GOUT ARTHRITIS

An inflammation disorder involving a joint(s) due to deposition of uric acid crystals; predominant in males.

Causes

  • Altered urate metabolism with deposition of urate salts in the joint and other tissues in advanced cases

Clinical features

Acute gout

  • Affected joint is hot, red, and swollen
  • Mostly attacks the big toe at the metatarsophalangeal joint (podagra), may occasionally start in other joints
  • Sudden severe pain (often at night)

Chronic gout

  • Repetitive acute attacks are followed by progressive cartilage and bone erosion
  • Deposition of tophi in soft tissue, e.g., ear cartilage, bursae, and tendon sheaths

Differential diagnosis

  • Joint infection
  • Rheumatoid arthritis
  • Injury
  • Pseudo gout (osteoarthritis)

Investigations

  • Joint aspiration uric acid crystals viewed by a polarising microscope
  • X-ray: Of the joint(s)
  • Blood: Serum uric acid (usually elevated)

MANAGEMENT

Acute attack

  • Rest and immobilisation
  • Start NSAIDS such as ibuprofen 400 mg every 8 hours
  • or Indomethacin 50 mg every 8 hours
  • Or Diclofenac 50 mg every 8 hours
    • Continue for the duration of the attack

If NSAIDS contraindicated

  • Prednisolone 40 mg once daily for 5 days
  • Or colchicine 0.5-1 mg initially followed by 0.5 mg every 2-3 hours until relief of pain, or if
    vomiting and diarrhoea occurs (max dose 6 mg).
    Do NOT repeat the course within 3 days

Chronic gout

  • Weight reduction
  • Control diet: healthy diet, limit alcohol consumption, coffee is beneficial
  • Avoid medicines which may increase uric acid: thiazide diuretics


If more than 2 attacks per year, and/or complications (renal stones, chronic tophaceous
gout), give:

  • Allopurinol starting dose 100 mg , increase monthly by 100 mg. Average maintenance dose
    300 mg, max 900 mg. Titrate to keep uric acid level <0.35 mmol/L
  • Do not start during acute attack, but continue with it if already started
  • Give prophylactic colchicine 0.5 mg every 12 hours for the first 3 months to prevent acute
    attacks
Note
  • DO NOT use allopurinol to treat asymptomatic hyperuricemia