Gout
Jill C. Cash and Julie Barnes
Definition
A.Gout is an acute, sudden inflammatory disease of the joint, caused by high concentrations of uric acid in the joints and bones.
B.Three stages of gout:
1.Acute gouty arthritis: Acute attack exhibiting severe pain, redness, warmth, and swelling of a joint, which may last from days (5–10 days) to weeks, if left untreated.
2.Intercritical gout: Period without flares.
3.Chronic/tophaceous gout: The progression of gout that has been inadequately treated, resulting in urate crystal deposits (tophaceous deposits) in the joints that can cause destruction, deformity, and disability of the joint.
Incidence
A.Gout is most common in men from ages 30 to 60 years. Women become increasingly susceptible to gout after menopause. It is estimated that gout occurs in approximately 3% of the adult population in the United States.
Pathogenesis
A.Primary: High levels of uric acid result from either increased production or decreased excretion rates of uric acid.
B.Secondary: Hyperuricemia results from primary disease processes such as hypertension, renal failure, kidney disorders, and so forth. See the following section Predisposing Factors.
C.Medications/toxins can also cause hyperuricemia.
Predisposing Factors
A.Chronic conditions: Hyperuricemia, chronic kidney disease, hypertension, diabetes mellitus, metabolic syndrome, ischemic cardiovascular disease (CVD), hyperlipidemia, obesity, osteoarthritis (OA).
B.Gender (men older than 30 years, postmenopausal women).
C.Medications that alter uric acid level (diuretics, acetylsalicylic acid, alcohol, nicotinic acid, ethambutol, pyrazinamide).
D.Dietary factors (high intake of beer and meat/fresh seafood products).
E.Family history of gout.
F.Lead poison.
Common Complaints
A.Redness, swelling, warmth, and/or pain in the joint (usually one joint only)—podagra (big toe). The pain is likely to be the most severe in the first 12 to 24 hours.
B.History of having severe joint pain with inflammation in other joints, followed by pain-free episodes.
Other Signs and Symptoms
A.Tophi are seen from several years of untreated gout.
B.Fever may be present in acute stages.
Subjective Data
A.Note when initial symptoms began.
B.Review patient history of gout.
C.Determine what makes the symptoms worse or better.
D.List medications/therapies used and the result of the different therapies used.
E.Review of recent dietary preferences (alcohol, meat, seafood).
Physical Examination
A.Check temperature, pulse, respirations, and blood pressure (BP).
B.Inspect:
1.Inspect the joints.
2.Note the presence of tophi on other joints.
C.Palpate the joints for tenderness, pain, and increase in temperature of skin.
Diagnostic Tests
A.Joint fluid aspiration for urate crystals is the gold standard in diagnosing gout. Inspect fluid with a polarized light microscopy to identify uric acid crystals.
B.Complete blood count with differential (CBC/diff): White blood cell (WBC) count elevated.
C.Erythrocyte sedimetation rate (ESR): Elevated in gout.
D.Serum uric acid level: Uric acid greater than 6.8 mg/dL. Serum uric acid level may be normal during acute attacks. Perform test at least 2 weeks after acute attack or when flare has resolved.
E.Rehumatiod factor (RF): titer.
F.X-ray or MRI: Identify bone cysts/gout tophi.
Differential Diagnoses
A.Gout.
B.Infectious arthritis.
C.Rehumatiod arthritis (RA).
D.Hyperparathyroidism.
E.Pseudogout (calcium pyrophosphate deposition disease) commonly occurs in the knee, wrist, or other joints.
F.Bursitis.
G.Cellulitis.
Plan
A.General interventions:
1.Rest the joint area; no heavy lifting or weight-bearing activity.
2.Aspirin products should not be used.
B. 
See Section III: Patient Teaching Guide Gout
:
1.Increase fluid intake to at least eight glasses of water daily.
2.Avoid alcohol intake and excessive meat and seafood products that trigger flares.
3.Medication treatment and compliance of taking the prescribed medications can be very effective in preventing the development of the chronic tophaceous gout stage.
4.Aspirin products should not be used.
C.Pharmaceutical therapy:
1.Analgesia:
a.NSAIDs most effective if started within 48 hours of presenting symptoms:
i.Indocin 50 mg every 8 hours for eight doses, then 25 mg every 8 hours until pain free for 1 to 2 days. Normal course is 5 to 7 days.
ii.Naproxen, 750 mg initially, followed by 500 mg every 12 hours.
iii.NSAIDs are contraindicated for patients with the diagnosis of renal insufficiency, heart failure, ulcer disease, NSAID allergy, and anticoagulation therapy.
b.Colchicine (Colcrys) is most effective if started within 12 to 24 hours of presenting symptoms: 1.2 mg initial dose, followed by 0.6 mg 1 hour later. Continue 0.6 mg one to two times daily until symptoms resolve. Medication may be stopped after the patient is free from symptoms after 2 to 3 days. Colchicine may also be used to prevent attacks. Colchicine warnings: Be aware of contraindications. Caution regarding drug interactions. Intolerable side effects of colchicine include nausea, vomiting, and diarrhea. Probenecid effects (inhibits tubular absorption, therefore increasing the serum plasma level) with other drugs include penicillin and methotrexate (MTX).
For long-term use, colchicine 0.6 mg/d may be used for patients who have more than one attack per year. See package insert for recommendations for more frequent use.
c.Corticosteroids may be used for patients who cannot tolerate oral medications:
i.Intra-articular steroid injection of methylprednisolone acetate may be given.
ii.Oral steroids may also be prescribed for patients who cannot take NSAIDs or colchicine and who cannot tolerate intra-articular steroid injection. Prednisone is safe. Be aware of rebound effects.
2.For hypersecretion of uric acid (frequent attacks of ≥2 yearly, tophi on exam or imaging, chronic kidney disease [CKD] stage 2 or worse, past urolithiasis), long-term therapy is needed to decrease uric acid production:
i.Allopurinol (Zyloprim) is the drug of choice. Starting dose 100 mg/d and titrate up over several weeks to a maximum of 300 mg/d. The goal is to keep the uric acid level less than 6.0 mg/dL.
ii.Febuxostat (Uloric) is also used to lower blood uric acid levels. The recommended dose is 40 mg/d with or without food; maximum dose is 80 mg/d. Initial laboratory studies include liver enzymes before beginning Uloric. Common side effects include liver problems, nausea, gout flares, joint pain, and rash.
3.For reduced excretion rates of uric acid, consider probenecid (Benemid) 250 mg by mouth twice a day for 1 week, then increase to 500 mg by mouth twice a day. Increased consumption of fluids must be encouraged. Avoid if CrCl is less than 50.
4.Chronic gout: If patients have three or more attacks per year, consider long-term therapy, low dose of NSAIDs, or allopurinol for 2 to 12 months.
a.Alternative medications for intolerance, renal insufficiency, and extensive tophi include oxypurinol, febuxostat, and uricase. Refer to rheumatology specialist.
Follow-Up
A.The patient should be contacted within 24 hours for evaluation.
B.Schedule follow-up visit in 1 month to reevaluate status.
C.Monitor serum urate during medication titration every 2 to 5 weeks to target.
D.Chronic gout: Obtain yearly uric acid levels; before initiating long-term therapy, obtain baseline blood urea nitrogen (BUN), serum lipid profile, and CBC and periodic liver enzymes.
Consultation/Referral
A.Consult and refer to physician or rheumatologist for aspiration of joint fluid and newer treatment options.
Individual Considerations
A.Pregnancy: Colchicine not recommended.
B.Geriatrics:
1.Reformation in joint areas may be seen in patients who have a history of gout from the uric acid deposits.
2.Complications for chronic gout include nephrolithiasis and chronic urate nephropathy.
3.Avoid Indocin in elderly patients because of the increased risk of adverse effects with other medications when compared with other NSAIDs.
4.NSAIDs are not recommended in the elderly with a history of heart failure, GI ulcers/disease, and renal impairment.
5.Individual considerations must be given in this population regarding GI, cardiac, renal, and liver disease.
6.Severe gout symptoms ≥2 years duration is associated with the prevalence of CVD in the adult and geriatric population. Studies have suggested that preventing gout-related inflammation could be clinically relevant to cardiovascular benefits. Recommendations of uricosuric agents for geriatrics with gout to help prevent CVD are fenofibrate and losartan.
7.Allopurinol in elderly population is beneficial, however, the following medications would have a negative interaction: warfarin, cyclosporine, chlorpropamide and thiazide diuretics.
8.The Beers recommendation is to avoid colchicine in geriatric patients with CrCl less than 30 mL/min secondary to increased risk of bone marrow toxicity, GI complications, and neuromuscular adverse effects.
9.Elderly patients with a severe gout attack are often misdiagnosed with septic arthritis because geriatrics clinically present indistinguishable symptoms of fever, leukocytosis, and C-reactive protein (CRP) elevation with gouty inflammatory response. Clinical guidelines recommend administering empirical antibiotics and observing patients until culture and sensitivity results are available before proceeding with invasive joint lavage. Studies revealed that joint lavage is associated with prolonged pain and increased length of hospital stay for patients ≥65 years old.