Gout

Question 1

What is Gout?

Answer 1

a type of crystal arthropathy associated with chronically high blood uric acid levels

Gout results from the deposition of monosodium urate crystals in joints and soft tissues.

Question 2

What is the most commonly involved joint in acute gout?

Answer 2

1st metatarsophalangeal joint (podagra)
- also CMCJ

This joint is typically affected at presentation.

Question 3

What causes the symptoms of gout?

Answer 3

Deposition of monosodium urate (MSU) crystals in joints and soft tissues

This leads to acute and chronic arthritis, tophi, urate nephropathy, and nephrolithiasis.

Question 4

What percentage of patients experience a second flare within 1 year after an initial gout attack?

Answer 4

60%

This increases to 78% within 2 years.

Question 5

What is the management strategy for gout?

Answer 5

Treat acute attacks and prevent recurrence by reducing SUA levels

Management includes medication and lifestyle adjustments.

Question 6

What are the non-modifiable risk factors for gout?

Answer 6

Age >40 years
male gender
FHx

These factors cannot be changed.

Question 7

List some modifiable risk factors for gout.

Answer 7

• Increased purine uptake (meats and seafood)
• Alcohol intake (especially beer)
• High fructose intake
• Obesity
• Congestive heart failure
• Coronary artery disease
• Dyslipidemia
• Renal disease
• Organ transplant
• Hypertension
• Smoking
• Diabetes mellitus
• Urate-elevating medications (e.g., diuretics)

Modifiable factors can be addressed through lifestyle changes.

Question 8

What are the main urate-lowering therapies (ULT) for chronic gout?

Answer 8

• Allopurinol
• Febuxostat

Both are xanthine oxidase inhibitors that reduce urate formation.

Question 9

What is the aim for serum uric acid (SUA) levels in gout management?

Answer 9

Reduce SUA to < 360 micromol/L

This target helps in managing gout effectively.

Question 10

True or False: Asymptomatic hyperuricemia requires treatment.

Answer 10

False

Asymptomatic hyperuricemia does not necessitate treatment.

Question 11

What is a pathognomonic finding for gout in synovial fluid?

Answer 11

MSU crystals

These crystals are indicative of gout when found in fluid aspirate.

Question 12

What is the first line treatment for acute gout?

Answer 12

• NSAIDs e.g. naproxen + PPI
• Colchicine 2nd
• oral steroids 3rd

These treatments are most effective when initiated within 24 hours of an acute flare.

Question 13

What is pseudogout?

Answer 13

An important differential diagnosis of gout caused by calcium pyrophosphate crystals

Pseudogout mainly occurs in older women with osteoarthritis.

Question 14

Fill in the blank: Regular _______ can help prevent gout.

Answer 14

exercise

Maintaining a healthy lifestyle is crucial in gout prevention.

Question 15

What lifestyle modifications can help prevent gout?

Answer 15

• Maintain optimal weight
• Regular exercise
• Diet modification (reduce purine-rich foods)
• Reduce alcohol consumption
• Smoking cessation
• Maintain fluid intake

These changes can significantly reduce the risk of gout attacks.

Question 16

What is gout associated with

Answer 16

High risk of CVD

Question 17

What therapies are indicated in chronic cases of gout

Answer 17

Urate lowering therapies (ULTs) after acute attack
- allopurinol and febuxostat which are both xanthine oxidase inhibitors and reduce urate formation

Question 18

What alternative drug therapies can be used to treat gout and how effective are they

Answer 18

Benzbromarone and sulfinpyrazone are LESS commonly used due to more side effects - they act increase renal excretion of uric acid

Question 19

how does gout typically present

Answer 19

single acute hot, swollen and painful joint

Question 20

what might X-ray of a joint affected by gout show

Answer 20

• Maintained joint space (no loss of joint space)
• Lytic lesions in the bone
• Punched out erosions
• Erosions can have sclerotic borders with overhanding edges

Question 21

when is use of colchicine indicated for treatment of gout

Answer 21

• used in pt where NSAIDs are contraindicated e.g. renal impairment or significant heart disease
• abdo symptoms + diarrhoea may be common side effects
• very dangerous in overdose and can cause multiple organ failure
• only prescribed for short course up to 6mg per course

Question 22

what are prophylactic interventions for gout

Answer 22

xanthine oxidase inhibitors which lower uric acid levels
- allopurinol
- febuxostat

prophylaxis is NOT started until weeks after the acute attack has resolved. once either one of the above is started, it is then continued during an acute attack

Question 23

what is a typical presentation of pseudogout

Answer 23

patient over 65 years old with a rapid-onset hot, swollen, stiff and painful knee

Other commonly affected joints are the shoulders, hips and wrists

Question 24

what investigations are used to reach a diagnosis of pseudogout

Answer 24

exclude septic arthritis 1st!!!!
- joint aspiration: calcium pyrophosphate (rhomboid shaped positively birefringent of polarised light)
- X-ray: chondrocalcinosis where calcium deposits in the joint cartilage show up as thin white line in middle of joint space