Gout (monosodium urate crystal disease)

Question 1

Management of acute attack

Answer 1

Bed rest

Keep weight of the bedclothes off the foot with a bed cradle or pillow under bedclothes

Indomethacin 50 mg (o) tds (if tolerated):

• until symptoms abate (usu. 3–5 d)
• then taper 25 mg tds until cessation of attack or
• If extreme, 100 mg (o) statim, 75 mg 2 h later,
• then 50 mg (o) 8 hrly, then 50–70 mg/d until total relief.

Relief can be expected in 24–48 h.

Any other NSAID (except aspirin) can be used in full dosage.

Consider adding an antiemetic (e.g. metoclopramide 10 mg (o) bd) or

Colchicine 0.5 mg (o) statim then 0.5 mg 6–8 hrly until pain relief (usu. 24–48 h) or diarrhoea develops (max. 6 mg/24 h)

• Must be given early.
• Avoid if kidney impairment.

Consider corticosteroids (if sepsis excluded):

• intra-articular, e.g. 1 mL, of triamcinolone under a digital nerve block (providing sepsis excluded) or
• prednisolone 20 mg/d until symptoms cease, usually 3–5 d, then cease or
• corticotrophin (ACTH), e.g. tetracosactrin 1mg IM in difficult cases

Avoid aspirin and urate pool lowering drugs (probenecid, allopurinol, sulphinpyrazone).

Monitor kidney function and electrolytes.

Question 2

Long-term therapy

Answer 2

When acute attack subsides preventive measures include:

weight reduction

a normal, well-balanced diet

avoidance of purine-rich food, e.g.

• organ meats (liver, brain, kidneys, sweetbread)
• tinned fish (sardines, anchovies, herrings)
• shellfish and game

nil or reduced intake of alcohol and sugary drinks, including fruit juices (fructose)

good fluid intake (e.g. water 2 litres/day)

avoidance of drugs such as diuretics (thiazide, frusemide) and salicylates

wearing comfortable shoes

Question 3

Drug prophylaxis

Answer 3

Allopurinol (a xanthine oxidase inhibitor) is the drug of choice.

Dose: 100–300 mg daily

Indications:

• hyperuricaemia (only if patient symptomless)
• frequent acute attacks
• tophi or chronic gouty arthritis
• renal stones or uric acid nephropathy

Method:

Start 6–8 wks after last acute attack

Start with 50 mg/d for 1st wk → up to 50 mg/wk to 300 mg

Cover with prednisolone 5 mg/d, colchicine 0.5 mg tds or

• indomethacin 25 mg bd for 6 mths
• (to avoid precipitation of gout)