- A disorder of purine metabolism characterised by hyperuricaemia and urate crystal deposition in the joints or soft tissues.
- Patients typically complain of a red, hot, swollen joint with pain on passive ROM.
- 1st MTPJ is classic followed by, ankle, knee finger, wrist, and elbow.
- Tophi are firm white translucent nodules that typically present 10 yrs after first attack, and are normally asymmetrical.
- Differential diagnosis include; Septic arthritis (A&E referral required), Pseudogout, OA, Reactive arthritis, Rheumatoid arthritis.
- No initial investigations are required to manage gout-like symptoms.
- Joint fluid microscopy and culture is indicated in cases of suspected septic arthritis or diagnostic uncertainty.
- Serum uric acid should be measured 6 weeks after an acute attack to confirm hyperuricaemia (upper limit M=420micromol/L, F=360micromol/L)
- Consider an XR of the affected joint to look for chondrocalcinosis.
- Click here for American College of Rheumatology criteria for diagnosis of acute gouty arthritis (image).
- If symptoms are mild and pt has high risk adverse effects consider self care > medications.
- Prescribe an NSAID (Diclofenac / Indometacin / Naproxen) ASAP and continue for 48hr after symptom resolution.
- Co-prescribe a PPI in at risk patients.
- If NSAIDs are contra-indicated prescribe oral Colchicine.
- If NSAIDs and Colchicine are contra-indicated consider oral corticosteroids.
- Advise patient to return if not improved after 3 days.
Patient Self care during acute gout
- Rest and elevate limb.
- Avoid trauma to joint.
- Review lifestyle advice.
If no improvement after 3 days:
- Review diagnosis and compliance and increase to maximum dosage medications.
- If still no improvement try alternative medication or refer for specialist assessment.
- Review patient after 4 weeks.
- Check serum uric acid level, BO, fasting glucose, renal function and lipid profile.
- Manage any underlying co-morbidities; hypertension, renal disease, diabetes.
- Recommend lifestyle advice.
- Consider prophylactic medication if pt has 2 + attacks/yr (e.g. Allopurinol).
- Aim for ideal body weight.
- Restrict red meat and protein intake.
- Avoid binge or excessive alcohol intake.
- Avoid dehydration.
- Convert to skimmed milk.
- Limit consumption of high sugar snacks.
- Stop smoking.
- Suspected septic arthritis (A&E referral required)
- Diagnostic uncertainty
- Pregnancy or <25yrs old
- Recurrent attacks on maximum dose Allopurinol.
- Requirement for IA steroid (but not skilled).
- Troublesome Tophi.