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1. Gout

2. What is Gout?
• inflammatory arthritis caused by deposition of
monosodium urate crystals in joints.
• Peak incidence in the 50s to 60s
• Most common in postpubertal males (uric acid rises after
puberty)
• Incidence rises in postmenopausal females (uric acid
rises after menopause)
• Men > Women

3. What goes wrong?
• increased production (10%) and diminished excretion
(90%) of uric acid

8. Clinical Presentation
• Asymptomatic hyperuricemia
• Acute gout
• Chronic (tophaceous) gout
• Renal disease

9. Asymptomatic hyperuricemia
• More than 75% of individuals remain asymptomatic.

10. Acute gout
• Acute onset of intense joint pain, swelling, erythema, and heat
• Fever (systemic manifestation of inflammation) may be present
• 50% of patients present with first metatarsophalangeal joint involvement
(podagra)
• Gout may also affect the ankles, midfoot, knees,wrists, shoulders, and
hands
• Attacks are usually monoarticular or oligoarticular(two to three joints); rarely
polyarticular until late in the disease course
• Early attacks are self-limited and will resolve over 3 to 10
days, even without treatment

11. Chronic (tophaceous) gout
• Tophi → Deposits of monosodium urate crystals in soft
tissue.
• After years of recurrent attacks, joints develop
–persistent pain,
–swelling,
–and deformity

12. Renal disease

• Nephrolithiasis risk 50% with serum uric acid
greater than 13 mg/dL.

13. Investigations
• Joint aspiration - polarising light microscopy for
crystals
• Crystals are needle-shaped, negatively birefringent, and
may be intracellular
• FBC - white cells raised
• ESR - raised
• X-ray - generally normal → Bone erosion at joints-
punched out’
• Serum urate
↓

16. Treatment of Acute Attack
• AIM- to reduce symptoms
• NSAID high dose
• Colchicine
– GI side effects,
– Most effective in 1st 24 hours
• Corticosteroid
• – If NSAID and colchicine contraindicated

17. Prophylaxis

• Lifestyle changes
• Low-purine diet,
• discontinue aspirin and diuretics,
• limit alcohol
• Colchicine 0.6 mg once or twice daily reduces or
eliminates attacks in approximately 95% of patients

18. Uric acid–lowering agents
• ※Do not start uric acid–lowering agents during acute
gout or without prophylaxis, as any change in the uric
acid concentration (up or down) may precipitate an acute
gout attack
• Uricosuric agents e.g., probenecid .....have limited
usefulness in setting of renal impairment
• Xanthine oxidase inhibition (e.g., allopurinol,
• febuxostat)