MRCP PACES Rheumatology Gout
Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Keele, UK. CC BY 2.0, via Wikimedia Commons

History

  • Symptoms
    • Acute onset
    • Severely painful
    • Maximal intensity within a day
    • Usually self-limiting within a few days
    • Typically monoarthritis or oligoarthritis
  • Risk factors
    • Male sex (less so with increasing age)
    • Increased alcohol intake
    • Dietary
      • Carbonated drinks
      • Red meat
    • Drugs
      • Diuretics (thiazaide and loop)
      • Cyclosporine
      • Initiation of uric acid lowering therapy without cover
    • Co-morbidities
      • Renal failure
      • Hypertension
    • Increased cellular turnover
      • Psoriasis
      • Acute leukaemia / lymphoma
      • Myeloproliferative disorders
      • Administration of cytotoxic drugs (tumour lysis syndrome)
      • Lead poisoning
  • Complications
    • Renal stones
    • Urate nephropathy

Examination

  • Examination of affected joint
    • Effusion
    • Tenderness
    • Warmth
    • Erythema
    • Range of movement
  • Examination of other joints
  • Inspect for gouty tophi (ears, tendons or bursae, usually on extensor surfaces)
  • Offer urine dipstick to look for haematuria

Investigations

  • Joint aspiration looking for negatively-birefringent crystals
    • Cell count, Gram stain and culture to rule out septic arthritis
  • Serum uric acid levels (but difficult to interpret during acute gout flare)
  • Renal function (urate nephropathy)
  • Urine microscopy to look for microscopic haematuria

Management

  • Acute attack
    • Analgesia
    • Non-steroidal anti-inflammatory drugs if no contra-indication
    • Colchicine if no renal impairment
    • Consider intra-articular corticosteroids or systemic corticosteroids
  • Uric acid lowering therapy
    • Indications
      • Chronic tophaeceous gout
      • Urate nephropathy
      • ≥ 2 attacks per year
      • A history of urolithiasis
    • Target: serum uric acid < 360 μmol/L
    • First-line: allopurinol (xanthine oxidase inhibitor)
      • May cause Stevens-Johnson syndrome or toxic epidermal necrolysis
      • Consider screening for HLA-B5801 prior to starting treatment in high-risk patients (Koreans with CKD, Han Chinese and Thai patients)
    • Second-line: feboxustat (also xanthine-oxidase inhibitor)
      • Need to monitor LFT
    • Anti-inflammatory prophylaxis
      • Colchicine 250 – 500μg / day or low-dose NSAIDs
      • Second-line: low-dose prednisolone
      • Continue for at least three months after target uric acid level reached, or 6 months after resolution of previously-detected tophi
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