Gout and pseudogout

Pathophysiology

• Primarily an illness of middle-aged and elderly adults
• Gout is most common form of inflammatory joint disease in men >40yr
• Presence of crystals does not exclude septic arthritis
• Precipitants
  • Trauma
  • Surgery
  • Significant illness
  • Change in medication

Clinical Features

• Joint pain may develop over period of hours
• Primarily involves first MTP, knee, ankle

Diagnosis

• Synovial fluid aspiration
  • +crystals, no bacteria on Gram stain
• Serum uric acid levels are not helpful (30% of pts w/ gout attack have normal levels)
• ESR may be elevated

Treatment

1. NSAIDs NOT contra-indicated
   1. Do not give to pts w/ renal insufficiency (use opioids instead)
   2. Substantial pain relief should occur within 2hr
   3. Options:
      1. Indomethacin 50mg po TID x3-5d, OR
      2. Ibuprofen 800mg PO TID x 3-5d
2. NSAIDs contra-indicated
   1. Colchicine
      1. Can be used as alternative agent to NSAIDs in pt w/ normal renal/hepatic function
      2. 1.2mg PO (load), followed by 0.6mg one hour later x 1
3. All patients
   1. Hold diuretics
      1. Start losaran to replace diuretic (has modest uricosuric effect)
   2. Alcohol and dietary counseling
   3. Continue uric acid-lowering agents if already on prophylactic regimen (do not start)
   4. Follow up with rheumatoloty
   5. Glucocorticoid injection
      1. Even if gout has been diagnosed in the past, be cautious with glucocorticoid joint injection if the current clinical picture is uncertain since a septic joint can coexist with gout.

See Also

• Joint Pain
• Monoarticular Arthritis
• Knee Diagnoses

Source

• Tintinalli - Gout