Gout

Exam Cram

• Gout is caused by urate crystals depositing within the join space

• These are acutely painful and produce a hot swollen inflamed joint, commonly big toe

• Diagnosis: urate crystals on joint aspirate (needle shaped, negative birefringence)

• Management:

  • • Acute- NSAIDs

    • Long term- allopurinol (lowers urate)

Outline

Background 

Gout is caused by intra-articular uric acid deposits from hyperuricaemia. Uric acid is produced by the metabolism of DNA. Therefore high uric acids are seen in individuals who consume seafood, wine and other foods with a high number of cells. 

Assessment

History:

• Acute hot swollen tender joint 12-72hrs

Examination:

• Joints- acute, hot swollen, tender; non-irritable

• Gouty tophi

Investigations

• Urate- can be raised or normal

• CT- dual scan

• Joint aspirate

  • • Negative birefringent crystals

    • Needle shaped

Diagnosis

Diagnostic criteria: urate crystals on joint aspirate

Differentials: Pseudogout, Septic arthritis, 

Classification: by site- pellagra: big toe

Management

Acute episode

1. NSAIDs

2. Colcichine

3. Prednisolone [particularly in CKD/ AKI]

Urate lowering therapy (ULT): 

Primary and secondary prevention-

1. Allopurinol

2. Febuxostat

3. Benzbromarone

Med Reg Notes

Starting ULT

• Starting ULT worsens gout symptoms, therefore it is often started two weeks after flair

• Delaying ULT too long will result in prolonged courses of NSAIDs without resolution of gout

• In severe re-occuring gout there is an argument to start it promptly, because there may never be a good window to start it

• ULT should be continued during subsequent acute flairs

Gout in Pregnancy

• ULT: allopurinol > febuxostat

Resources and References

Page written in 2024.