Gout

Question 1

Risk factors

Answer 1

Male
Obesity
High purine diet (e.g. meat and seafood)
Alcohol
Diuretics
Existing cardiovascular or kidney disease
Family history

Question 2

Joints affected

Answer 2

Base of big toe (metatarso-phalangeal joint)
Wrists
Base of thumb
Gout can also affects big joints like the knee and ankle.

Question 3

Diagnosis

What needs to be excluded

Answer 3

Gout is diagnosed clinically or by aspiration of fluid from the joint. Excluding septic arthritis is essential as this is a potentially joint and life threatening diagnosis.

Aspirated fluid will show:

• No bacterial growth
• Needle shaped crystals
• Negative birefringent of polarised light
• Monosodium urate crystals

Joint xray:

• Typically the space between the joint is maintained
• Lytic lesions in the bone
• Punched out erosions

Question 4

Management

Answer 4

During the acute flare:

• NSAIDs (e.g. ibuprofen) are first line and cannot be used in renal impairment
• Colchicine second line (common side effect is diarrhoea and cannot be used in CKD)
• Steroids can be considered third line

Question 5

Prophylaxis

Answer 5

Allopurinol is an xanthine oxidate inhibitor use for the prophylaxis of gout. It reduces uric acid level.

Allopurinol transiently raises urate levels and NSAID or colchicine cover has to be introduced for 3 months

Do not initiate allopurinol prophylaxis until after the acute attack is settled