Gout
Crystal-Induced Arthropathies usually males
Definition
Derangement in purine metabolism, resulting in hyperuricaemia,
monosodium urate crystal deposits in tissue (tophi) and synovium
(microtophi).
Pathophysiology
Sources of uric acid diet and exogenous
Synthesis
Hypoxanthine xanthine uric acid catalyzed by
xanthine oxidase
Hyperuricemia
Primary or Genetic
1. Idiopathic renal under secretion
2. Idiopathic overproduction or abnormal enzyme
production/function
Secondary
1. Dietary excess beer, seafood, red meat
2. Under-excretion (90%) renal failure, drugs, systemic conditions
3. Over-production (10%) increased nucleic acid turnover state (post-
chemo, myeloproliferative disease, lymphoma, leukaemia, renal disease)
Sudden changes in uric concentration are important
a. Acute gout can occur with normal s-uric acid
b. Change in pH, temp, initiation of antihyperuricemics may
precipitate acute gouty attack
Precipitants alcohol, dietary excess, dehydration, drugs,
trauma, illness, surgery, starting xanthine oxidase inhibitor
therapy
Associated Conditions
1. Hypertension
2. Obesity
3. Diabetes
4. Ischaemic heart disease
1
Specific Symptoms and Signs
Acute Gouty Arthritis
1. Severe pain, redness, joint swelling, usually involving lower extremities
2. Limited joint mobility
3. Attack subsides spontaneously within days-weeks
(may recur)
Tophi indicates chronic recurrent gout
1. Urate deposits on cartilage, tendons, bursae, soft tissue,
and synovial membranes
2. Common sites first MTP, ear helix, olecranon
bursae, tendon insertions (Achilles tendon)
Kidney
1. Gouty nephropathy
2. Uric acid calculi
Investigations
Investigations
1. Joint aspiration 90% of joint aspiration show crystals of
monosodium urate
2. X-ray tophi as soft tissue swelling, punched out lesions-
erosion with “over-hanging” edge
2
Treatment
Acute Gout
1. NSAIDS high dose, taper as improvement
a. Corticosteroids IA, oral, intra-muscular (NSAIDS contraindicated
or failed)
2. Colchicine within 12 hrs (effectiveness limited)
3. Allopurinol DON’T start during acute flare
Chronic Gout
1. Conservative
a. Avoid foods with high purine content meat, sardines, shellfish
b. Avoid drugs with hyperuricemic effect alcohol, thiazide,
ethambutol, pyrazinamide
2. Medical
a. Anti-hyperuricemic drugs allopurinol, febuxostat (inhibit
xanthene oxidase)
b. Uricosuric drugs Probenecid failure or intolerance
3. Prophylaxis
a. Colchicine and low-dose NSAIDS
4. Renal disease secondary to hyperuricemia low dose allopurinol and
monitor creat
Indications for treatment with anti-hyperuricemia
1. Recurrent attacks, tophi, bone erosion, urate kidney stones
2. Renal dysfunction with high urate load (controversial)
