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/hr PO until efficacy or side effects occur (vomiting/diarrhea)
   2. Steroids
      1. Prednisone burst
3. All patients
   1. Hold diuretic, if on
      1. Start losaran to replace diuretic (has modest uricosuric effect)
   2. Alcohol and dietary council
   3. Continue uric acid-lowering agents if already on prophylactic regimen (do not start)
   4. Follow up with rheumatoloty

See Also

• Joint Pain
• Monoarticular Arthritis

Source

• Tintinalli