Gout

Recognition

Gout presents usually as an oligoarticular illness with intermittent flares eventually progressing to a more chronic persistent polyarticular deforming arthritis. Eliciting a history of podagra (flare of a single joint, particularly the big toe) is highly suggestive of the diagnosis.

Examination

This may reveal tophi if you look for them. Ear lobes are classically searched, but elbows are often more rewarding. If you aren’t sure, aspirate either the tophus or a joint and send for microscopy to look for negatively birefringent crystals under polarised light. In joint fluid these are highly characteristic and look like splinters sticking right through leukocytes.

Also consider the illness in patients presenting with a more typically rheumatoid arthritis picture involving predominantly the hands.

Radiology

Classical findings are joint erosions slightly away from the joint margin, which differentiate them from those in rheumatoid arthritis.¹

Laboratory investigations

A serum urate is very helpful, although occasionally it may be normal during an acute attack (it usually isn’t!) Aspiration of synovial fluid yielding the typical negatively birefringent crystals, is diagnostic and quick. Definitions of normal urate levels should be treated with some circumspection, and any level > 0.36 micromol/L² is of interest in an individual with clinical features compatible with gout. Another quoted threshold of 0.6 micromol/L is clearly associated with a higher probability of developing gout later, even if asymptomatic at the time of the measurement.

Treatment of gout:

Acute flare – ibuprofen 400mg 8 hourly (usually settles in a few days). Colchicine is another option, recommended when NSAIDs are contra-indicated. In practice, most of the time when that is the case, colchicine is also contraindicated. In many patients, the most sensible option is a short course of prednisone 30mg/d, for about 5 days.

Treatment after the acute phase:

Allopurinol is the drug of choice in patients with normal renal function. Start with 100mg per day and increase to 300mg per day to achieve a measurable drop in serum urate: a reasonable goal is to aim for a serum urate of less than 0.35 mmol/l. Treating to a target is a commonly espoused strategy, and seems reasonable, although not backed up by any good evidence yet, and subject to considerable variation in international practice.³

In order to prevent further flares while waiting for the allopurinol to work, some authors suggest adding colchicine 0.5mg 12 hourly.

Although starting allopurinol ‘during’ the acute attack is no longer as clearly incorrect as it was previously, the RCT evidence that starting early is safe and doesn’t prolong the acute phase is still sparse⁴ It is probably reasonable to wait a week or so until the patient is clearly no longer acutely symptomatic, but it is important not to delay too long, to avoid the sadly common situation of recurrent attendances for acute events and lack of care between them.

The patient in cardiac or renal failure with gout.

Consider the option of local corticosteroid injection into a single inflamed joint – it generally works very well. The other options for individuals in whom NSAIDS are contra-indicated are colchicine 0.5 mg 12 hourly or a very short (5 day) course of 30 mg/day of oral prednisone.

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1. Weaver JS, Vina ER, Munk PL, Klauser AS, Elifritz JM, Taljanovic MS. Gouty Arthropathy: Review of Clinical Manifestations and Treatment, with Emphasis on Imaging. J Clin Med. 2021 Dec 29;11(1):166. doi: 10.3390/jcm11010166. PMID: 35011907; PMCID: PMC8745871. ↩

2. Desideri G, Castaldo G, Lombardi A, Mussap M, Testa A, Pontremoli R, Punzi L, Borghi C. Is it time to revise the normal range of serum uric acid levels? Eur Rev Med Pharmacol Sci. 2014;18(9):1295-306. PMID: 24867507. ↩

3. Chang-Nam Son, Sarah Stewart, Isabel Su, et al. Global patterns of treat-to-serum urate target care for gout: Systematic review and meta-analysis,Seminars in Arthritis and Rheumatism,2021;51(4):677-684 ISSN 0049-0172,https://doi.org/10.1016/j.semarthrit.2021.04.011.https://www.sciencedirect.com/science/article/pii/S0049017221000664 ↩

4. Hill EM, Sky K, Sit M, Collamer A, Higgs J. Does starting allopurinol prolong acute treated gout? A randomized clinical trial. J Clin Rheumatol. 2015 Apr;21(3):120-5. doi: 10.1097/RHU.0000000000000235. PMID: 25807090. ↩

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