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
- Gout: monosodium urate negative Negatively birefringent
- Pseudogout: calcium pyrophosphate positive birefringence crystals
- Serum uric acid levels are not helpful (30% of pts w/ gout attack have normal levels)
- ESR may be elevated
- no bacteria on Gram Stain
Treatment
- Patients usually only require opioid and NSAID treatment in the ED with continued NSAID treatment as an oupatient. However any combination of the following treatments are acceptable[1]
NSAIDs
- Do not give to patients with renal insufficiency (use opioids instead)
- Substantial pain relief should occur within 2hr
- Options:
- Indomethacin 50mg po TID x3-5d, OR
- Naproxen 500mg po BID x3-7d, OR
- Ibuprofen 800mg PO TID x 3-5d
Other options
Colchicine
- Can be used as alternative agent to NSAIDs in pt with normal renal/hepatic function
- 1.2mg PO (load), followed by 0.6mg one hour later x 1 [2]
- Renal impairment not absolute contraindication for acute flare but may consider dose reduction.
- Dose adjustments for CYP3A4 inhibitors (HARRT, Calcium Channel Blockers, fluconazole, erythromycin, clarithromycin)
- Colchicine should not be administered intravenously
Steroids
- Prednisone 30 to 50 mg initially, and gradually tapered over 10 days, results in clinical resolution without rebound pain or complications[3][4]
Glucocorticoid injection
- 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.
All patients
- Hold diuretics
- Consider starting losartan to replace diuretic (has modest uricosuric effect)
- Alcohol and dietary counseling
- Continue uric acid-lowering agents if already on prophylactic regimen (do not start)
- Follow up with Primary Doctor or Rheumatology if having continued flares
See Also
Source
- Tintinalli - Gout
- ↑ Khanna D. et al. 2012 American College of Rheumatology guidelines for management of gout. Part 2: Therapy and antiinflammatory prophylaxis of acute gouty arthritis. Arthritis Care Res. Oct 2012;64(10):1447-61
- ↑ Terkeltaub RA et al. High versus low dosing of oral colchicine for early acute gout flare: Twenty-four-hour outcome of the first multicenter, randomized, double-blind, placebo-controlled, parallel-group, dose-comparison colchicine study. Arthritis Rheum. 2010;62(4):1060.
- ↑ Groff GD et al. Systemic steroid therapy for acute gout: a clinical trial and review of the literature. Semin Arthritis Rheum. 1990;19(6):329
- ↑ Janssens H. et al. Use of oral prednisolone or naproxen for the treatment of gout arthritis: a double-blind, randomised equivalence trial. Lancet. 2008;371(9627):1854.