Gout – ACR 2012 guideline Part 1

Gout carries a risk of long-term morbidity and impaired quality of life.

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Risk factors for gout

1. Male > Female (7x)
2. Age (7% >65yo men, 3% >85 women)
3. hyperuricemia – consider the reasons and possible measures to alleviate it
4. Chronic kidney failure, chronic heart dz
5. Metabolic syndrome, obesity, dyslipidemia, HTN, DM
6. Organ transplantation
7. Drugs: diuretics, cyclosporine, low-dose ASA
8. Food high in purine: Meat, seafood, Alcohol, high-sugar soft drinks

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Clinical Dx

• Based on typical pain, swelling and erythema
• Possible Clinical Features:
  1. Acute episodic arthritis – self-limited painful swelling & redness affecting a single joint (often 1st MTP)
  2. Acute episodes can progress to chronic arthritis of one or more joints
  3. Hyperuricemia – not diagnostic as serum urate may be normal in attacks & some pt w/ elevated levels don’t develop gout. Rule out 2o causes of hyperuricemia
  4. Tophi: tissue deposits of monosodium urate crystals — may be observed on PE, imaging or pathologic examination
     • In articular, periarticular, bursal, bone, auricular and cutaneous tissues.
  5. Urolithiasis & acidic urine
  6. Chronic interstitial nephropathy – rare
• Clinicians should evaluate symptom severity and burden as well as risk factors and comorbidities

Definitive Dx

• Detection of urate crystals in synovial fluid or aspirated from a tophus
  • not always needed/available in clinical practice.
• Culture of synovial fluid may assist detection of co-existing septic arthritis.
• X-rays are not typically useful for diagnosis of acute attacks.

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Tx Acute attacks – Relief pain, swelling, and disability. 1st Line: Colchicine po & NSAID (part 2 of the guideline)

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Management for pt with a confirmed dx of gout – to reduce attacks by Lowering Hyperuricemia: target <6mg/dL (<5mg/dL in some pt: eg. with tophi or chronic tophaceous gouty arthopathy)

• Lifestyle:
  1. Avoid Meats, seafoods with ↑ purine content (organ meats, shellfish, sardines)
     • Limit serving sizes of beef, lamb, pork, high purine seafood
  2. Avoid soft drinks with high-fructose corn syrup
     • Limit sweet fruit juices, sweetened drinks, table sugar, desserts
  3. Avoid EtOH if frequent attacks or not well controlled.
     • <= 2 drinks / d – men & <=1 drink / d – women, especially beer, if dz is controlled
  4. Limit table salt
  5. Encourage healthy diet with low-fat dairy products, vegetables, adequate hydration
  6. Exercise & Wt loss if obese
  7. Smoking cessation
• Medical Rx:
  1. Eliminate non-essential meds that induce hyperuricemia
  2. 1st line: Allopurinol and febuxostat (Xanthine oxidase inhibitor), titrated to maximum appropriate dose
     • Gouty arthritis + tophus/tophi (clinical or imaging dx)
     • >=2 attacks/yr
     • CKD >=stage 2 or past urolithiasis
     • Monitor serum urate Q2-5 wk during titration of urate lowering Tx & 2x/yr once the target is achieved. 
  3. Alt: Probenecid (uricosuric agent – eGFR >50 required) if C/I with xanthine oxidase inhibitor or as additional Tx
  4. Pegloticase as additional Tx
  5. Serum urate lowering therapy can begin during an acute attack provided that an anti-inflammatory agent has been initiated. ??