Gout Flashcards
what must be ruled out if patient presents with a hot, red, swollen joint
septic arthritis
gout risk factors
male
high alcohol intake
high purine intake: steak oily fish and maritime
diuretics
high BMI
other features of metabolic syndrome: DM, HTN
investigations in hot red swollen joint
FBC - WBC for septic arthritis
CPR/ESR - inflammation raised in gout and septic arthritis
blood cultures if suspecting septic arthritis
renal and liver function - detect end organ indication, baseline and needed for gout and RF meds. can also influence choice of AB in septic arthritis
If history susceptive of RF - rheumatoid factor, anti-CCP
JOINT ASPIRATION and synovial fluid analysis - gold standard
Imaging - not required for an acute joint, no benefit in septic arthritis or gout
serum urate - no diagnostic value in gout. can be normal/low in an acute episode as uric acid has precipitated in joint. repeat a few weeks after attack has settled
diagnosis of gout
joint aspiration: urate crystals on microscopy is the gold standard
typical presentation of gout
red hot swollen 1st MTP of the foot
systemically well
cause of gout
too much uric acid being made or the kidneys aren’t working and filtering it out properly
primary cause - too much uric acid unsure why
secondary cause
eating too much meat, increases uric acid
alcohol means that uric acid can’t be filtered by the kidneys as alcohol is instead
renal insufficiency
leukaemia and other blood disorders
management of an acute attack of gout
1) NSAIDs are the drug of choice when theres no contraindications - not ideal if renal impairment or ulcers, bleeds etc
2) Colchicine effective alternative if patients can’t be prescribed NSAIDs, ideally started within 12 hours of flare of onset
intra-articular corticosteroids are highly effective in acute gout provided septic arthritis has been ruled out. Oral/IM/IA steroids can be effective in those unable to tolerate the above. Not ideal for diabetics, consider if not responding to alternative treatment
when to give prophylactic management
had two or more attacks of acute gout per year
tophus or tophi by clinical or imaging study
CKD stage II or worse
urolithiasis (formation of stony concentrations in bladder or urinary tract)
Aim of prophylactic therapy
maintain lower serum uric acid sUA (300micromoles/L)
treat to target
the lower the sUA the more chances of dissolution of tophi and decreased risk of acute attacks
What is the prophylactic treatment for gout?
ALLOPURINOL - first line
introduce 2-4 weeks after acute flare
Xanthine oxidase inhibitor
aim to start 100mg daily
in patients with CKD stage 4 or worse start at 50mg daily
titrate every 2-5 weeks
max dose 300mg in those with significant renal failure, everyone else shouldn’t exceed 900mg/day - treat to target (sUA <300micromoles/L)
SE: rash
allopurinol hypersensitivity syndrome
if patients can’t take allopurinol, febuxostat is the alternative
how to counsel someone regarding prophylactic gout treatment
1) lifestyle changes
2) allopurinol
check for renal or hepatic impairment
start 2-4 weeks after acute flare
lifelong
tablet
OD or BD
take after meals and encourage good hydration and fluid intake 2-3L
will stop the acute flare ups of gout as it decreases amount of a crystal (uric acid) which is building up in your joints and causing gout
increased risk of acute gout attacks in first 6 months so we will give you other medication to help this, start this 2 weeks before
seek medical help if you develop a rash
lifestyle changes suggested in gout
- Reduce alcohol intake/ avoid if possible
- Avoid sugary drinks, heavy meals and excessive intake of meat and seafood
- Foods rich in vitamin C can also help reduce urate levels
- Regular exercise should be encouraged
- Reduce dietary intake of purines
- Reduce weight
- Patients with gout are at an increased CVD risk – stop smoking
- Every patient should be systemically screened for associated co-morbidities and CV risk factors consider renal impairment, coronary heart disease, heart failure, stroke, peripheral arterial disease, obesity, hyperlipidaemia, HTN, DM and smoking – ALL should be addressed as a part of gout management
