Gout

Question 1

What are the key characteristics of gout

Answer 1

Characterised by hyperuricaemia and the deposition of monosodium urate crystals in and around the joints

Question 2

What effect does urate crystals have when they are deposited in and around the joints

Answer 2

Cause attacks of acute inflammatory arthritis resulting in the joint to become hot, swollen and painful

Question 3

What type of arthropathy is gout

Answer 3

crystal arthropathy

arthropathy just means joint disease

Question 4

Gout is associated with chronically high levels of what in the blood?

Answer 4

uric acid

Question 5

What is gouty tophi

Answer 5

Occurs in gout

It is subcutaneous deposits of uric acid typically affecting the small joints and connective tissues of the hands, elbows and ears.

Question 6

What joints in the hand is most commonly affected by gouty tophi

Answer 6

Occurs in gout

The distal interphalageal joints (DIP) joints

Question 7

Name some of the risk factors for gout

Answer 7

• Developed countries
• Male gender
• Older age
• Obesity
• High purine diet e.g. meat and seafood
• AKI and CKD
• Diabetes
• Family history of crystal arthropathy

Question 8

Gout is a disorder of which form of metabolism

Answer 8

Purine metabolism

Question 9

Uric acid is a breakdown product of what?

Answer 9

Purine

Question 10

How is uric acid excreted by the body

Answer 10

Predominantly renal excreted (70%) with the remaining excreted via GI tract

Question 11

Imbalance between production and excretion of uric acid causes hyperuricaemia leading to supersaturation and precipitation of monosodium urate crystals.

What are the three places these crystals typically end up

Answer 11

Soft tissue

Joints

Kidneys

Question 12

Imbalance between production and excretion of uric acid causes hyperuricaemia leading to supersaturation and precipitation of monosodium urate crystals.

What are the three main mechanisms leading to the crystal formation?

Answer 12

Purine overproduction e.g. increased cell turnover or lysis of cells leading to release of purines

Increase purine intake e.g. seafood, red meat, alcohol

Decreased uric acid secretion e.g. CKD, medication such as diuretics

Question 13

How does increase in cell turnover or lysis of cells causing hyperuricaemia

Answer 13

The destruction of the cell causing the release of purines

Purines are broken down into uriac acid

Thus there is imblanace between production and excretion causing the hyperuricaemia

Hyperuricaemia does not always lead to gout, but the incidence of gout increases with urate level.

Question 14

What 3 types of food and drink is there a high purine content

Answer 14

Seafood

Red meat

Alcohol

Question 15

The deposition of urate crystals may occur asymptomatically.

Give two examples of when this occurs?

Answer 15

In chronic gout

Formation of gouty tophi

Question 16

Gout is characterised by episodes of acute attacks/flare ups that trigger an acute inflammatory reaction leading to acutely painful swollen joints.

What triggers these acute attacks?

Answer 16

Generally due to increased production of uric acid either exogenous or endogenous

Question 17

Name an exogenous trigger that causes an increase in the production of uric acid trigger an acute attack of gout

Answer 17

High purine foods e.g. seafood, red meat

Question 18

Name two endogenous trigger that causes an increase in the production of uric acid trigger an acute attack of gout

Answer 18

Chemotherapy (increased cell breakdown)

Trauma and surgery

Question 19

How long does an acute inflammatory attack of gout usually last?

Answer 19

Several days

Question 20

What are the 3 key clinical features of an acute inflammatory attack of gout

Answer 20

Pain/tenderness of the affected joint(s)

Swelling of the affected joint(s)

Erythema of the affected joint(s)

Question 21

Gout is characterised by acute attacks of inflammation and then a period of remission.

What symptoms does a patient usually experiences during these periods of remission

Answer 21

Often symptom-free

Question 22

What joint is usually the first presentation/affected joint in gout

Answer 22

1st metatarsophalangeal (MTP) joint

Question 23

The 1st metatarsophalangeal (MTP) joint is the usually first joint affected in gout.

What other joints are commonly affected

Answer 23

Other joints include knees, ankles, carpometacarpal joints, wrists

In the majority of cases it is monoarticular (affecting only one joint at a time)

Question 24

What is Chronic tophaceous gout

Answer 24

Occurs when hyperuricaemia is left untreated

Characterised by hard subcutaneous nodules (tophi) which are the result of deposition of uric acid and formation of urate crystals in soft tissues e.g. ear, fingers, toes etc

The DIP joints are most affected in the fingers

Question 25

How is gout diagnosed

Answer 25

Clinical diagnosis that can be confirmed with arthrocentesis i.e. joint aspiration

Question 26

Arthrocentesis is a useful investigation for gout. What can it tell you that makes it useful

Answer 26

Can rule out other diagnoses - particularly septic arthritis that can commonly present with similar presentation to gout ## Footnote *Arthrocentesis is another name for joint aspiration*

Question 27

Gout is a clinical diagnosis however investigations can be useful to rule out other potential causes and to confirm the diagnosis What is the gold standard investigation in gout

Answer 27

Arthrocentesis

Question 28

What characteristics would be seen in arthrocentesis for gout

Answer 28

Presence of needle-shaped monosodium urate crystals that are negatively birefringent under plane-polarised light

Question 29

Blood uric acid levels are not usually checked when a patient presents with gout Why?

Answer 29

Patients typically present when they have an acute attack of gout Uric acid must be checked once the acute episode has settled down (typically 2 weeks later)

Question 30

Uric acid must be checked once the acute episode of gout has settled down (typically 2 weeks later). Why is this?

Answer 30

As the uric acid level at the time of an acute attack is not a true representation of the level May be high, normal or low during the acute attack

Question 31

The goal of managing an acute attack of gout is symptom relief and preservation of joint function. What 3 pharamceutical options are available?

Answer 31

NSAIDs, corticosteroids or colchicine

Question 32

The goal of prophylaxis management of gout is to prevent recurrent attacks and chronic joint destruction. What are the two ways in which this is done?

Answer 32

Combination of lifestyle changes and urate lowering therapy

Question 33

Lifestyle changes is part of the prophylaxis management of gout. Name some of the lifestyle changes

Answer 33

* Reduce alcohol intake * Avoid purine-based foods e.g. seafood * Medication review, particularly those that may cause hyperuricaemia e.g. diuretics, chemotherapy

Question 34

Urate Lowering Therapy is part of the prophylaxis management of gout. When are patients offered this medication

Answer 34

Should only be started at least one week after an acute episode has resolved as it may worsen the acute episode Offered to all patients after their first attack of gout

Question 35

Why must urate lowering therapy be started at least one week after an acute episode of gout has resolved?

Answer 35

Starting or increasing urate lowering therapy can itself cause a gout flare

Question 36

What is the 1st line urate lowering therapy given in the prophyalxis management of gout

Answer 36

Allopurinol

Question 37

What role does Allopurinol have in the management of gout

Answer 37

Urate lowering therapy used to prevent recurrent attacks and chronic joint destruction

Question 38

What drug class if allopurinol

Answer 38

Xanthine oxidase inhibitor

Question 39

What is the 2nd line urate lowering therapy used in the prophylaxis management of gout

Answer 39

Febuxostat

Question 40

What are the three complications of gout

Answer 40

Joint destruction Kidney disease Urolithiasis (kidney stones comprised of urate)