CPG: Management of

Gout
Adi Asraf b Yusof
Introduction
 Gout is defined as a peripheral arthritis
resulting from the deposition of sodium urate
crystals in one or more joints.
 Uric acid or urate (its salt) is the end product

of purine metabolism
 Ethnic groups in Malaysia and China have

higher mean urate levels than most Caucasian

populations.
Clinical manifestation
 Typical sequence involves progression
through:
◦ asymptomatic hyperuricemia
◦ acute gouty arthritis
 Acute, self limiting, monoarticular
 Lower limbs more commonly affected
◦ interval or intercritical gout
◦ chronic or tophaceous gout
 Polyarticular, formation of tophi
Clinical manifestation (cont)
 Tophi
◦ chalky deposits of MSU crystal
◦ Subcutaneous & painless
◦ Firm, nodular & fusiform swelling
◦ Common sites include, digits of hands and feet
Clinical features
Feature Typical Gout Elderly onset
Age of onset Peak in mid 40’s Over 65 yrs
Sex distribution Men > women Men = women,
If over 80 yrs old
men < women
Presentation Monoarticular Polyarticular
Lower extremity Upper extremity
(podagra mostly)
Tophi After yrs of attack May occur early
Associated feature Obesity Renal insufficiecy
Hyperlipidemia Diuretic use
HPT
Heavy drinker
Diagnosis
 Clinical diagnosis
◦ Fulfill 2 out of 4 criteria
 History of at least 2 attacks of painful joint swelling
with complete resolution within 2 weeks
 Clear history/observation of podagra
 Presence of tophus
 Rapid response to colchicine within 48 hrs after tx
started
 Definitive diagnosis
◦ Synovial fluid analysis (monosodium urate, MSU
crystal seen in synovial fluid)
Monosodium urate crystal (MSU)
Investigation
 Baseline investigation
◦ Full blood count (FBC)
◦ Renal profile
◦ RBS
◦ Lipid profile
◦ Urinalysis
 Further investigation
◦ 24-hour urinary excretion
Investigation (cont)
 Joint aspiration
◦ Definitive
◦ Based on synovial fluid char + crystal identification
(MSU)
 Skeletal X-ray
◦ Usually normal in acute gouty arthritis
◦ Chronic tophaceous gout: soft tissue abnormalities
+ erosive bone lesion
 Renal imaging
 Skeletal X-Ray

Acute gouty arthritis Chronic tophaceous gout

Management: Lifestyle & Diet
 Aim to:
◦ Achieve IBW
◦ Prevent acute attacks of gout
◦ ↓ serum urate level
 Weight reduction – gradual (0.5-1 kg/week)
 Restrict alcohol intake - ↑ renal excretion of
purine
 Reduce purine-rich food intake (i.e. red meat,
seafood)
 Consume low fat dairy product
 Maintain adequate fluid intake (2-3L)
Management: Medication
Asymptomatic Hyperuricaemia
 Serum urate conc abnormally high (male: >7.0

mg/dL, female: 6.0 mg/dL)

 But with no signs/symptoms of urate deposition

 Investigate the contributing factors

 If drug-induced (i.e. thiazide diuretics), discontinued

or changed if clinically appropriate.

 Generally, no pharmacologic treatment required

unless
◦ Persistent severe hyperuricaemia
◦ Persistent elevated urinary excretion of urate
◦ Tumour lysis syndrome
Management: Medication
 Acute Gouty arthritis
 NSAIDs

◦ Any NSAIDs other than aspirin

◦ Rapidly effective in ↓ inflammation and pain, particularly if given right away
after acute attack.
◦ C/I in pt with hx of peptic ulcer disease, hypertension, renal impaired &
cardiac failure
 COX2 inhibitor
◦ For those at risk of peptic ulcer disease or intolerant to NSAIDs
◦ Better safety profile in terms of gastric bleeding
◦ C/I in pt with active peptic ulcer disease, HPT, renal impaired and cardiac
failure.
 Colchicine
◦ Alternative drug for those C/I with both NSAIDs and COX2 inhibitor
◦ However, most prominent side effect is profuse diarrhea thus limit it
usefulness particularly in elderly pt.
Management: Medication
 Acute Gouty arthritis
 Glucocorticoids
◦ In elderly people and those C/I with either NSAIDs & COX2
inhibitor, glucocorticoids may be preferred.
◦ Only for short term treatment, thus side effects are rare
◦ Several RoA are available; intrarticular, intramuscular and
also oral.

 Allopurinol*
◦ Not to be started unless the acute attack had resolved
◦ If pt on long term allopurinol, DO NOT STOP the treatment
during acute attack
Management: Medication
 Chronic Gouty arthritis
◦ Aim to reduce sUA level < 6.0mg/dL
◦ Started after acute attack well controlled (1-2 wks)
◦ NSAIDs, colchicine DO NOT ↓ urate level
◦ Hypouricaemic drugs – NO analgesic + anti-
inflammatory effect
◦ Lifelong treatment
 Allopurinol
◦ Xanthine oxidase inhibitor -> hypouricaemic drugs
◦ Superior than probenecid
◦ Adjust in renal impaired pt
◦ In normal pt – start at 100-150mg OD, increase by
100-150mg every 4 weeks -> 300mg OD
◦ Max dose: 800mg daily
 Probenecid
◦ Alternative to allopurinol
◦ C/I in pt with UA overproduction + overexcretion,
urate nephropathy
Management: Medication
 Urate nephropathy
◦ ↑ urine output
 Maintain water intake of 3L/day or more
 In ESRF, limit fluid intake
◦ ↑ urine pH
 Target urine pH: 6.5 – 7
 Potassium citrate
◦ ↓ urate excretion
 By ↓ dietary purine intake
 Allopurinol
Management: Medication
 Urate nephrolothiasis
◦ Radioluscent in nature
◦ Ultrasound imaging preffered
◦ Extracorpeal shockwave lithotripsy & percutaneous
nephrolithotomy can be used to treat intrarenal
stones (5-15mm) and complex staghorn stones
◦ Pure urate stones readily chemolysed by potassium
citrate or sodium bicarbonate.
 Purine nucleotides

Hypoxanthine Allopurinol
Xanthine Xanthine
oxidase
Uric acid

Urinary Alimentary Tissue deposition

excretion excretion in excess

Urate crystal microtophi

Uricosurics
Phagocytosis
Colchicine with acute
NSAIDs
inflammation
and arthritis 25
Management: Surgery
 Last resort
 Considered in

◦ Advanced tophi deposition -> major joint

destruction
◦ Loss of joint movement + severe pain
◦ Tophi collection -> pressure symptom
◦ Tophaceous ulcer
◦ Cosmetic (i.e. ear lobe tophi)
References
 CPG: Management of Gout (Oct 2008)

 MICROMEDEX(R) Healthcare Series Vol. 146

 Lexi-Comp Drug Information Version 1.4.1

 http://www.gout.com/professional/gout_information/prevalence_a
nd_incidence.aspx

 MOH Drug Formulary 2009

 http://www.merriam-webster.com

 http://www.buzzle.com/articles/purine-rich-foods.html
 t i o n
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a n THANK YOU