Gout Overview and Clinical Features

Gout Overview

• Gout is a metabolic disorder caused by uric acid buildup (hyperuricaemia).
• Urate crystals deposit in joints (acute gouty arthritis), soft tissues (tophi and tenosynovitis), and the urinary tract (urate stones).
• Four stages of gout exist: asymptomatic hyperuricemia, acute gouty arthritis, intercritical gout, and chronic tophaceous/gouty arthritis.

Asymptomatic Hyperuricemia

• Significantly more common than overt gout (10 times more frequent)
• Characterized by elevated serum uric acid levels (>0.42 mmol/L in men, >0.36 mmol/L in women)
• Usually without symptoms, often requiring no treatment.

Clinical Features of Gout

• Primarily affects men (5-8% prevalence), with earlier onset (40-50) compared to women (60+).
• Acute attacks involve excruciating pain, typically affecting the big toe (great toe).
• Joint area becomes red, shiny, swollen, hot, and extremely tender.
• Symptoms often improve within 3-10 days without treatment or with colchicine, NSAIDs, or corticosteroids.

Causes and Precipitating Factors

• Diet: seafood, meat, liver, kidney, high purine foods
• Excessive alcohol (binge drinking)
• Surgery
• Starvation, dehydration, acute illnesses
• Medications: frusemide, aspirin, alcohol, cytotoxic drugs, thiazide diuretics
• Chronic kidney disease
• Myeloproliferative and lymphoproliferative disorders (e.g., leukemia)
• Sugary drinks containing fructose
• Cytotoxic agents (tumor lysis)
• Hypothyroidism
• Low-dose aspirin

Gout Arthritis

• Monoarthritis (affecting one joint) in about 90% of gout attacks, most commonly the big toe's metatarsophalangeal (MTP) joint (75%).
• Can also involve other lower limb joints: toes, midfoot, ankles, and knees.
• Polyarthritis (affecting multiple joints) more common in older men, potentially impacting the distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints of fingers.
• Affects all synovial joints potentially.

Nodular Gout

• Predominantly in postmenopausal women with kidney impairment on diuretic therapy.
• Causes pain and tophi around osteoarthritic interphalangeal joints (especially DIP joints) of fingers.

Gout Diagnosis

• Synovial fluid aspiration from affected joints, bursae, or tophi to visualize uric acid crystals using polarized microscopy is the definitive diagnostic test.
• Elevated serum uric acid levels (though up to 30% are within normal limits during an acute attack).
• X-rays may show punched-out erosions at joint margins.

Gout Management - Acute Attack

• First-line: Nonsteroidal anti-inflammatory drugs (NSAIDs, except aspirin) in full dosage, taken orally until resolution. Treatment continued for a week after symptoms subside.
• Alternative: Corticosteroids (prednisolone 15-30 mg daily) taken orally until symptoms improve, then gradually reduced. Local or intramuscular injections are also possible.
• Colchicine: 1 mg orally immediately, followed by 0.5 mg 1 hour later for a single dose (total 1.5 mg) course early to avoid severe kidney dysfunction and prolonged use. Must avoid concomitant use with macrolide antibiotics (e.g clarithromycin), especially in chronic kidney disease.
• Principles: Rapid pain relief, prevent further attacks, prevent destructive arthritis, address precipitating factors and comorbidities.

Gout Management - Long-Term

• Lifestyle Modifications: Weight loss, healthy diet, avoiding purine-rich foods (organ meats, certain fish, shellfish, game), reducing red meat, processed foods, fried foods, sweets, and alcohol, reducing sugary drink intake, adequate water intake (2 L daily), avoiding diuretics (thiazides, frusemide), and avoiding salicylates/low-dose aspirin. Comfortable shoes to avoid joint pressure. Avoid prolonged fasting.
• Medications (prophylaxis): Allopurinol (xanthine oxidase inhibitor) is the first-line choice for frequent attacks, tophi or chronic arthritis, kidney stones. Dose: 100-300 mg daily

This quiz covers the essential aspects of gout, a metabolic disorder characterized by uric acid buildup. Learn about its stages, clinical features, and how it predominantly affects men. Understand the significance of asymptomatic hyperuricemia and its implications.