Gout

Background

• Hyperuricemia leading to arthritis

Pathophysiology

• Increased uric acid intake or decreased excretion

Risk Factors

• Diet high in meat and seafood
• Alcohol intake
• Chronic kidney disease
• Uric acid kidney stones
• Lymphoproliferative disorders
• Medications
  • Thiazides
  • Loop diuretics
  • Allopurinol (starting or stopping)

Clinical Manifestations

• Hot, red joint with decreased range of motion
• "Bedsheet sign": prefer to keep joint uncovered due to pain

Investigations

• Arthrocentesis
  • Elevated white cells with negative Gram stain
• serum uric acid, expected to be high but can be normal during a gout attack

Management

Acute

• Colchicine 1.2mg then 0.6mg an hour later
• NSAIDs
• Prednisone 0.5mg/kg/day for 5-10 days then stop, or for 2-5 days then taper over 7-10 days

Chronic

• Urate-lowering therapy
• First-line: allopurinol 100mg/day (halve it for CKD)
  • Titrate up as high as 800mg/day until target serum urate level of 0.35mmol/L achieved (6mg/dL)
  • Can start at 50mg/day and titrate up by 50mg/day every two weeks
• Second-line: febuxostat 40mg/day (up to 80mg/d)
• Alternative: probenecid, pegloticase
• Lifestyle changes
  • Avoid organ meats, decrease red meat

Further Reading

• 2012 American College of Rheumatology Guidelines for Management of Gout. Part 1: Systematic Nonpharmacologic and Pharmacologic Therapeutic Approaches to Hyperuricemia. Arthritis Care Res. 2012(64)10:1431-1446. doi: 10.1002/acr.21772
• 2012 American College of Rheumatology Guidelines for Management of Gout. Part 2: Therapy and Antiinflammatory Prophylaxis of Acute Gouty Arthritis. Arthritis Care Res. 2012(64)10:1447-1461. doi: 10.1002/acr.21773