Acute gout diagnosis and management 2023
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| Gout in Right great toe (pic: pixabay) |
Table of Contents (toc)
Introduction
It is a crystal arthropathy due to deposit of urate or uric acid crystals.
This is usually seen in acted painful join and patients may come to emergency or OPD.
Caused by precipitation and deposition of uric acid crystals in the joints.
Etiology
Primary Hyperuricemia
Idiopathic
Increased production of uric acid
Decreased excretion of uric acid
Aggravated by the dietary habits
Secondary Hyperuricemia
1. Decreased excretion
Most common cause
Medications like pyrizinamide, aspirin, loop and thazide diuretics, niacin
Chronic renal insufficiency
Ketoacidosis
Post-menopausal age
2. Increased Production
Tumor lysis sundrome
Hemolytic anemia
Lesh Nyhan syndrome
Purine rich diets like red meats, sea foods, calcium poor diet
Obesity
3. Combined effect
Alcohol and diet containing high purine (like in a party with barbeque)
Decreased uric acid excretion
Clicnical features of gout and hyperuricemia
1. Asymptomatic stage
(may be more than 10 years) – but slowly this stage keeps on affecting the body
2. Acute gouty arthritis
Acute severe pain with overlying erythema, decreased range of motion, swelling and warmth
Mostly occurs at night and patient usually wakes up from sleep due to pain
Pain peaks in 12-24 hours and regressed ver a period of days to weeks
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| Acute gouty arthritis |
3. Chronic gout
Takes several years
Tophi formation
Types of tophi
- Bone tophi
- Soft tissue tophi
Renal complications include Nephrolithiasis and nephropathy.
Trigger of acute gouty arthritis
Here is the list of things or events that ma trigger the gouty arthritis episode.
- Purine rich meal
- Alcohol
- Trauma
- Surgery
- Diuresis
- Dehydration
Inflammation of different joints and their names in gout
1. Podagra:
MTP if the big toe
Occurs at night
Wakes up the patient
Most common site
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| Podagra |
2. Gonagra
Inflammation of the knee
Features similar to other joints
3. Chiragra
Inflammation of the fingers
MTP of the thumb mostly involved
Note: Desquamation of the overlying skin may occur in the secondary phase of the disease.
Diagnosis of Gout
Synovial fluid analysis (Gold Standard)
- Cell count
- Gram staining and culture sensitivity test
- Polarised light microscopy
How to differentiate Gouty arthritis vs Septic arthritis?
- Gouty arthritis has less cell cunt (<2000 vs >50000)
- There will not be any pus like synovial fluid
- No crystal in Polarised light microscopy
- No bacteria in culture and sensitivity test
Polarised light microscopy for gout
- Yellow colored polarised light is used
- Crystalls lie parallel to the axis of polarisation of light
- It will show needle shaped monosodium urate crystals that are negatively birefringement.
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| Urate crystals in microscopy |
Use of serum uric acid level inacute gout flair up
It is not useful in acute gout management or check prognosis
It is useful for prevention
it is useful for management and monitoring of chronic gout
Xray finding: Punched out lytic lesion called rat bite lesion
What to do if synovial fluid vannot be taken?
Synovial fluid analysis is gold standard
No finding in first episode of gout
Finding will be in repeated episode
Can be useful in chronic gout
Initially there might not be any damage that can be seen in the xray.
Xray finding: Punched out lytic lesion called rat bite lesion
Septic arthritis cannot be ruled out.
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| Rat bite lesion in chronic gout |
Below is another example of rat bite lesion.
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| rat bite lesion in chronic gout |
Treatment of acute gout
Lifestyle modification
- Limit alcohol use (has high purine)
- Limit intake of high purine diet like red meat, sea foods, sellfish
- Limit high fructose corn syrup like sugary foods, juices and non diet sodas
- Weight loss
General measures
Change offending drugs like diuretics to ACEI or ARB
Rest and ice the affected joint
Medical management
First lines
- NSAIDS
- Glucocorticoids(Drug of choice)
- Colcicine (Last choice for example PUD)
Second line
IL-1 inhibitors or ACTH
Third line
Combination above medications
Intrarticular corticosteroids
Do not mix NSAIDs and Gucocorticoids
Choice of corticosteroids
Prednisone (0.5 to 1 mg/kg)
Prednisolone (0.5 mg/kg) upto one week
Methylprednsolone (IV/IM/Inaarticular)
NSAIDs choice in Gout:
Naproxen (750 mg stat then 250 mg TDS)
Selecoxib
Etoricoxib
Avoid aspirin because it decreases uic acid excretion and even precipates gout. If patient is taking low dose aspirin continue it.
Colchicine is beneficial if taken within 12 hrs of acute gout.
Dose of colchicine
1.2 mg stat then 0.6 mg after one hout.
Side effects of colchicine
Diarrhea (common)
Myopathy
Contraindication of Colchicine
* CKD patients *
Management of chronic gout
Uric acid lowering drugs
- Xanthene oxidase inhibitor: allopurinol 1st line
- Uricosuric : Probenecid 2nd line
- Recombinant uricase : Pegloticase (uric acid to allantoin) 3rd line
Contraindication: Never start urate loweing therapy in acute gout flare up patient if they’re not taking any already.
Start these drugs after inflammation/acute flare up subsided.
If not other joint will also be involved.
Indication of urate lowering drugs
Damage due to chronic gout
Tophi development
Frequent attacks
Target of treatment is <6mg/dl
Checklist of Gout management:
- Consider other serious illnesses like septic arthritis
- Do diagnostic tests (arthosentesis, blood, imaging)
- Consult rheumatology if in doubt
- Provide analgesia
- Rest and ice
- Do not discontinue urate lowering therapy, do not start if not taking
- Start as early as possible
- NSAIDS
- Colchicine
- Steroids
- Combination (do not combine steroids and nsaids)
- Follow up and indication of long term urate lowering therapy.
