchicine (i.e. up to 6 days with colchicine 500 micrograms twice a day, or up to 3 days with colchicine 500 micrograms four times a day), and
Do not repeat treatment within three days.
elderly or people with an eGFR of 10-50 mL/minute/1.73m2 use a reduced dose or increase the dosage interval. Colchicine is contraindicated in people with an eGFR less than 10 mL/minute/1.72m2.
If NSAIDs or colchicine not tolerated a short course of oral corticosteroids can be given or consider IM corticosteroid injection
Paracetamol for pain/relief
Do not stop allopurinol or febuxostat during an acute attack of gout if the person is already established on these drugs
if no improvement in 1-2 days patient advised to return to GP
Referral
diagnostic uncertainty
risk of adverse effects
failure to respond to treatment
usually affects big toe first
severe pain and erythema
rapid onset
tophi usually 10 years after first attack
Review after 1-2 weeks
Prevention
ULT should be offered to all people with daignosis of gout
ULT starts after acute attack has resolved
1st Line Allopurinol 2nd Line Febuxostat, usually life long
Primary prevention of gout, tophi, cardiovascular disease or renal disease with ULT in people with asymptomatic hyperuricaemia is not recommended although lifestyle advice can be considered.
acute attacks and tophi has resolved and serum urate levels between 300-360micromol/l following review, treatment could be stopped if increased CVS or renal risk
Septic arthritis suspected
intra articular steroid injection indicated