24 - Gout

Question 1

gout AKA?

Answer 1

monosodium urate

Question 2

define tophi?

Answer 2

accumulation of uric acid in tissues

Question 3

what mechanism underpins gout?

Answer 3

purine metabolism - having excess uric acid

Question 4

where does 2/3 of urate come from?

Answer 4

breakdown of purine (result of breakdown of DNA)

Question 5

where does 1/3 of urate come from?

Answer 5

purine breakdowns of food and drink

Question 6

where is uric acid excreted?

Answer 6

kidney (70%) and biliary tract (30%)

Question 7

2 causes of hyperuricaemia?

Answer 7

overproduction and under-excretion

Question 8

give 4 examples of overproduction leading to hyperuricaemia?

Answer 8

tumour lysis syndrome, severe exfoliative psoriasis, cytotoxic drugs, HGPRT deficiency

Question 9

give 4 examples of under excretion leading to hyperuricaemia?

Answer 9

renal impairment, hypertension, hypothyroidism, lead poisoning

Question 10

why does alcohol increase risk of gout? (2)

Answer 10

1 - metabolism of ethanol to acetyl CoA results in increased formation of adenosine monophosphate
2 - inhibits uric acid secretion by increasing lactic acid levels in blood

Question 11

what causes Lesch Nyan syndrome?

Answer 11

HGPRT deficiency

Question 12

what is the role of HGPRT enzyme?

Answer 12

recycle purines into purine nucleotide pool

Question 13

name 2 purines?

Answer 13

hypoxanthine and guanine

Question 14

describe the pathway of HGPRT deficiency in becoming gout?

Answer 14

purines are not recycled -> purines are broken down and excreted as uric acid -> body produces more purines -> again not recycled -> continues to overproduce uric acid

Question 15

who gets gout?

Answer 15

usually men, peak age being 70/80s

Question 16

name 3 RFs associated with gout?

Answer 16

obesity, high fat/seafood diet, dehydration

Question 17

what is often the classic presentation of flare of gout?

Answer 17

Away on holiday, more alcohol, sunny (dehydration) , aware of sore red big toe at night and in morning it is agony, with difficulty walking and can’t bear to touch it

Question 18

how long does episode of gout last?

Answer 18

5-7 days

Question 19

what is the gold standard investigation for gout?

Answer 19

aspiration of joint

Question 20

name 2 other investigations?

Answer 20

polarising microscopy and culture

Question 21

symptoms of gout?

Answer 21

severe pain, hot and tender joint, red & shiny skin over affected joints

Question 22

what is the 1st line management for acute flare of gout?

Answer 22

NSAIDs

Question 23

when can colchicine be used to treat gout?

Answer 23

use as 1st line if NSAIDs are not appropriate

Question 24

name 2 groups of people who might not be suited to using colchicine?

Answer 24

elderly and renal impairment

Question 25

when can steroids be used to manage gout?

Answer 25

in case of no infection

Question 26

name 1 SE of colchicine?

Answer 26

diarrhoea

Question 27

when does hyperuricaemia need prophylaxis?

Answer 27

if more than 1 attack within 12 months

Question 28

when should hyeruricaemia not be treated?

Answer 28

asymptomatic

Question 29

when should treatment for lowering uric acid be used?

Answer 29

after the acute attack has settled

Question 30

which drug should be used to lower uric acid levels?

Answer 30

allopurinol

Question 31

what type of drug is allopurinol?

Answer 31

xanthine oxidase inhibitor

Question 32

name 4 lifestyle modifications for improving gout?

Answer 32

lowering CVS RFs, smoking cessation, balanced diet, lower alcohol intake