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
  1. Options:
    1. Indomethacin 50mg po TID x3-5d, OR
    2. Naproxen 500mg po BID x3-7d, OR
    3. Ibuprofen 800mg PO TID x 3-5d

Other options

Colchicine

  1. Can be used as alternative agent to NSAIDs in pt with normal renal/hepatic function
  2. 1.2mg PO (load), followed by 0.6mg one hour later x 1 [2]
  3. Renal impairment not absolute contraindication for acute flare but may consider dose reduction.
  4. Dose adjustments for CYP3A4 inhibitors (HARRT, Calcium Channel Blockers, fluconazole, erythromycin, clarithromycin)
  5. 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

  1. 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

  1. Hold diuretics
  2. Consider starting losartan to replace diuretic (has modest uricosuric effect)
  3. Alcohol and dietary counseling
  4. Continue uric acid-lowering agents if already on prophylactic regimen (do not start)
  5. Follow up with Primary Doctor or Rheumatology if having continued flares

See Also

Source

  • Tintinalli - Gout
  1. ↑ 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
  2. ↑ 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.
  3. ↑ 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
  4. ↑ 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.
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