Gout

Question 1

What causes gout?

Answer 1

Monosodium urate crystal deposition

Question 2

Define gout

Answer 2

An acute inflammatory arthritis characterised by hyperuricaemia and deposition of urate crystals

Note: you don’t always have to have hyperuricemia

Question 3

Which joints are primary affected in gout?

Answer 3

1st MTP 
Mid foot
Ankle 
Knee
Fingers
Wrist
Elbow
Any joint

Question 4

What is it called when it affects the 1st MTP?

Answer 4

Podagra

Question 5

Epidemiology

Answer 5

Rare in pre-menopausal women

Being male is a risk factor

Question 6

Signs

Answer 6

Tophi (visible depositions) 
Joint stiffness
Swelling 
Tenderness
Erythema
Warmth

Question 7

Aetiology

Answer 7

Older age
Male sex
Menopausal status

FOOD:
Consumption of meat, seafood, alcohol
DRUGS:

Use of diuretics, ciclosporin and tacrolimus, pyrazinamide, aspirin

(increased tubular reabsorption of urate and decreased GFR)

CONDITIONS: 
obesity
exogenous insulin (reduces renal excretion of urate)
HTN 
Renal insufficiency 
Diabetes mellitus
Hyperlipidemia
Leukemia 
Alcohol excess
Polycythemia
FH of gout

RECENT:
Surgery
Fasting
Chest infection

Question 8

Investigations

Answer 8

Arthrocentesis for synovial fluid analysis 
Serum urate 
Xray 
Full FBC
U and E 
LFTs
CRP

Question 9

Why do we look at LFT?

Answer 9

Alcohol excess can precipitate gout (due to tubular dysfunction)

Question 10

Why do we do full FBCs?

Answer 10

Polycythemia and leukemia can precipitate gout

Question 11

Why do we look at Us and Es?

Answer 11

To check for renal stones as hyperuricemia can result in this

Question 12

What would an xray of the podagra show?

Answer 12

Punched out, bony erosion seen in relation to 1st MTP

Soft tissue swelling in relation to the 1st MTP

Question 13

What do you expect to find in the aspiration?

Answer 13

Negatively birefringent crystals on microscopy

Question 14

How do these crystals appear?

Answer 14

Yellow and needle shaped

Question 15

First line treatment for acute gout

Answer 15

NSAIDS

Question 16

If the patient can’t have NSAIDs due to e.g. a history of duodenal ulcer, what would you prescribe them?

Answer 16

Colchicine

Question 17

SE of colchicine?

Answer 17

Diarrhoea

Vomiting

Question 18

Long term therapy for chronic gout?

Answer 18

Allopurinol

Question 19

How does allopurinol work?

Answer 19

It inhibits the xanthine oxidase enzyme which normally converts hypoxanthine to uric acid in the purine catabolism pathway.

Question 20

Give one reason how alcohol could cause gout

Answer 20

Alcohol increases the acidity of the urine
Uric acid is a weak acid therefore
At normal physiological conditions, it only weakly ionises, so it stays more as urate
In strongly acidic urine, it is more likely to stay unionised as urate
Urate is strongly reabsorbed…
Precipitating gout !

Question 21

Which foods and drinks should be avoided?

Answer 21

Red meat/bacon
Sardines
Alcohol
Sugary drinks

Question 22

What would an xray of podagra show?

Answer 22

Punched out erosions
soft tissue swelling
tophi

Question 23

Management

Answer 23

RICE
Rest
Ice
Compression
Elevation

Dietary advice
NSAIDS/colchicine/steroids - think PPI

Question 24

Prophylaxis management

Answer 24

Allopurinol

Question 25

When would you start prophylactic treatment?

Answer 25

Two or more attacks of acute gout
Tophi
Chronic gouty arthritis
Joint damage
Renal impairment
Hx of urinary stones
Diuretic use
Young age of onset of primary gout