Gout

Question 1

How does gout typically present?

Answer 1

Acute monoarthropathy with sever joint inflammation.

Question 2

Where do most instances occur? + other sites

Answer 2

> 50% in the metatarsalphalangeal joint of the big toe

Also the ankle, foot, small joints of hand, elbow, knee

Question 3

What is the disease process in gout and what causes it?

Answer 3

• Deposition of monosodium urate crystals in and near joints
• Precipitated by trauma, surgery, starvation, infection or diuretics
• Associated with raised plasma urate

Question 4

What are the long term complications of gout?

Answer 4

Urate deposits (tophi) and renal disease (stones, interstitial nephritis)

Question 5

What are the possible differential diagnoses?

Answer 5

EXCLUDE SEPTIC ARTHRITIS

- consider haemarthrosis, CPPD, and palindromic RA

Question 6

What are the causes gout?

Answer 6

1) Hereditary
2) high dietary purines
3) alcohol excess
4) diuretics
5) leukaemia
6) cytotoxis (tumour lysis)

Question 7

What other disease processes is it associated with?

Answer 7

1) Cardiovascular diease
2) Hypertension
3) Diabetes mellitus
4) Chronic renal failure

Gout is a marker for these so investigate further

Question 8

How is gout investigated?

Answer 8

Polarised light microscopy of synovial fluid shows negatively-bifringent urate crystals

Serum urate is normally raised (but may be normal)

Radiographs

• early stages show only soft-tissue swelling
• later, well-defined ‘punched-out’ erosions are seen in junta-articular bone
• there is no sclerotic changes and joint space is maintained until late into disease process

Question 9

How do you treat acute gout?

Answer 9

High dose NSAIDs or coxib (e.g. etoricoxib 120mg/24hrs), symptoms should subside 3-5 days

Colchicine if contra-indications to NSAIDS e.g. peptic ulcer, heart failure, anticoagulation,

Steroids of all above contraindicated (renal impairment)

Rest and elevate affected joint, ice-packs

Question 10

What are the lifestyle changes used in the prevention of gout?

Answer 10

• lose weight

- avoid prolonged fasts, alcohol excess, purine-rich meats and low dose aspirin (which increases serum urate)

Question 11

What is the prophylaxis regime and when is it indicated?

Answer 11

Start if >1 attack in 12 months, tophi or renal stones
Aim is to reduce crystal deposition and attacks

• Allopurinol, titrate from 100mg/24hr, increasing every 2 weeks until plasma urate is