1. Team Meeting Presentations
In the Clinic - Gout
Team Meeting Presentations

2. Risk Factors for Gout Hyperuricemia Male sex if <60 Obesity
High purine diet (red meat; shellfish)
Alcohol (esp beer and spirits) and high fructose drinks
Medications (thiazides; cyclosporine)
CKD
Lead exposure
Organ transplantation
Specific diseases (htn, DM, hyperlipidemia, hematologic malignancies; genetics

3. Are there effective strategies for primary prevention of gout?
Dietary modifications, weight loss
Pharmacologic therapy is not recommended when hyperuricemia is assymptomatic
Pharmocologic therapy is recommended in pts on chemo for hematologic malignancies
Uric acid lowering drugs and hydration prevent secondary gout due to tumor lysis
Without this treatment, uric acid nephropathy with tubular obstruction can develop

4. Is gout associated with increased risk for CV disease and can this be prevented?
Both CV disease and gout are associated with serum markers of inflammation
CV disease risk is increased in persons with gout or hyperuricemia
Opinions differ on whether the association of an elevated serum urate level with increased CV disease is modifiable

5. What symptoms and physical findings suggest gout?
Warmth, swelling, redness and severe joint pain
Of first attacks, 90% are monoarticular
Common sites of crystal deposition, tophus development: helix of the ear, lower extremities
Other sites: periarticular structures (bursae, tendons)
Crystals are more likely in previously diseased joints
Other forms of arthritis increase gout risk

6. Symptoms and Findings
Episodic self-limited joint pain, swelling, erythema
Attacks often occur at night or in early morning
Trauma may trigger release of crystals into joint space
Attacks often subside in 3-14 days without treatment

7. Tests to Diagnose Gout Serum urate level- may be normal in acute flare
CBC with differential
Synovial fluid or tophus aspirate examination
Polarizing scope, cell count culture
Radiography – to r/o other causes or for findings suggestive of chronic gout

8. Podagra

9. Uric Acid Crystals

10. Radiograph – chronic gout

11. Value of radiography in the diagnosis of gout
Early in course- to r/o other conditions
Later in course – can show prominent, proliferative bony reaction
Gout related tophi cause bone destruction away from the joint
Gout less likely to cause joint space narrowing than psoriatic arthritis or rheumatoid arthritis

12. Differential Diagnosis of Gout
Rheumatoid arthritis
Symmetrical polyarthritis in small joints of hands and feet
Hand involvement more likely than in gout
Subcutaneous nodules in 20%
XRAY – soft tissue swelling; diffuse joint space narrowing, marginal erosions of small joints, osteopenia

13. Differential Diagnosis of Gout
Pseudogout – calcium pyrophosphate deposition disease
Appears in unusual places - elbows, wrists – without trauma
Affects 10-15% >65
XRAY – looks like RA or osteoarthritis but with bony repair
Cartilage calcification
Triangular cartilage - pathognomonic

14. Differential Dx of Gout – cont’d
Septic Arthritis –
Fever, arthritis, great tenderness
Up to ½ have concomitant RA
Source is often evident
Diagnose and treat immediately to avoid joint destruction

15. Differential Diagnosis Gout- Cont’d
Cellulitis – gout often mistaken for cellulitis also
Erythema, swelling of the extremity, very tender, febrile
Often previous surgery or infection at the site
Xray – soft tissue swelling
Staph/strep most likely

16. Differential Dx- Gout – Cont’d
Osteoarthritis – bony enlargement without signif inflammation – usually – May often involve the halus valgus – as in gout
Psoriatic arthritis – DIP’s often, nail changes – XRAY central erosions, subchondral sclerosis, bony repair signs;uric acid levels might be high due to proliferative skin changes
Sarcoidosis – acute disease can involve ankles – look for subcut nodules, erythema nodosum
Assoc parotits, uveitis, hilar adenopathy, lung involvement

17. When to consider hospitalizing a patient with gout?
To distinguish gout from septic arthritis
Joint fluid analysis
Empiric antibiotics until diagnosis is clear
Repeated synovial fluid analysis if needed for culture, urate crystals, cell counts
To control pain
Aspiration of joint fluid may help
Gout is one of the most painful conditions

18. Non Drug Therapy in Gout
Reduce high purine foods in diet
Reduce alcohol and high fructose drinks
Weight loss – to decrease urate levels
Hydration
Diet high in fiber, vitamin C, folate
Replace medications that reduce uric acid excretion whenever possible

19. Diet Issues High purine animal and fish sources
Red meat, meat extracts, organ meats, seafood
Yeast products – baked goods and beer
Mushrooms, spinach, asparagus, cauliflower
Legumes – peas, dried beans

20. Drugs for Acute Gout NSAIDS Colchicine (oral)
First line –analgesic/antiinflammatory
Ibuprofen and Naproxen better tolerated than indomethacin; don’t use aspirin
Start at higher dose and taper over 1 week
Side effects as usual
Caution in elderly
Don’t use in anticoagulated patients
Colchicine (oral)
Most effective if started hours after onset
Lower doses reduce side effects (0.6 mg tid)
Side effects – GI, bone marrow suppression, myopathy, neuropathy, dermatitis, urticaria, alopecia, purpura
Myelosuppression can be severe at high doses; reduced with a short course
Caution when using other CYP3A4 inhibitors
Reduce dose for renla or hepatic dysfunction; avoid if on dialysis

21. Drugs for Acute Gout Corticosteroids (oral)
For polyarticular gout when NSAIDS contraindicated
Side effects
Corticosteroids (intraartiular injection)
For monoarticular gout when NSAIDS not ideal
Side effects – risk for damage to nerves, tendons, vascular structures; joint infection risk; usual oral steroid risks
Rule out infectious cause before injecting join
Opiates –
For severe pain
Oral combinations of oxycodone, hydrocodone, codeine
Severe cases – morphine IV or SC
Short term - until inflammation resolved

22. Drugs to Prevent Gout and Complications of Hyperuricemia
To prevent growth of crystalliine deposits
Deposits can lead to chronically stiff, swollen joints and debilitating arthritis
To reduce tophi
To prevent flare recurrence
60% flare again in 1 year, 78% within 2
Subsequent attacks may last longer, involve more joints
To prevent uric acid stones
Occurs in 10-40% of persons with gout
Goal is to reduce urate <6 mg/dl

23. Drugs to prevent gout and complications of hyperuricemia
Allopurinol
Start mg/d, increase by 100 mg.d every 1-4 weeks; reduced dose for CKD
Not in acute attack, concurrent colchicine may reduce risk for flare
Watch for hypersensitivity syndrome
Other side effects – rash, fever, headache, uritcaria, interstitial nephritis
LFTs and CBC monitored
Febuxostat
Start mg/d; increase to achieve goal urate level
Steady state urate after 2 week use
LFT abn, diarrhea, headache, nausea, rash
No dose adjustment needed in mild to mod CKD

24. Other Drugs to reduce Uric acid level
Rasburicase
To prevent tumor lysis
Not if G6PD deficient
Start 24 hours before chemo
Probenicid
0.5-2 mg /day divided 2X/day, dose adjust until urate level normalizes
Uricosuric – use only if underexreter
Don’t use with aspirin
Increases methotrexate toxicity
Rare anaphylaxis
Not effective in pts with signif CKD

25. Drugs to prevent Gouty attacks
Colchicine (oral)
Dose and use depends on cr clearance; avoid if <10 ml/min
Continue for 6 months after serum urate <6 or until tophi disappear
Use caution with other CYP3A4 inhibitors
May need to dose reduce with calcium channel blockers
Side effects GI intolerance, bone marrow suppression, dermatitis, urticaria, alopecia, purpura
Myopathy, neuropathy may increase with renal disease or with statin use
Avoid in severe liver disease

26. Indications for long term drug therapy to prevent gout and complications of hyperuricemia
At least 2-3 acute attacks of gout
Tophaceous gout
Severe attacks or polyarticular attacks
Radiographic evidence of joint damage from gout
Nephrolithiasis
Identifiable inborn metabolic deficiency causing hyperuricemia

27. When to think about referring for specialty consultation…
Consult with a rheumatologist or orthopedist
When joint sepsis is suspected
When gout is poorly controlled
When diagnosis is unclear
When gout occurs with other forms of arthritis
To aid in deciding on timing of initiation of meds or complicated regimens
Consult with rheum in pts with inherited metabolic disease for patients aged <20 with gout
Consult with nephrologist for help managing pts with CKD and/or urate nephropathy