1. Gout Asad Khan Consultant Rheumatologist
Heart of England NHS Foundation Trust

2. Overview Background Diagnosis Risk factors Acute treatment
Long-term treatment
Pseudogout

3. Gout Inflammatory arthritis due to monosodium urate crystal deposition
Presents with acute self-limiting attacks of severe pain
Chronic – causes tophaceous deposits, joint damage and chronic pain
Rising prevalence (2.49% in 2012)
Curable!

4. Blue: men Red: women Green:overall (Kuo et al, Ann Rheum Dis
Blue: men Red: women Green:overall (Kuo et al, Ann Rheum Dis Apr; 74(4): 661–667.)

5. Neutrophil activation
Purine
Hypoxanthine
Adenine
Xanthine
Chemistry
Inosine
Uric acid
Guanosine
Deposition
Excretion
Neutrophil activation

6. Risk factors Male/post menopausal Metabolic syndrome Diet
High purine intake
Alcohol (beer/spirits)
Fructose
Drugs, including:
Diuretics
Low dose aspirin
Ciclosporin
Increased cell turnover (malignant/haematological)
Genetic predisposition/disease
Lead (saturnine gout)

7. Diagnosis Gold standard In clinical practice
Diagnostic aspiration and polarised light microscopy
In clinical practice
Characteristic patterns of disease presentation
Can be difficult to distinguish from septic arthritis

8. Microscopy

9. Podagra

10. Tophi

11. Othe tests Bloods XRs Ultrasound/CT? Urate in “intercritical” period
Punched out periarticular erosion
Ultrasound/CT?

13. Treating acute attacks
Full dose NSAID
Beware of comorbidities, especially renal impairment
Colchicine 500mcg 2-4 day
Adjust if low GFR
Drug interactions – including statins
Prednisolone
Non genomic vs genomic doses (30-35mg is evidence based)
Intrarticular glucocorticoid injection
Combination

14. Neutrophil activation
Xanthine Oxidase
Purine
Hypoxanthine
Adenine
Xanthine
Chemistry
Inosine
Uric acid
Uricase
Anti IL-1
Guanosine
(Allantoin)
Uricosuric
Neutrophil activation
Excretion

15. Dietary exclusion High purine content – avoid
Oily fish, shellfish
Game
Offal
Marmite/yeast extract
Moderate purine content – in moderation
Meat/chicken
Beans/legumes/peas
Spinach/cauliflower/asparagus
Mushrooms
Wholegrains
Alcohol

16. Dietary inclusion Low purine – fine to eat
Bread/pasta
Milk (milk protein uricosuric?)
Eggs
Other fruit and vegetables
Butter, cheese, ice cream, chocolate, cake (beware comorbidities…)
Low fat dairy and vegetable protein sources
Black cherry

17. Pharmacological treatment
Review regular medications
Treat acute attack first
Discuss urate lowering therapy at first attack, offer if >1 attack/year
Reducing uric acid can precipitate/extend attack
Prophylactic therapy along with urate lowering drug
Target uric acid <300 umol/l (or <360)

18. Prophylactic treatment
Up to 6 months
Low dose colchicine 500mcg once daily
Long term NSAID
IM depomedrone 120mg

19. Xanthine oxidase inhibitors
Allopurinol
Start at 100mg, build up to 300mg
Up to 900mg titrated against serum uric acid
Adjust dose in CKD
Beware drug reactions (inc DRESS)
Febuxostat
80mg or 120mg
Safe in mild/moderate renal impairment
Contraindicated in ischaemic heart disease/heart failure

20. Uricosuric Formulary – probenecid
Others – sulfinpyrazone, benzbromarone (latter associated with liver toxicity)
Coming soon – lesinurad?
Locally initiated in secondary care

21. Medication review Reduce/avoid diuretics Uricosuric drugs Bumetanide?
Losartan
Fenofibrate
Atorvastatin

22. Others IL-1 inhibitors Uricase Eg Anakinra, canakinumab
Not NICE approved (anakinra not licensed)
Uricase
Pegloticase – not NICE approved
Rasburicase – to prevent tumour lysis syndrome

23. Uric acid and cardiovascular risk
Noted association between gout and cardiovascular disease
Is serum uric acid an independent risk factor? Trend of association with:
Hypertension
IHD/heart failure
CKD
Diabetes
Only proven associations: gout, nephrolithiasis
Is low serum uric acid harmful?
Reactive oxygen species scavenger, possible association with neurodegenerative diseases
Currently – raised serum uric acid not an indication for treatment
But diagnosis of gout should prompt for assessment of cardiovascular risk

24. Pseudogout Calcium pyrophosphate crystal deposition
Large joints – knee, wrist, hip
Risk factors
Age
Hyperparathyroidism
Haemochromatosis
Other calcium haemostasis disoders
Acute attacks – treat as for gout
Prophylaxis – none available

25. (University of California, San Diego)

26. Summary Commonest inflammatory arthritis
Generally diagnosed by pattern of disease rather than joint aspiration
Treatment:
Acute
Followed by urate lowering therapy
Lifestyle
Pharmacological
With prophylaxis
See BSR (2017) and EULAR (2016) guidelines