Gout

Question 1

What is Gout?

Answer 1

A chronic inflammatory arthritis related to hyperuricaemia characterised by acute flare ups.

Question 2

What are the non-modifiable risk factors?

Answer 2

• Age > 40 yrs
• Gender = MALE

Question 3

What are the modifiable risk factors?

Answer 3

• Increased purine uptake (Diet high in meat and seafood)
• Alcohol intake (esp. beer!)
• High fructose intake
• Obesity
• CVD
• Dyslipidaemia
• Renal disease
• Organ transplant
• Smoking
• DM
• Urate-elevating medications
  
  • e.g. Diuretics

Question 4

What is the pathophysiology?

Answer 4

Deposition of monosodium urate crystals that accumulate in joints & soft tissues, leading to inflammation that causes symptoms.

Question 5

What are the symptoms?

Answer 5

• Sudden-onset, severe pain
  
  • Single joint presents first
  • Typically affects first MTPJ (Podagra)
  • Can also present in any other joint
• Stiffness in affected joint(s)
• Erythema in affected joint(s)

Question 6

What are the signs?

Answer 6

• Warmth/erythema in affected joint(s)
• Tophi
• Fever

Question 7

What is this?

Answer 7

Tophi

• Subcutaneous deposition of MSU crystals.
• Can be found on
  
  • Fingers
  • Olecranon process
  • Toes
  • Achilles tendons
  • Knees
  • Helix of ears

Question 8

What investigation is crucial in making a diagnosis of gout?

Answer 8

​Bloods

• U&E
• Uric acid

Polarised microscopy of synovial fluid aspirate

Question 9

How do MSU crystals appear under polarised light?

Answer 9

Negatively birefringent

Question 10

What is an important differential of gout?

Answer 10

Pseuodogout

Caused by calcium pyrophosphate crystals.

Mainly occurs in older women.

Question 11

What is the difference in the appearance of synovial fluid in Gout vs. Psuedogout?

Answer 11

Question 12

What lifestyle recommendations can you make in order to prevent future attacks?

Answer 12

• Maintain optimal weight
• Regular exercise
• Diet modification
  
  • Reduce purine-rich foods
• Reduce alcohol consumption (beer & liquor)
• Smoking cessation
• Maintain fluid intake (Avoid dehydration)

Question 13

What is the management of acute gout?

Answer 13

• NSAIDs
• Oral/IM steroids
• Colchicine

HIGHLY EFFECTIVE WITHIN 24 HRS OF ACUTE FLARE

Question 14

What is the management of chronic gout?

Answer 14

Urate lowering therapy (ULT) after acute attack:

• Allopurinol
• Febuxostat
• Benzbromarone
• Sulfinpyrazone

Question 15

In a few words, explain the mechanism of action of allopurinol & febuxostat.

Answer 15

Both are xanthine oxidase inhibitors & reduce urate formation.

Question 16

In a few words explain the mechanism of action of Benzbromarone & Sulfinpyrazone.

Answer 16

Increase renal excretion of uric acid

Question 17

What are the aims of urate lowering therapy (ULT)?

Answer 17

To reduce SUA to < 360 micromol/L

Question 18

How do you treat asymptomatic hyperuricaemia?

Answer 18

YOU DON’T!

Question 19

What are the complications of untreated gout?

Answer 19

• Joint destruction
• Kidney disease
• Kidney stones