Gout

Dhaneshwar Prasad Yadav

Junior Intern
Introduction
 Gout is a metabolic disease that most often affects middle-aged to
elderly men and postmenopausal women.

 It results from an increased body pool of urate with hyperuricemia.

 It typically is characterized by episodic acute arthritis or chronic

arthritis
Acute arthritis
 Acute arthritis is the most common early clinical manifestation of
gout.

 Usually, only one joint is affected initially, but polyarticular acute

gout can occur in subsequent episodes.

 The first episode of acute gouty arthritis frequently begins at night

with dramatic joint pain and swelling.
Chronic arthritis
 As gout becomes chronic, multiple joints may be involved, and
deposition of urate crystals in connective tissue (tophi) and kidneys
may occur.
Clinical manifestations
 Metatarsophalangeal joint of the first toe is commonly affected
(podagra), but other joints such as the knee, ankle, PIPs, or DIPs may
be initially involved

 First episode often occurs at night with severe joint pain waking the
patient from sleep; the joint rapidly becomes warm, red, and tender
(it looks exactly like cellulitis)

 Without treatment the joint pain goes away spontaneously within

3–14 days.
Precipitating factors
 Excessive alcohol ingestion,
 Red meat intake,
 Trauma,
 Surgery,
 Infection,
 Steroid withdrawal,
 Drugs (hydrochlorothiazide,furosemide, pyrazinamide and ethambutol)
 serious medical illness.
Differential diagnosis
• Rheumatoid Arthritis
• osteoarthritis
• CPPD
Diagnosis
• Even if the clinical appearance strongly suggests gout, the
presumptive diagnosis ideally should be confirmed by needle
aspiration of acutely or chronically involved joints.

• During acute gouty attacks, needle-shaped MSU crystals typically are

seen both intracellularly and extracellularly
Radiographic Features
• Cystic changes, well-defined erosions with sclerotic margins (often
with overhanging bony edges), and soft tissue masses are
characteristic radiographic features of advanced chronic gout.

• Dual-energy computed tomography (CT) can show specific features

establishing the presence of urate crystals.
 Treatment
ACUTE GOUTY ARTHRITIS
 The mainstay of treatment during an acute attack is the administration of anti-
inflammatory drugs such as nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine,
or glucocorticoids.

 Both colchicine and NSAIDs may be poorly tolerated and dangerous in the elderly and
in the presence of renal insufficiency and gastrointestinal disorders.

 Steroids oral (rarely intraarticular) in elderly patients who cannot tolerate NSAIDs/
colchicine or in patients with renal impairment

 Ice pack applications and rest of the involved joints can be helpful.
 Colchicine : Useful regimens are one 0.6-mg tablet given every 8 h with
subsequent tapering or 1.2 mg followed by 0.6 mg in 1 h with
subsequent day dosing depending on response.

 NSAIDs given in full anti-inflammatory doses are effective in ∼90% of

patients.
eg. Indomethacin, 25–50 mg tid;
Naproxen, 500 mg bid;
Ibuprofen, 800 mg tid;
Diclofenac, 50 mg tid;
Celecoxib 800 mg followed by 400 mg 12 h later, then 400 mg bid
Treatment
Chronic Arthritis
• Goal is to decrease uric acid levels. This is usually required for life and
initiated in those whose recurrent gouty attacks cannot be corrected
by low-purine diet, alcohol limitation, avoiding diuretics, etc.

• Unlike acute gout, the uric acid level here may help the physician to
follow the effect of hypouricemic treatment.
Treatment
• Allopurinol can be used in overproducers, undersecretors, or patients
with renal failure or kidney stones

• Febuxostat is used in those intolerant of allopurinol.

• Pegloticase dissolves uric acid: used in refractory disease