Gout - Diagnosis and Management Summary 3 Conditions for Gout to Manifest: 1. Hyperuricemia 2. Monosodium urate deposition in joints and/or soft tissues 3. A reaction to phagocytosed crystals that leads to an acute inflammatory response Risk Factors: • Advanced age • Male sex • Metabolic syndrome • Medications (diuretics) Epidemiology: • Men in 4th to 5th decade • Postmenopausal women Presentation: • Acute Intermittent Gout • Great toe (podagra): 50% of initial attacks • Other joints include forefoot, ankles, knees, fingers, wrist, elbow • Nocturnal onset → Peak 12-24 Hours • Fever, erythema, swelling, significant pain • Intercritical Gout: • Asymptomatic period between attacks • Chronic Recurrent Gout • Increasingly severe/frequent attacks • Arthritis may become persistent, polyarticular • Soft tissue involvement (cellulitis mimic, bursitis) • Chronic Tophaceous Gout • Chronic recurrent gout + tophi • Tophi on extensor elbows, Achilles tendon, fingers Synovial Fluid Testing: • WBCs >2000-100,000/μL • Neutrophil predominance • Urate crystal • Needle-shaped, negatively birefringent • Acute gout • Intracellular (leukocyte) crystals • Intercritical gout • Extracellular crystals • Gram stain and culture • Diagnose concomitant infection Serum Urate Levels: • Not helpful in acute gout • ↑ C-reactive protein, ESR, leukocytosis • Nonspecific findings Imaging: • Uncertain diagnosis or arthrocentesis not possible • Ultrasound → double contour sign • Dual-energy CT → MSU deposits • Plain films (chronic gout) → erosions with overhanging cortical bone Treatment: • Discontinue diuretics; consider losartan (uricosuric) • Weight loss, alcohol reduction • Specific dietary restrictions (insufficient evidence) • Acute gout treatment; consider comorbidities/drug interactions • Glucocorticoids (oral, intra-articular, or intramuscular) • NSAIDs • Low-dose colchicine Hyperuricemia: Allopurinol Therapy • First-line therapy • Decrease dosage in CKD • Indications • ≥2 attacks in a year • 1 attack + stage ≥3 CKD or nephrolithiasis, serum urate level >9 mg/dL • Tophi • +Radiographic signs of chronic gout • Concomitant low-dose colchicine, NSAIDs, or prednisone Hyperuricemia: Other Therapy • Febuxostat → patients intolerant of allopurinol; boxed warning • Probenecid → possibly combined with allopurinol • IV pegloticase → severe recurrent or tophaceous gout • Oral drug failure • Risk for severe allergic reactions • Serum urate level target <6 mg/dL #Gout #diagnosis #management #treatment #rheumatology
