Crystal arthropathies

Question 1

What is gout?

Answer 1

A crystal arthropathy characterised by chronically high blood uric acid levels

Question 2

What is the pathophysiology of gout?

Answer 2

Urate crystals are deposited in the joints, causing them to become hot, swollen and painful

Question 3

What are gouty tophi?

Answer 3

They are subcutaneous deposits of uric acid, typically affecting the small joints and connective tissues in the hands, elbows and ears

Question 4

Which joints are the most affected in the hands?

Answer 4

DIPs

Question 5

How does it typically present?

Answer 5

With a single acute hot, swollen and painful joint

Question 6

What is an important differential for gout?

Answer 6

Septic arthritis - life threatening

Question 7

Risk factors for gout

Answer 7

Male 
Obesity 
High cholesterol
Existing CVD/ renal disease
Diet high in uric acid - meat and seafood
Alcohol 
Diuretics 
Family history

Question 8

What are the typical joints affected

Answer 8

Base of big toe (metatarso-phalangeal joint)
DIPs in hands
Wrists 
Base of thumb (carpometacarpal joint) 
Knee 
Ankle

Question 9

How is gout diagnosed?

Answer 9

Clinically by aspiration of fluid from the joint

Question 10

Aspirated fluid in gout will show

Answer 10

Negative for bacterial growth
Needle shaped crystals
Negative birefringent of polarised light
Monosodium urate crystals

Question 11

On joint xray for gout, you will see:

Answer 11

Typically the joint space is maintained
Lytic lesions in the bone
Punched out lesions
Erosions can have sclerotic borders with overhanging edges

Question 12

Management of gout:

Answer 12

First line: NSAIDS e.g. ibuprofen
Second line: colchicine
Third line: steroids

Question 13

When are NSAIDs contraindicated?

Answer 13

In patients with nsaid allergy
Asthma
Hx of GI bleeding/ ulcers

Question 14

Side effects of colchicine

Answer 14

GI upset

Diarrhoea

Question 15

How can the side effects of colchicine be combatted?

Answer 15

The effects are dose dependent - start on low dose to cause less upset

Question 16

When is prophylaxis against gout indicated?

Answer 16

AFTER the acute attack

Question 17

What is the prophylaxis for gout

Answer 17

Allopurinol

Question 18

What is allopurinol

Answer 18

Xanthine oxidate inhibitor - it reduces uric acid levels

Question 19

What other advice would you give to a patient with gout as part of their management?

Answer 19

Lifestyle changes can reduce risk of developing gout/ acute attacks
Reduce alcohol and purine-based food intake (meat and seafood)
Drink more water
Exercise
Lose weight

Question 20

When should allopurinol be stopped?

Answer 20

Never - unless SEs are intolerable once started can be continued through an acute attack.
But do NOT start it for the first time during an acute attack

Question 21

What dose of colchicine is given?

Answer 21

500micrograms 2-4 times a day until symptoms are relieved. 6mg max course