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Gouty ArthritisAka: Gout, Podagra
- Epidemiology
- Men and post-menopausal women more commonly affected
- Prevalence: 2% of men over age 30 and women over age 50 years
- Increasing Prevalence in United States related to Obesity and aging population
- Incidence of gout attacks
- Pathophysiology
- See Uric Acid
- See Hyperuricemia
- Gout occurs when Uric Acid levels exceed solubility limits
- Monosodium urate crystals deposit in joints, kidney, and soft tissues
- Isolated and asymptomatic Hyperuricemia is common and requires no treatment
- Risk Factors
- Most common
- Obesity
- Alcohol use
- High purine diet (meats, seafood)
- Diuretic therapy including Thiazide Diuretics
- Other risks
- Diabetes Mellitus
- Hyperlipidemia
- Hypertension
- Atherosclerosis
- Renal insufficiency
- Myeloproliferative disease
- Most common
- Causes: Triggers for acute gout attacks
- See Hyperuricemia
- See Risk Factors above
- Recent increase in Alcohol or purine intake
- Medication use (Allopurinol stopped or started, Diuretic or Chemotherapy started)
- Acute infection
- Intravenous Contrast dye exposure
- Presentations
- Monoarthritis (most common)
- Acute bursitis
- Tenosynovitis
- Acute polyarticular gout
- Symptoms
- Associated Symptoms
- Chills
- Fever as high as 104 F (40 C)
- Severity: Very severe pain
- Unable to bear weight
- Too painful to put on socks
- Intollerant to light touch from blankets
- Region:
- First Metatarsophalangeal joint of great toe (most common)
- Known as Podagra
- Affected in 50% of first gout attacks
- Mid-tarsal joints
- Ankle joints
- Knee joints
- First Metatarsophalangeal joint of great toe (most common)
- Characteristics: Joint pain
- Excruciating, crushing type pain
- Timing: Joint pain
- Acute onset of lower extremity joint pain
- Wakens patient from sleep
- Associated Symptoms
- Signs
- Acute
- Joint Inflammation
- Erythema, tenderness and swelling at affected joint
- Pain extends well beyond joint
- Entire foot involved in some cases
- Asymmetric joint involvement
- May only involve one side with the first attack
- Skin over joint is tense and shiny
- Joint Inflammation
- Chronic
- Gouty Tophi (develop after >=10 years)
- Chronic arthritis
- Chronic deposition occurs with recurrent attacks
- Acute
- Labs
- Complete Blood Count
- Leukocytosis (may be as high as 40,000 wbc/mm3)
- Serum Uric Acid increased (Hyperuricemia)
- Synovial Fluid Exam (critical if Septic Arthritis is considered)
- Polarizing Microscopy
- Negatively birefringent
- Needle shaped Uric Acid crystals
- Gram Stain and Culture
- Rule out Septic Arthritis
- Urine Uric Acid (24 hour collection)
- Complete Blood Count
- Imaging: Affected joint(s)
- Xray of affected joint shows asymmetric swelling
- Diagnosis: Requires one of the following
- Monosodium urate crystals in Synovial Fluid or
- Test Sensitivity: 84%
- Test Specificity: 100%
- Gouty Tophi with urate crystals identified on Nodule aspirate or
- Test Sensitivity: 30%
- Test Specificity: 99%
- Minimum of 6 criteria present from the following list
- Plain radiograph demonstrates subcortical cysts without Erosions
- Plain radiograph demonstrates asymmetric swelling within a joint
- Test Sensitivity: 42%
- Test Specificity: 90%
- First metatarsophalangeal joint tender or swollen
- Test Sensitivity: 96%
- Test Specificity: 97%
- Hyperuricemia
- Test Sensitivity: 92%
- Test Specificity: 91%
- Unilateral first metatarsophalangeal joint arthritis
- Unilateral tarsal joint arthritis
- Inflammation peaked within one day
- Monoarthritis episode
- More than one acute arthritis attack
- Effected joints with overlying redness
- Gouty Tophi suspected (but not yet confirmed by aspirate)
- Synovial Fluid culture negative for organisms during an Acute Monoarthritis attack
- Monosodium urate crystals in Synovial Fluid or
- Differential Diagnosis
- Septic Arthritis (critical to distinguish)!
- Pseudogout
- Other conditions
- Cellulitis
- Reactive Arthritis
- Rheumatoid Arthritis
- Osteoarthritis
- Neuropathic arthritis (Charcot Joint)
- Management: Acute attack
- NSAIDs (any are effective if adequately dosed)
- Avoid in elderly, renal or liver disease, Heart Failure, or Peptic Ulcer Disease
- Indomethacin (historically has been preferred NSAID in gout)
- Start: 50mg orally three times daily for 2-3 days
- Then: 25mg orally three times daily for 4-10 days
- Naproxen 500 mg orally twice daily for 4-10 days
- Sulindac 200 mg orally twice daily for 4-10 days
- Colchicine
- Use as an alternative agent due to GI toxicity
- Avoid in severe liver or kidney disease
- Requires adjusted dosing in renal disease
- Consider 0.6 orally daily to twice daily taken as adjunct to NSAID (see above)
- Most beneficial if started within first 24 hours of attack
- Corticosteroids
- Rule-out Septic Arthritis first!
- Use with caution in Diabetes Mellitus
- Effective alternative to NSAIDs (less risk of peptic ulcer)
- Systemic agents
- IV: Methylprednisolone 40 mg (consider if NPO in hospital)
- IM: Depo-Medrol 80 to 120 mg single dose IM
- Oral
- Prednisone 40 mg orally daily for 5 days
- then Prednisone 20 mg orally daily for 5 days
- then Prednisone 10 mg orally daily for 5 days
- Intra-articular Corticosteroid
- Large single joints and refractory cases to other treatment
- Avoid exacerbating or unhelpful measures
- See Prevention below
- Aspirin in small doses aggravates disorder
- Acetaminophen not helpful
- Phenylbutazone risks outweigh any benefits
- Bone Marrow suppression
- Aplastic Anemia
- NSAIDs (any are effective if adequately dosed)
- Prevention: Medications
- Contraindications
- Do not use in acute attack
- Indications
- Recurrent Gout (>3 gout attacks per year)
- Tophaceous gout
- Nephrolithiasis
- Choice of agent based on 24h Uric Acid secretion
- Over-producer (Used for under-excreters also)
- Allopurinol 100-300 mg/day
- Adjusted dosing in renal insufficiency
- Febuxostat (pending FDA approval in 2007)
- Allopurinol 100-300 mg/day
- Under-Excreter
- These agents are now rarely used
- Allopurinol used now for both types of gout
- Probenecid 250 mg PO bid (MAX: 1500mg bid)
- Sulfapyrazine 50 mg PO bid (MAX: 100mg bid)
- These agents are now rarely used
- Over-producer (Used for under-excreters also)
- Concurrently start with prophylaxis, low dose x3-6mo:
- Indomethacin 25 mg PO bid for 3-6 months or
- Colchicine 0.6 mg PO daily to bid for 3-6 months
- Contraindications
- Prevention: General
- Adjunctive Uricosuric medications
- Adjunctive agents to consider
- Dairy products may be protective
- Eating cherries lowers serum Uric Acid
- Coffee lowers gout attack risk
- However significant decrease only at >3 cups/day
- Choi (2007) Arthritis Rheumatism 56(6):2049
- Vitamin C: 500 mg/day lowers Uric Acid 0.5 mg/dl
- Avoid provocative factors (See Hyperuricemia)
- Avoid purine-rich foods (See Purine Content in Foods)
- Avoid Alcoholic beverages (especially beer)
- Avoid Thiazide Diuretics
- Associated Conditions: Other Uric Acid Conditions
- Uric Acid Nephrolithiasis
- Asymptomatic Hyperuricemia
- Course
- Gout attack episodes last 5-7 days with or without treatment
- References
- Klippel (1997) Primer Rheumatic Diseases, p. 230-4
- Buckley (1996) Am Fam Physician 54(4):1232
- Eggebeen (2007) Am Fam Physician 76:801
- Harris (1999) Am Fam Physician 59(4):925
- McDonald (1998) Postgrad Med 104(6):117
- Pittman (1999) Am Fam Physician 59(7):1799
Gout (C0018099) | |
|---|---|
| Definition (MSH) | Hereditary metabolic disorder characterized by recurrent acute arthritis, hyperuricemia and deposition of sodium urate in and around the joints, sometimes with formation of uric acid calculi. |
| Definition (CSP) | hereditary metabolic disorder characterized by recurrent acute arthritis, hyperuricemia and deposition of sodium urate in and around the joints, sometimes with formation of uric acid calculi. |
| Concepts | Disease or Syndrome (T047) |
| ICD9 | 274, 274.9 |
| MSH | D006073 |
| Basque | GOTA |
| Danish | Urinsyregigt |
| Dutch | Jicht |
| English | Gout, Gouts |
| Finnish | KIHTI |
| French | Goutte |
| German | Gicht |
| Hebrew | shigadon -GOUT |
| Hungarian | koszveny |
| Italian | Gotta |
| Norwegian | URINSYREGIKT |
| Portuguese | Gota |
| Spanish | Gota |
| Swedish | GOUT - GIKT/ARTHRITIS URICA |
| Parent Concepts | Inflammatory polyarthritis (C1692871), Metabolic Diseases (C0025517), Purine-Pyrimidine Metabolism, Inborn Errors (C0034139), Gout (C0018099), Disorder of purine metabolism (C0268104), Other metabolic and immunity disorders (C0178259), ENDOCRINE, METABOLIC AND NUTRITIONAL (C0497395), Diagnosis/Diseases Component (C0497531), Arthritis (C0003864), Rheumatism (C0035435), Hyperuricemia (C0740394) |
| Sources | AIR, AOD, COSTAR, CSP, CST, DXP, ICD9CM, ICPC, ICPCBAQ, ICPCDAN, ICPCDUT, ICPCFIN, ICPCFRE, ICPCGER, ICPCHEB, ICPCHUN, ICPCITA, ICPCNOR, ICPCPOR, ICPCSPA, ICPCSWE, LCH, MSH, MTH, NCI, NDFRT, OMIM, SCTSPA, SNOMEDCT Derived from the NIH UMLS (Unified Medical Language System) |
Podagra (C0221168) | |
|---|---|
| Concepts | Disease or Syndrome (T047) |
| English | Podagra |
| Spanish | podagra |
| Parent Concepts | Arthropathies NOS (C0022408), Disorder of toe (C0555981), Finding of joint of toe (C0576334) |
| Sources | COSTAR, CST, DXP, SCTSPA, SNOMEDCT Derived from the NIH UMLS (Unified Medical Language System) |