Gout

Gout is a form of inflammatory arthritis characterized by recurrent attacks of a red, tender, hot, and swollen joint, commonly affecting the base of the big toe. It results from elevated levels of uric acid in the blood, which crystallizes and deposits in joints, tendons, and surrounding tissues.

Causes:

  • Hyperuricemia: Excessive uric acid in the blood is the primary cause of gout.
  • Diet: High intake of purine-rich foods (red meat, seafood), alcohol (especially beer), and sugary beverages increases risk.
  • Genetics: Family history of gout increases susceptibility.
  • Health Conditions: Obesity, hypertension, chronic kidney disease, and metabolic syndrome.
  • Medications: Diuretics (thiazides and loop), aspirin, and other drugs increase uric acid levels.
  • Age and Gender: More common in men and postmenopausal women.

Diagnosis:

  • Clinical Presentation: Acute onset of joint pain, swelling, redness, and tenderness, often at metatarsophalangeal (MTPJ) of the the big toe.
  • Laboratory Tests:
    • Serum Uric Acid Levels: Elevated levels support the diagnosis but are not always conclusive.
    • Joint Fluid Analysis: Uric acid crystals in joint fluid confirm diagnosis.
  • Imaging: X-rays to rule out other joint diseases; ultrasound can detect urate crystals.

Differential Diagnosis:

  • Pseudogout: Caused by calcium pyrophosphate deposition; typically affects larger joints.
  • Septic Arthritis: Joint infection that requires immediate treatment.
  • Rheumatoid Arthritis: Autoimmune disease causing joint inflammation.
  • Osteoarthritis: Degenerative joint disease.
  • Cellulitis: Infection of the skin and subcutaneous tissues.

Management:

  • Acute Attack:
    • NSAIDs: First-line treatment for pain and inflammation.
    • Corticosteroids: For patients who can’t tolerate NSAIDs.
    • Colchicine: Effective especially when taken early in the attack.
  • Preventive Treatment:
    • Urate-Lowering Therapy: Allopurinol or febuxostat to maintain serum uric acid below target levels.
      • RACGP like low dose allopurinol 50mg + colchicine 500mg to prevent flare.
      • RACGP like treatment for life
      • RACGP like addition of probenecid if allopurinol insufficient
    • Lifestyle Modifications: Weight reduction, dietary changes, reduced alcohol intake, increased water consumption.
    • Education: Informing the patient about the nature of the disease, triggers for attacks, and importance of compliance with medications.
  • Monitoring: Regular monitoring of serum uric acid levels and renal function.
  • Dietary Advice: Limit intake of high-purine foods, alcohol, and fructose.

When to Refer:

  • Uncertain diagnosis or atypical presentation.
  • Failure to respond to standard treatment.
  • Frequent attacks or complications like tophi or kidney stones.
  • Patients with coexisting kidney disease.

Follow-Up:

  • Regular follow-up to monitor serum uric acid levels and adjust medications ie increase the Allopurinol dose to reach target
    • < 0.36 mmol/L
    • < 0.30 mmol/L tophaceous gout
  • Evaluation for treatment side effects.
  • Assessing and managing associated comorbidities.

Proper management of gout involves not only treating acute attacks but also maintaining long-term uric acid levels through medication and lifestyle changes to prevent future attacks and complications.