Gout

Question 1

Features of gout?

pain typically reaches maximum in?

> 50% occur in which joint?

more common in males or females?

Answer 1

Single peripheral joint becomes excruciatingly painful (often nocturnal)

6-12hrs

males 4:1

> 50% occur in MTP joint og big toe

Question 2

Features of pseudogout?

strongly associated with?

Ix - polarised light microscopy shows?

Ix - radiograph?

Answer 2

same as gout but in larger joint of elderly

OA

positive birefringent crystals

associated with soft tissue calcium deposition on X-ray (chondrocalcinosis).

Question 3

which diagnosis do you need to consider?

how do you exclude it?

Answer 3

Septic arthritis

by sending off aspiration for bacteria culture

Question 4

Gout

• deposition of urate or calcium pyrophosphate crystals?
• what would suggest chronic gout?

Answer 4

by deposition of monosodium urate crystals in/near joints.

• polyarthritis, fever and malaise - uric kidney stones may also develop

Question 5

Ix (Gout)

• what do you find on polarised light microscopy for ?
• Radiograph findings in early and late?

Answer 5

• Polarized light microscopy of synovial fluid will show negatively bi-refringent urate crystals.
• Radiographs show only soft tissue swelling in early stages but later you get well-defined erosions ‘look like hole punches on side of bone’

Question 6

RFs for gout

RFs for pseudogout

Answer 6

High purine diet (red meat, shellfish)
Alcohol

OA
>40
hypothyroidism
hyperparathyroidism

Question 7

Presentation is similar in acute gout and acute pseudo gout - but presentation is slightly different - affect different joints?

Answer 7

Acute gout = MTP of big toe

Acute pseudogout = large joints (knee, ankle or wrist)

Question 8

Tx of Gout

• what do you give first? and until when?
• what do you administer if non-responding to above or CI?
• what are CI to NSAID?
• if still resistant?

Answer 8

• high dose NSAID until 48 hours after gout has resolved.
• colchicine
• elderly patients on warfarin
• intra-articular steroid injections

Question 9

Tx of Pseudogout

• conservative?
• medical?
• if resistant?

Answer 9

conservative: cool pack, rest

NSAIDs

intra-articular injections

Question 10

for both gout and pseudogout: need to do aspiration of joint fluid, to?

Answer 10

exclude septic arthritis

Question 11

gout is caused by chronic hyperuricaemia which is a uric acid level > than?

Answer 11

(uric acid > 0.45 mmol/l)

Question 12

Prevention of gout

Lifestyle changes?

Medication - what are the conditions for allopurinol?

when can you start allopurinol + what should you give alongside it?

alternative to allopurinol?

Answer 12

• weight loss
• less alcohol
• change diet (avoid red meats)

if 2 or more attacks of gout in one year - can start allopurinol or after first attack in high risk people (long term diuretics)

Introduction of allopurinol may trigger an attack so wait until 3 weeks after acute episode for it to be administered and compliment with a regular NSAID.

febuxostat (xanthine oxidase inhibitor ) more effective than allopurinol in reducing urate levels,

Question 13

Gout: drug causes?

Answer 13

Diuretics (long term)
- furosemide/thiazide

Alcohol

Question 14

A 71-year-old man presents with an erythematous, swollen first metatarsophalangeal joint on the left foot. This is causing him considerable pain and he is having difficulty walking. He has never had any previous similar episodes. His past medical history includes atrial fibrillation and type 2 diabetes mellitus and his current medications are warfarin, metformin and simvastatin. What is the most appropriate treatment of this episode?

intra-articular corticosteroid
colchicine 
ibuprofen 
diclofenac 
prednisolone

Answer 14

colchicine

NSAIDs should be avoided in elderly patients taking warfarin due to the risk of a life-threatening gastrointestinal haemorrhage.

Question 15

A 54-year-old male with a past medical history of hypertension, obesity, gout and hypercholesterolemia has a sudden onset of diarrhoea.

Which of his medications is most likely to be responsible?

amlodipine
colchicine
simvastatin
allopurinol

Answer 15

colchicine

Colchicine can cause diarrhoea

Diarrhoea is a classic side effect of colchicine, a drug used to treat acute exacerbations of gout.

Question 16

A 56 year old gentleman is being treated as an inpatient for a duodenal ulcer. He notices that his first metatarsophalangeal joint is severely inflamed on waking this morning. There is swelling and tenderness of the joint, and fluid is sent for microscopy. He has a past medical history of hypertension. What is the best initial medication to prescribe?

diclofenac 
allopurinol 
cyclizine 
colchicine 
indomethacin

Answer 16

colchicine

Diclofenac and indomethacin (NSAIDs) are contraindicated because of his duodenal ulcer. Colchicine is a suitable alternative.

Question 17

A 59-year-old man with a history of gout presents with a swollen and painful first metatarsophalangeal joint. He currently takes allopurinol 400mg od as gout prophylaxis. What should happen to his allopurinol therapy?

stop and recommence in 4 wks
reduce allopurinol dose
switch to colchicine
continue allopurinol

Answer 17

continue allopurinol

Patients already prescribed allopurinol should continue to take it at the same dose during acute episodes.

Question 18

A 40-year-old man presents to the Emergency Department with pain in his left foot. He thinks this may have been triggered by dropping a heavy box on it at work a few days ago. He is known to have type 2 diabetes mellitus which is managed with metformin. On examination there is erythema, tenderness and swelling in the distal, medial aspect of the left foot.

What is the most appropriate management?

allopurinol
naproxen
IV Abx
supportive stocking

Answer 18

naproxen

Question 19

A 57-year-old man with a history of ischaemic heart disease presents with an hot, erythematous and painful left 1st metatarsophalangeal joint. The attack settles following a course of non-steroidal anti-inflammatories. He currently takes aspirin 75 mg od for secondary prevention of ischaemic heart disease. What should happen regarding his medication?

switch to clopidogrel
continue aspirin at current dose
increase aspirin dose
stop aspirin

Answer 19

continue aspirin at current dose

Aspirin in a dose of 75-150mg is not thought to have a significant effect on plasma urate level

Question 20

A 76-year-old gentleman attends the emergency department complaining of an acutely painful, red great hallux.

He describes similar episodes of this pain previously, though none have been this severe. The pain has come on relatively suddenly from waking this morning. No other joints are affected. He has had minimal relief from taking ibuprofen at home.

The doctor has a working diagnosis of gout but decides to confirm this suspicion with a joint aspiration and analysis of the synovial fluid.

Which of the following are the typical findings on joint aspiration in gout?

brick shaped +ve
needle shaped +ve
needle shaped -ve
brick shaped -ve

Answer 20

needle shaped -ve

Joint aspiration in gout shows needle shaped negatively birefringent crystals under polarised light

needle = negative ‘n’ rule

Question 21

Gout- monosodium urate crystals that are ?

Pseudogout- calcium pyrophosphate crystals are?

Answer 21

Gout- monosodium urate crystals that are needle-shaped that are negatively birefringent under polarised light

Pseudogout- calcium pyrophosphate crystals are rhombic/brick shaped that are positively birefringent under polarised light

gout = needle 
pseudogout =  brick

think pseudo = prick
think prick = brick