Gout carries a risk of long-term morbidity and impaired quality of life.
Risk factors for gout
- Male > Female (7x)
- Age (7% >65yo men, 3% >85 women)
- hyperuricemia – consider the reasons and possible measures to alleviate it
- Chronic kidney failure, chronic heart dz
- Metabolic syndrome, obesity, dyslipidemia, HTN, DM
- Organ transplantation
- Drugs: diuretics, cyclosporine, low-dose ASA
- Food high in purine: Meat, seafood, Alcohol, high-sugar soft drinks
Clinical Dx
- Based on typical pain, swelling and erythema
- Possible Clinical Features:
- Acute episodic arthritis – self-limited painful swelling & redness affecting a single joint (often 1st MTP)
- Acute episodes can progress to chronic arthritis of one or more joints
- 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
- 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.
- Urolithiasis & acidic urine
- 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:
- Avoid Meats, seafoods with ↑ purine content (organ meats, shellfish, sardines)
- Limit serving sizes of beef, lamb, pork, high purine seafood
- Avoid soft drinks with high-fructose corn syrup
- Limit sweet fruit juices, sweetened drinks, table sugar, desserts
- Avoid EtOH if frequent attacks or not well controlled.
- <= 2 drinks / d – men & <=1 drink / d – women, especially beer, if dz is controlled
- Limit table salt
- Encourage healthy diet with low-fat dairy products, vegetables, adequate hydration
- Exercise & Wt loss if obese
- Smoking cessation
- Avoid Meats, seafoods with ↑ purine content (organ meats, shellfish, sardines)
- Medical Rx:
- Eliminate non-essential meds that induce hyperuricemia
- 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.
- Alt: Probenecid (uricosuric agent – eGFR >50 required) if C/I with xanthine oxidase inhibitor or as additional Tx
- Pegloticase as additional Tx
- Serum urate lowering therapy can begin during an acute attack provided that an anti-inflammatory agent has been initiated. ??
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