GOUT
Dr. Andree B. Caillet, M.D
.
OVERVIEW
Gout is the most common crystal induced arthropathy and usually
follows a course of asymptomatic hyperuricemia, acute intermittent gout,
and chronic tophaceous gout. Gout occurs primarily in men with peak incidence
of onset occurring in the 40’s and 50’s. The condition is associated with
obesity, hypertension, alcohol intake, starvation, and serum creatinine
levels.
DIAGNOSIS
Definitive diagnosis can only be made by confirmation of the presence of
monosodium urate crystals in synovial fluid or tissues. If fluid can not
be aspirated, presumptive diagnosis can be made based on
1. Patient history: acute monoarticular arthritis followed by
a symptom free period, rapid peak of symptoms within 24 hours, and rapid
resolution of symptoms with NSAIDS.
2. Exam: heat, erythema, tenderness and swelling over affected
joint. Presence of tophi (check ear, olecranon process, dorsum of fingers,
and finger pads). Big toe MTP joint is most commonly involved, but the
forefeet, heels, ankles, wrists, fingers, elbows, and other joints may
be affected. It is occasionally polyarticular and fever may occur.
3. Lab studies: Elevated uric acid. Patients with hyperuricemia
may never develop gout however and patients with gout may have normal uric
acid levels. In an acute attack, x-rays are not helpful. In chronic gout,
defined erosions with characteristic overhanging edges in a around affected
joints are seen.
TREATMENT
Consider patients other comorbidities especially renal and GI diseases
1. Colchicine no longer used first line for acute attacks because
of side effects. If used, most effective if used in first 48 hours. Initial
dose 1 mg, then 0.5mg at 2-hour intervals up to 6 times on the first day.
Second day increase interval to 6 hours. Then decrease to BID until symptoms
resolve. GI toxicity is decreased with this regimen. Discontinue for diarrhea,
nausea or vomiting
2. NSAIDs drugs of choice if no contraindications
a. Indocin 50 mg QID X 2d; 50 mg TID X 2d; 25 mg TID until attack resolved
b. Ibuprofen 800 mg TID and reduce to 400 mg QID
c. Diclofenac 50 mg TID and reduce to 25 mg TID
d. Naproxen 750 mg initially followed by 250 mg TID
If over 65 consider having patient hold concomitant aspirin during
treatment; usually bring relief within first day; regardless of NSAID used,
use at full strength; NSAIDs more effective for attacks that are more than
2-3 days old.
3. Steroids use if contraindications to NSAIDs and/or colchicines
or polyarticular attack; intra-articular if monoarticular attack; 40 mg
Kenalog in large joints and 5-10 mg in small joints of hands or feet; systemic
steroids are used more often in polyarticular attacks and when NSAIDs are
contraindicated; triamcinolone 40-60 mg IM or tapering doses of prednisone
40-60 mg qd; no significant incidences of rebound attacks have been reported
with systemic steroids
LONG TERM TREATMENT
Goals are to prevent recurrence and complications of chronic gout
including tophi and renal stones.
1. General measure
Obese patients are advised to lose weight; decrease alcohol consumption;
low purine diet including organ meats, seafood, legumes; purine from the
diet contributes only about 1 mg/dl to the serum urate level.
2. Prophylaxis
Patients with frequent attacks and when starting urate lowering drugs;
colchicines BID most common dose, but may be controlled on QD or TID; side
effects are uncommon; continue prophylaxis for 1-2 months after acute attack;
start colchicines at the same time as urate lowering drugs and continue
until urate level is normal and stable for 2-3 months
3. Urate lowering drugs are indicated in certain situations.
A 24-hour urine for urate excretion will tell if a patient is an over
producer or an underexcretor. Daily excretion of 700 mg of urate indicates
overproduction. Uricosuric drugs increase renal excretion of urate and
are indicated in patients with normal renal function and no history of
kidney stones.
Probenecid 1-2 grams qd (Start at 500 mg qd divided BID and gradually
increase to 3000 mg qd to achieve a uric acid level between 5-6 mg/dl.
May require alkalinization of the urine with bicarbonate and keeping high
urine volumes to decrease the chance of precipitating uric acid stones.
Allopurinol is a xanthine oxidase inhibitor and decreases uric
acid production. Usual dose is 300 mg but requires dosage adjustment for
GFR. Start at 100 mg QD X 1 week, then 200 mg QD X 1 week, then 300 mg
QD. Check uric acid level in 1 month and adjust dose up or down. Max dose
is 600 mg.
Indications for Allopurinol are specific
a. uric acid stones
b. tophaceous gout
c. renal insufficiency
d. frequent attacks
e. >3 mg/dl over upper limits of normal uric acid
Asymptomatic Hyperuricemia
>7 mg/dl in males and >6 mg/dl in females; should not be treated
unless it is greater than 3 mg/dl over upper limits of normal. The theory
is to prevent potential renal damage and acute gout. Otherwise the expense
and side effects/toxicity of urate lowering drugs are not warranted when
acute gout can be easily treated if it occurs. Acute severe overproduction
of urate with Asymptomatic hyperuricemia such as in tumor lysis may prompt
treatment with Allopurinol
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