Gout monosodium urate crystal disease

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Gout is an abnormality of uric acid metabolism resulting in hyperuricaemia and urate crystal deposition. Urate crystals deposit in:

• joints—acute gouty arthritis

• soft tissue—tophi and tenosynovitis

• urinary tract—urate stones

Four typical stages of gout are recognised: Stage 1

asymptomatic hyperuricaemia

Stage 2

acute gouty arthritis Stage 3

intercritical gout (intervals between attacks)

Stage 4

chronic tophaceous gout and chronic gouty arthritis Asymptomatic hyperuricaemia

• 10 times more common than gout 7

• elevated serum uric acid (> 0.42 mmol/L in men, > 0.36 mmol/L in women)

• absence of clinical manifestations

• usually does not warrant treatment

Typical clinical features of gout

• mainly a disease of men

• onset earlier in men (40-50) than women (60+) 5

• acute attack o excruciating pain in great toe o early hours of morning

• exquisitely tender to touch

• may be precipitated by o alcohol excess, e.g. binge drinking o surgical operation o starvation o drugs, e.g. frusemide, thiazide diuretics

• relief with colchicine, NSAIDs, corticosteroids

• can subside spontaneously (3 to 10 days) without treatment

The arthritis

Monoarthritis in 90% of attacks:

• other joints—usually lower limbs other toes o ankles o knees

Polyarticular onset is more common in old men and may occur in DIP and PIP joints of fingers. No synovial joint is immune. Refer to Figure 31.7 .

Common tilos

Loss common rnetatarsijphalí joint—gr

Dip Joint Touching

DIP joints knees angles toes

Fig. 31.7 Gout: possible joint distribution

DIP joints knees angles toes

Fig. 31.7 Gout: possible joint distribution

Other features

• prone to recurrence

• tophi in ears, elbows (olecranon bursa), big toes, fingers, Achilles tendon (take many years)

• can cause patellar bursitis

Nodular gout

Develops in postmenopausal women with renal impairment on diuretic therapy who develop pain and tophaceous deposits around osteoarthritic interphalangeal (especially DIP) joints of fingers. 14

• elevated serum uric acid (up to 30% can be within normal limits with a true acute attack) 13

• synovial fluid aspirate ^ typical uric acid crystals using compensated polarised microscopy; this should be tried first as it is the only real diagnostic feature

• X-ray: punched out erosions at joint margins


For the acute attack, options include:

• NSAIDs, e.g. indomethacin 100 mg (o) statim, 75 mg 2 hours later, then 50 mg (o) tds for 24-48

Diagnosis hours, then 50-75 mg/day

Note: Any other NSAID can be used. Add an antiemetic, e.g. metoclopramide 10 mg (o) tds.

• corticosteroids: intra-articular following aspiration and culture (gout and sepsis can occur together); a digital anaesthetic block is advisable. An oral course can be used: start with prednisolone 40 mg/day for 4 days then decrease gradually over 10 days

• corticotropin (ACTH) IM in difficult cases, e.g. synthetic ACTH: tetracosactrin 1 mg IM

• colchicine (only if NSAIDs not tolerated):

0.5-1 mg (o) statim, then 0.5 mg (o) 3 or 4 times a day until pain relief (usually 24-48 hours) or diarrhoea develops (max: 6 mg/24 hours)

Note: Avoid aspirin.

Monitor renal function and electrolytes.

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