| ID | 175 |
|---|---|
| Name | ACUTE GOUT |
| Cause | |
| Signs Symptoms | |
| Diagnosis | |
| Investigations | Investigations: 1. Blood test: Leucocytosis, high E.S.R., Serum uric acid level (normal level 2-6 mg %)- it is usually raised (but not diagnostic because asymptomatic hyperuricemia is very common). 2. Radiology: Asymmetrical soft tissue swelling; irregular punched-out bony erosions near the articular margins or osteoarthritic changes of the joints. 3. Synovial fluid exam: Whenever possible synovial fluid should be aspirated & examined under polarising light- bore fringence of needle shaped monosodium urate crystals can be seen. |
| Management | Treatment:’2 A. Acute attack: General management: 1. Rest in bed and immobilisation of the affected joints should be done. 2. Diet: A very high purine diet such as- red meat, offal, sea-foods, & alcohol should be avoided during the acute attack. 3. Hot and cold compress over the affected joints are beneficial. Medical treatment: 1. Use of NSAIDs as analgesics: A fast acting oral NSAID, such as Indomethacin 25-50mg orally 8 hourly after meal, continued until the symptoms have resolved (usually 5-10 days) + a PPI drug should be given as a protective measure for peptic ulceration. In case of patients at high risk for upper gastrointestinal bleeding, a COX-2 inhibitor can be given as an alternative, such as celecoxib 100-200mg twice daily; but, recently COX-2 inhibitors are not advised for long-term use because of it’s increased risk for cardiovascular events. 2. Colchicine: Now a days colchicine is not recommended in the treatment of acute gout flares.1 3. Corticosteroids: If pain is very severe and not responding to above drugs, corticosteroids are often used and a dramatic symptomatic relief is achived in most of the cases of acute attacks. The drugs can be used-Tab. Dexamethasone (1 tablet 0.5mg) 2 tablet 6 hourly orally. In case of monoarticular gout, triamcinolone 10-40mg (depending on the size of the joint) intra-articular injection is most effective. In case of polyarticular gout, methylprednisolone 40mg may be given i.v daily, tapered over 7 days; Or, prednisolone 40-60mg may be given orally daily, tapered over 7 days. Before, intra-articular administration of corticosteroids joint aspiration & gram-stain with culture of synovial fluid should be done. B. Long-term Management (or Management between attacks): 1. Urate-lowering therapy (ULT): When acute attack subsides, prophylactic therapy with urate-lowering drugs should be given for prolonged period, such as- i. Allopurinol (a xanthine oxidase inhibitor), the drug of choice, the initial dose is 300mg daily (if kidney functions normal and prophylactic colchicine is given) in divided doses orally. In the absence of prophylactic colchicine, the initial dose should be 100mg daily orally. (Allopurinol is the drug of choice for long-term prophylaxis because of its convenience and low incidence of side-effects). Febuxostat, Xanthine oxidase inhibitor, can be used particularly in patients in whom allopurinol is not tolerated or contraindicated. The recommended starting dose is 80mg daily, no dose adjustment is required in renal impairment. ii. Colchicine, the usual dose is 0.5mg once or twice daily. Colchicine is generally indicated in patients who have chance of future attacks, and in patients who have started treatment with uricosuric drugs or allopurinol (to suppress attacks precipitated by abrupt changes in the seram uric acid level due to allopurinol). iii. Uricosuric drugs: The indication for uricosuric drug treatment is the increasing frequency or severity of acute attaks. When these drugs used concomitantly with cochicine, they may reduce the frequency of recurrences of acute attacks. Commonly the following drugs are used- Probenecid, initially 500mg orally daily (in divided doses); gradually may be increased to l-2gm daily orally (in divided doses). Or, Sulphipyrazone, initially 50-100mg orally twice daily; gradually may be increased to 200-400mg twice daily orally. 2. Avoid diuretics & Salicylates: Thiazide and loop diuretics inhibit renal excretion of uric acid, similarly a low-dose of aspirin also can aggravate hyperuricemia, so both of these should be avoided in patients with gout. 3. Diet: During maintainance therapy in between attacks, high purine diet (red meat, offal, sea-foods), & alcohol shuold also be avoided. 4. Advice to avoid the precipitating factors. 5. Treatment of complications (i.e renal failure, renal stone). Indications for prophylactic therapy:2 1. Recurrent attacks of gouty arthritis 2. Tophi or evidence of chronic gouty arthritis 3. Associated renal disease 4. Gout and markedly raised serum urate. |
| Introduction | |
| History | |
| Etiology | |
| Clinical Features | Clinical features: The metatarsophalangeal joint of the great toe is the site of first attack of acute gouty arthritis. Other sites are the ankle, the knee, the small joints of the feet and hands, the wrist and elbow. Onset may be insidious or explosively sudden. The affected joint is hot, red and swollen with shiny overlying skin and dilated veins, It is excruciatingly painful and tender. Very acute attacks may be accompanied by fever, leucocytosis, and a raised E.S.R. If untreated, the attack lasts for days or weeks but it eventually subsides spontaneousy. More often there is a tendency to have recurrent attacks. Acute attacks may be precipitated by sudden rises in serum urate following dietary excess, alcohol, severe dietary restriction or diuretic drugs, trauma, unusual physical exercise, surgery, systemic illness etc |
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