Gout and Hyperuricaemia

Question 1

Background

Answer 1

Gout - type of arthritis where crystals of sodium urate form inside and around joints.

Will have raised uric acid conc. in the blood (Hyperuricaemia).

Can affect any joint but mainly distal joints like toes, knees, ankles, fingers.
Causes: purine rich diet, high alcohol intake, increased cell turnover and impaired uric acid excretion.

Meds that can increase uric acid:
- Diuretics & Other HTN drugs
- Low dose aspirin
- Niacin

Other risk factors:
Family history, genetics, overweight, High cholesterol/BP/ diabetic/ OA/ kidney issues, had surgery/injury, Post menopausal, men.

Question 2

Signs & Symptoms

Answer 2

severe pain
Joint feeling hot and tender
Swelling around joint
Red, shiny skin over joint

Question 3

Diagnosis

Answer 3

Measure serum urate level. =/>360 micromol/L (6 mg/dL) confirms it.
- If below this but still gout sus test again in 2-4 weeks.

if still unsure in 2ndry care arrange:
joint aspiration and microscopy of synovial fluid. NO aspiration then X-ray, ultrasound, or CT

Question 4

Treatment

Answer 4

Acute:
Start ASAP. 1ST LINE =
Colchicine, High dose NSAID (excluding aspirin), short course oral corticosteroid.
2nd line = Intraarticular/IM corticosteroid injection if above unsuitable.
IL-1 inhibitor if above unsuitable.
maybe PPI for NSAID user.
Ice packs/paracetamol for pain

Colchicine = 500mcg BD-QDS MAX 6mg. dont repeat within 3 days. Don’t induce fluid retention so better for HF patients.

Prevention: avoid excessive alcohol, high purine foods, lose weight, regular exercise, stay hydrated

Long term:
Urate lowering therapy:
Aim for under 360 but more frequent gout people aim 300.
Formation of uric acid reduced by xanthine-oxidase inhibitors, Allopurinol or Febuxostat. (1st LINE)
Start after 2-4 weeks from flare up settling.

IF resistant or intolerant of above use Uricosuric drugs, (Sulfinpyrazone or Benzbromarone)
- increase excretion or uric acid.

GIVE COCHICINE WHILST titrating up/starting urate lowering therapy. (PROPHYLAXIS)
ALT low dose NSAID/ corticosteroid
or IL1 if above unsuitable.

Question 5

Referral/Follow up

Answer 5

Acute:
Follow up 4-6 weeks after flare settled. measure serum urate level. asses lifestyle and co morbidities: - CKD testing (eGFR and ACR)?
REFER: ASAP if septic arthritis.

Long term:
Urate lowering therapy:
- Check serum urate level monthly. use to guide dosing.
- Still frequent attacks := check compliance, review triggers, referral?
- can do annual serum urate test
- MONITOR kidney function (eGFRcreatinine and albumin: creatinine ratio [ACR RATIO])
Allopurinol - monitor hypersensitivity
Febuxostat - Monitor LFT periodically.

REFER: ASAP if septic arthritis.