Gouty Arthritis in Family medicine

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Gouty arthritisNatee Sornkerd

PMC conference

Medical student, Faculty of Medicine, Burapha University

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Definition

• Gout 

disease of hyperuricemia andmonosodium urate deposition in thebody

• Gouty arthritis

 joint inflammation caused bymonosodium urate crystals in thesynovial fluid and/or joint tissues

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Clinical features 

•  Acute onset, usually monarticular, recurringattacks of arthritis, often involving the firstmetatarsophalangeal (MTP) joint

• Polyarticular involvement more common withlong-standing disease

• Hyperuricemia in most; identification of urate

crystals in joint fluid or tophi is diagnostic• Dramatic therapeutic response to NSAID

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General consideration(1) 

• Primary gout is a metabolic disease ofheterogeneous nature, often familial,associated with abnormal amounts of

urates in the body and characterized earlyby a recurring acute arthritis, usuallymonarticular, and later by chronic

deforming arthritis

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• Secondary gout is from acquired causes ofhyperuricemia Medication (diuretics, low-dose aspirin,

cyclosporine, and niacin)

Myeloproliferative disorders

Chronic kidney disease

Hypothyroidism, psoriasis, sarcoidosis, andlead poisoning

General consideration(2) 

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•  Alcohol ingestion promotes hyperuricemia byincreasing urate production and decreasingthe renal excretion of uric acid

• Hospitalized patients frequently suffer attacksof gout because of changes in diet (eg,inability to take oral feedings following

abdominal surgery) or medications that leadeither to rapid reductions or increases in theserum urate level

General consideration(3) 

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Origin of hyperuricemia

1.Ideopathic2.Secondary hyperuricemia 

 Increased production of purine

• Increase purine production : Enzyme defect• Increase nucleic acid degeneration : Hematologic ds

 Decreased clearance of uric acid

• Dehydration

• Intrinsic kidney disease

• Functional impairment of tubular transport

• Medication : Alcohol, Pyrazinamide, Ethambutol

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Epidemiology 

• Common in Pacific Islanders, eg, Filipinosand Samoans

• 90% of patients with primary gout aremen, usually over 30 years of age

• In women, the onset is typicallypostmenopausal

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History taking 

• Recurrent mono or oligoathritis involve joints of lower extremities

• More common in male (age >35 year)

• Take history about Alcohol, Hospitalize,Medication

•

Other medical problems: DM, HT, DLP,Obesity, Urethral stone

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Physical examination 

•  Arthritis

• Tophus

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LAB 

• CBC, UA, LFT, BUN, Cr

• Specific test

 –

Joint fluid aspiration for Gram stain, Culture,Examination under polarized microscope

 – Serum uric acid level

 – 24hr uric acid in urine

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Symptoms and Sign(1)

1. Sudden onset of arthritis 

• Frequently nocturnal

•

No precipitating or following rapidfluctuations in serum urate levels

• MTP joint of the great toe

•

Feet, ankles, and knees, are also affected• May develop in periarticular soft tissues

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Symptoms and Sign(2)

2. As the attack progresses 

• The pain becomes intense

•

The involved joints are swollen andexquisitely tender

• The overlying skin is tense, warm, anddusky red

• Fever is common

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Symptoms and Sign(3)

3. Tophi

• They are usually seen only after severalattacks of acute arthritis

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Symptoms and Sign(4)

•  Asymptomatic periods of months or yearscommonly follow the initial attack

•  After years of recurrent severe monarthritisattacks, gout can evolve into a chronic,deforming polyarthritis of upper and lowerextremities that mimics rheumatoid arthritis

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Diagnosis

• Joint fluid aspiration

• Diagnostic criteria

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Criteria for diagnosis • More than one attack of acute arthritis• Maximal inflammation developed within 1 day•  Attack of monarticular arthritis• Joint redness observed• First metatarsophalangeal joint painful or swollen• Unilateral attack involving first MTP• Unilateral attack involving tarsal joint• Suspected tophus•

Hyperuricemia•  A symptomatic swelling within a joint (radiograph)• Subcortical cysts without erosions (radiograph)• Negative culture of joint fluids for microorganisms

during attack of joint inflammation

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Joint fluid analysis

• Monosodium urate crystals insynovial fluid or a tophus is definitediagnosis of gout

• The crystals, which may be extracellular orfound within neutrophils, are needle-likeand negatively birefringent when

examined by polarized light microscopy

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yeLLow when paraLLel to the condenser.

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Laboratory Test

• The serum uric acid >7 mg/dL

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Imaging Studies

• Early in the disease, radiographs show nochanges

• Later, punched-out erosions with anoverhanging rim of cortical bone ("ratbite") develop.

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Differential diagnosis 

• Septic arthritis

• Pseudogout

•

Rheumatoid arthritis

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Management 

• Providing rapid and safe pain relief.

• Preventing further attacks.

•

Preventing formation of tophi anddestructive arthritis.

•  Addressing associated medical conditions.

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Treatment 

•  Acute attacks: High-dose NSAIDs,Colchicine or Steroids

• Maintenance therapy: Uricostatic agent,

Uricolytic agent, Uricosuric agent

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NSAIDs

• NSAIDs high doses for 3-4 days and thentapered for a total of 7-10 days

• Indomethacin, naproxen, sulindac

• e.g., Indomethacin 75 –105 mg/d orallyand continued until the symptoms haveresolved then tapering

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Colchicine

• Inhibition of neutrophil chemotaxis andactivation.

• GI upset, bone marrow suppression

• The therapeutic index of colchicine isnarrow especially in the elderly.

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Steroids 

• Glucocorticoids give rapid relief withinhours of therapy. Systemic therapy isinitiated with high doses that are then

tapered rapidly

• e.g., prednisone 30-60 mg/day for 3 days,then tapered over 10-14 days

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Prevent recurrent attack  

• Recurrent attacks of gout can beprevented with the use of colchicine

• Colchicine 0.3-1.2 mg daily or on alternatedays

• Stop Colchicine when no tophus andnormal uric acid level for 6-12mo

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Drugs decreasing uric acid 

• Recurrent attacks > 3episodes per year

• Tophus

•

Stone in urinary tract• Serum uric acid > 9mg/dL

• Renal clearance of uric acid > 800 mg/day

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Uricosuric drugs 

• Probenacid 1000-2000mg/d tid

• Benzpromarone 25-100 mg/d OD 

•

 Age< 60• Normal renal function

 – Probenacid  CCr>80cc/min

 –

Benzpromarone

 CCr>30cc/min• Renal clearance of uric acid > 800 mg/day

• No stone in urinary tract

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Uricostatic drugs 

•  Allopurinol 100-300mg/d OD

• Xanthine oxidase inhibitor

•

Tophus• Renal clearance of uric acid > 800 mg/day

• Found stone in urinary tract

•Failure to treat with Uricosuric agent

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