Gout

Question 1

What is gout

Answer 1

Persistent raised plasma uric acid (urate) concentration -> leads to uric acid crystal formation -> painful inflammation within joints (mainly big toe)

Question 2

How does gout occur

Answer 2

Monosodium urate crystals (MSU) deposit in cartridge in the joint space resulting from sustained hyperuricaemia (high levels of uric acid) this leads to an inflammatory response

Question 3

What is the metabolism of purines to uric acid

Answer 3

Uric acid is the end product of purine nucleic acid degradation
1. adenine and guanine are metabolised though the same pathway
2. deamination occurs of adenine
3. ribose-5-P removal
4. BOTH are converted to xanthine
5. Converted to uric acid
6. Uric acid is excreted renally

Question 4

What are the symptoms of gout

Answer 4

Rapid onset (hours/days)
Severe pain
Swelling
Redness and warmth
Tenderness in joint

Question 5

What are the risk factors of gout

Answer 5

Age
Male
Obesity
Purine rich diet (alcohol, red meat, seafood)
Renal impairment (CKD)
Hypertension
Drugs (diuretics, ACEi, beta blockers)
Family history of gout

Question 6

What are the foods with decreased risk of gout

Answer 6

Cherries
Vegetable protein
Vitamin C
Coffee
Dairy

Question 7

What is the diagnosis of gout

Answer 7

Gold standard - MSU monosodium urate crystal detection in synovial fluid from joint

GP observation
X-ray
Ultrasound
CPR C-reactive protein and ESR

Question 8

When would you refer gout to secondary care

Answer 8

URGENT ASAP - septic arthritis (generally unwell, painful hot swollen joint)
Unresponsive to uric acid lowering
Persistent SE despite Max NSAID
Gout complications (neuropathy)
Gout persists despite Uric acid levels lowered
Young onset below 30
Pregnancy
Needing specialist benzbromarone

Question 9

What is the acute management of gout

Answer 9

Start ASAP for 1-2 weeks and R.I.C.E
1st line NSAIDS max dose (or cox2inhibitor) &PPI
2nd line colchicine
3rd line corticosteroids
Poor response can combine

Question 10

What is the chronic management of gout

Answer 10

1st line allopurinol
2nd line febuxostat
3rd line benzbromarone (specialist)

Question 11

When is long term treatment for gout needed

Answer 11

2+ attacks in year
Tophi
Young
CKD and gout
Continuing diuretics (heart failure and gout)
Uric acid renal stones

Question 12

When would you start chronic management and how long to wait if an attack of gout happens

Answer 12

DONT start chronic during an attack (1-2 weeks after) BUT continue if already on drug and a attack occurs

Question 13

Allopurinol MOA

Answer 13

Lowers serum uric acid
Inhibits xanthine oxidase
Deposition of urate crystals in tissue (tophi) is reversed

Question 14

MOA of uricouric drugs (benzbrolarone)

Answer 14

Inhibit Renal tubules from reabsorbing uric acid
Increase renal excretion and decrease urate levels in serum

Question 15

Is life long therapy needed

Answer 15

Once sUA targets reached
Reduce ULT dose to maintain targets, check annually, continue lifelong unless modifiable risk factor addressed and cure achieved

Question 16

Colchine serious SE

Answer 16

STOP severe nausea and vomiting
SAME day assessment if take too much of colchine (even if no SE)

Question 17

Colchine CI and cautions

Answer 17

C/I heart failure
Caution/ lower dose - fluoxetine, erythromycin, clarithromycin
Renal impairment and stain - elderly

Question 18

Colchine add info

Answer 18

Normally 2-3 days until symptoms are relieved or vomiting & diarrhoea occurs DONT repeat within 3 days

If c/I can take steroids

Question 19

Allopurinol dose / special

Answer 19

Don’t start during an attack (1-2 weeks after) but continue if already on drugs and a attack occurs

Take after meals to reduce GI SE

Question 20

Allopurinol monitoring

Answer 20

sUA monthly to achieve serum urate below targets

Question 21

Allopurinol SE and SERIOUS SE

Answer 21

GI problems - take after meals

STOP if rash occurs but if it’s mild and resolves can continue if rash occurs again DISCONTINUE

Question 22

Allopurinol C/I and cautions

Answer 22

AVOID azathioprine (inhibits metabolism of azathioprine - accumulation of toxic metabolites)

Increased risk of hypersensitivity in renal impairment - dose adjustment

Question 23

Febuxostat dose / special

Answer 23

Don’t start during an attack (1-2 weeks after) but continue if already on drugs and a attack occurs

Question 24

Febuxostat SE and serious SE

Answer 24

GI problems, Odema

STOP if hypersensitivity
steven-Johnston syndrome
Actue anaphylactoid/ shock DISCONTINUE and DO NOT restart

Question 25

Febuxostat c/I and cautions

Answer 25

AVOID azathioprine (inhibits metabolism of azathioprine - accumulation of toxic metabolites)

C/I liver impairment, thyroid disorders, heart failure
Increased risk in PT. With CV disease