Gout – ACR 2012 guideline Part 1

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

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

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.

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

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. ??
Posted in 55 Joint Disorder, 99 Priority Topics, FM 99 priority topics, Rheum

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