Gout

Question 1

Which joint does gout most commonly affect?

Answer 1

More than 50% of cases occur in the metatarsophalangeal joint of the big toe (podagra)

Question 2

Where else can it affect?

Answer 2

Ankle, foot, small joints of the hand, knee, elbow or wrist

Question 3

Can it be polyarticular or not?

Answer 3

It can be polyarticular

Question 4

What is gout?

Answer 4

Deposition of mono sodium u rate crystal in the synovium causing acute inflammation

Question 5

Is it more com one in women or men?

Answer 5

Men (4:1)

Question 6

How does this mono sodium urate crystal deposition occur?

Answer 6

Hyper uricaemia occurs, 10-20% of patients with this develop gout

Question 7

What factors increase the levels of uric acid in the plasma?

Answer 7

Obesity, huh alcohol, hypertension, renal impairment, long term diuretic use

Question 8

What events can precipitate attacks of gout?

Answer 8

Trauma, surgery, starvation, infection, diuretic use

Question 9

What develops long term due to gout?

Answer 9

Gout trophi form in the pinna, tendons and joints
Renal disease (stones/interstitial nephritis)

Question 10

What are the main differentials to consider?

Answer 10

Septic arthritis, Palindromic RA, CPPD (pseudogout), haemoarthrosis

Question 11

Gout is associated with what diseases?

Answer 11

Cardiovascular disease, hypertension, diabetes, diabetes, chronic renal failure

Question 12

What investigations would you do?

Answer 12

Polarised light microscopy, serum urate, FBCs, XR

Question 13

Under polarised light microscopy what characteristic do urate crystals have? (That calcium pyro phosphate are the opposite of)

Answer 13

Monosodium urate crystals in synovial fluid are negatively bifringent

Question 14

What might XR show?

Answer 14

Soft tissue inflammation. Juxta-articular erosions later, everything else may look normal, no loss of joint space till very late

Question 15

Why is serum urate not that useful?

Answer 15

As urate levels may very well be normal and cannot exclude gout if normal

Question 16

What is the treatment of gout?

Answer 16

High dose NSAIDS or coxib (COX-2 inhibitor)
Elevate and rest joint
Should clear in 3-5 days

Question 17

What would you give if CI to NSAIDS and coxib (peptic ulcer, heart failure, anticoagulant ion)

Answer 17

Colchicine

Question 18

What conservative measures help to prevent gout?

Answer 18

Lose weight, exercise, avoid prolonged fasts, stop drinking XS, avoid purine rich meats and low dose aspirin which increase plasma urate

Question 19

When would you start the patient on prophylactics?

Answer 19

If they have had more than 1 attack in the past 12 months

Question 20

What drug would you give to prevent gout?

Answer 20

Allopurinol (100mg/24hrs tut rate up to 300mg/8hrs)

Question 21

What might allopurinol trigger?

Answer 21

An acute attack of gout

Question 22

Despite attacks what should you avoid?

Answer 22

Stopping allopurinol once an established treatment

Question 23

What are the SEs of allopurinol?

Answer 23

Rash, lowered WCC, fever

Question 24

What can be used if CI to allopurinol?

Answer 24

Febuxostat

Question 25

What is the typical presentation of gout?

Answer 25

Acute monoarthropathy with severe joint inflammation

Question 26

What enzyme is responsible for converting purines into uric acid?

Answer 26

Xanthine oxidase

Question 27

What proportion is caused by impaired excretion compared to increased production of uric acid?

Answer 27

90/10