Gout

Question 1

What are some differentials for a single hot swollen joint?

Answer 1

Gout
Pseudogout
Septic arthritis
Psoriatic arthritis

Question 2

What are the risk factors for gout?

Answer 2

Male
Alcohol intake
High purine intake 
Diuretics 
BMI
Diabetes
Hypertension

Question 3

What investigations should be done if gout is suspected?

Answer 3

FBC
CRP & ESR 
Serum urate 
Joint aspiration and synovial fluid analysis - gram stain, culture, microscopy
U&E
LFTs

Question 4

What may be seen on polarising microscopy in gout?

Answer 4

Needle-like crystals of monosodium urate

Question 5

What is the treatment for acute gout?

Answer 5

Fast acting oral NSAIDs at max dose

If renal impairment: colchicine

Question 6

What dose should colchicine be prescribed at?

Answer 6

500 micrograms BD

Avoid adverse effects esp. diarrhoea

Question 7

When should prophylactic gout treatment be initiated?

Answer 7

Two or more attacks of acute gout per year
Tophus or tophi on imaging
CKD stage II or worse
Urolithiasis

2-4 weeks after acute attack has subsided

Question 8

What is the aim of prophylactic gout therapy?

Answer 8

Maintain serum uric acid <300micromoles/L

Question 9

What is used for gout prophylactic therapy?

Answer 9

Allopurinol 100mg daily, titrate every 2-5 weeks
Max dose = 900mg

LIFELONG

CKD 4 start at 50mg daily

Question 10

What are the side effects of allopurinol?

Answer 10

10% patients develop a rash
Allopurinol hypersensitivity syndrome - high mortality

Alternative = febuxostat

Question 11

What should be given alongside initial phase of urate lowering therapy?

Answer 11

Colchicine or low dose NSAID for first 6 months