Acute Management of Gout

Question 1

What causes gout?

Answer 1

Caused by a build up and deposition of sharp needle-like monosodium urate crystals in areas of slow blood flow like the joints and renal tubules

Question 2

What do purines and pyrimidines both contain?

Answer 2

Nitrogen atoms

Question 3

What are purines and pyrimidines key components of?

Answer 3

Nucleic acids (found in DNA, RNA)

Question 4

What is the relationship between purines, pyrimidines and gout?

Answer 4

When cells and the NA’s within those cells breakdown, the purines are also broken down into uric acid, this uric acid can be filtered out of the blood and excreted in the urine, uric acid has limited solubility in body fluids and can manifest as hyperuricaema when the rate as which it is made exceeds solubility, uric acid can lose an ion (at pH 7.4) to become urate, combined with sodium this becomes monosodium urate, crystals can form due to increased ingestion of purines or internal sources

Question 5

What foods are high in purines?

Answer 5

Liver and kidneys, game, oily fish, seafood, meat and yeast extracts (marmite, gravy), soft drinks, alcohol (especially beer, stout, port)

Question 6

What foods are low in purines?

Answer 6

Dairy, eggs, breads and cereal, pasta and noodles, fruit and vegetables

Question 7

What foods can lower serum uric acid levels/help its excretion?

Answer 7

Dairy products can lower serum uric acid levels

Cherries are high in vitamin C and also help to increase uric acid excretion

Question 8

What are some of the risk factors for developing gout?

Answer 8

Increased purine intake, overproduction of urine acid, loop and thiazide diuretics, taking medications that can raise uric acid levels (aspirin, ciclosporin), genetic predisposition, obesity, hypertension, dyslipidaemia, alcohol intake, male gender

Question 9

Why are loop and thiazide diuretics associated with the development of gout?

Answer 9

Kidney excretes around 2/3 of the uric acid produced by the body (remainder is excreted via the biliary tract), loop and thiazide diuretics cause volume depletion and reduce tubular renal secretion of uric acid

Question 10

What are some of the key symptoms of gout?

Answer 10

Usually affects the first metatarsal joint of the big toe (known as podagra), extremely painful and will wake patient up with a feeling their toe is ‘on fire’, other joints can be affected (elbows, knees etc.)

Question 11

When is the pain of gout worst?

Answer 11

In the hours following the attack and then lessens with time, but can last from days to weeks

Question 12

What causes the symptoms of gout?

Answer 12

The area becomes inflamed due to migration of WBC’s (leukocytes) to eliminate uric acid and release cytokines

Question 13

What can happen if a patient has repeat attacks of gout?

Answer 13

Can develop chronic gout, a type of arthritis with joint tissue destruction and deformity
Chronic gout can also lead to a permanent build up of urate crystals tophi which form along the bones underneath the skin

Question 14

What are patients with chronic gout at an increased risk of developing?

Answer 14

Kidney stones (made of urate crystals) and urate nephropathy

Question 15

What are the 2 main aims of management of gout?

Answer 15

To relieve pain and swelling so 1st line treatment is NSAID’s, where NSAID’s are not suitable colchicine can be used
To maintain serum uric acid levels below saturation point, if this is done, crystal deposits dissolve

Question 16

When should treatment for an attack be started?

Answer 16

NSAID’s should be started immediately at high doses which are then reduced 24 hours after complete resolution of the attack
Colchicine should also be started immediately (takes around 6 hours to action vs. 2 hours in NSAID’s)

Question 17

Should treatment for an attack of gout be given continually?

Answer 17

NSAID’s should not be used continually

Question 18

What is the mode of action of Colchicine?

Answer 18

Arrests the assembly of microtubules in neutrophils and inhibits various cell functions

Question 19

What is given as last line treatment in gout?

Answer 19

Corticosteroids can be given where both NSAID’s and colchicine are C/I, can be given orally, IM or IA

Question 20

What are some of the key counselling points for a patient taking Colchicine?

Answer 20

Rest the joint and use an ice pack to reduce inflammation
Be careful when using other medications such as PI’s, macrolides and ciclosporin
Ensure the patient doesn’t have severe renal impairment or chronic heart failure
Monitor vitamin B12 levels as absorption may be impaired

Question 21

When is uric acid lowering therapy required?

Answer 21

If a patient has 1 or more acute attacks within 12 months of an initial attack
In some patient groups, it is appropriate to start prophylaxis after the first attack, those with visible tophi, uric acid stones and those who need to continue on diuretics

Question 22

What drugs are used in uric acid lowering therapy and how do they work?

Answer 22

Allopurinol - inhibits the action of the enzyme xanthine oxidase and in turn reduces the production of uric acid
Febuxostat - xanthine oxidase inhibitor, more selective and potent
Uricosurics - increase uric acid excretion

Question 23

What lifestyle advice can be given to patients to prevent gout reoccurance?

Answer 23

Moderate physical exercise (not intense as this can raise uric acid levels due to increased cell turnover)
Lose weight
Ensure purine intake <200mg/day
Alcohol consumption <14 units/week and 3 alcohol free days/week