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



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