Acute Gouty Arthritis

Clinical Description

Acute painful joint in patient with Gout arthritis

Signs and Symptoms

• Affected joint is painful, tender, warm, swollen and red. Attacks usually last 7 days
• Typically, monoarticular and occurs in men in most cases. The first metatarsophalangeal (MTP) joint of great toe commonly involved

Investigations

• Full blood count
• Serum uric acid
• Serum urea and creatinine
• Joint fluid microscopy
• ESR and CRP

Treatment

General measures

• Encourage Rest
• Ensure abundant fluid intake

The main objective of treatment is to decrease pain and swelling, reduce serum uric acid levels

• Give Ibuprofen 800mg 12 hourly preferably after food in established cases until attack subsides

Alternatively:

• Give Indomethacin 50-75mg 8 hourly with food or
• Give Diclofenac Sodium 25-50mg 8 hourly preferably after food and preferably suppositories
• Give Colchicine 1.0mg followed by 0.5mg no more frequently than 4 hourly until pain is relieved or diarrhoea or vomiting starts. Maximum of 6mg per course; course should not be repeated within 3 days
• Give Prednisolone 30 -50mg daily for 5 -7 days

Prevention of Attacks

• Encourage physical exercise
• Encourage reduction in dietary protein (if intake is high)
• Avoid alcohol <14 units/week
• encourage to drink >2 litres of water daily
• Only indicated in recurrent gout attacks.
• Allopurinol 100 mg daily after food is the first line Urate lowering therapy
• Maintenance dose: Up to 200 -600mg daily; dosage >300 mg to be given in divided doses; may be required life long
• Gradually increase over 1-3 weeks to 300 mg daily, according to plasma or urinary uric acid concentration
• Do not start this treatment until an acute attack has completely subsided

Complications

Chronic recurrent gout

• Frequent polyarticular arthritic attacks with bony deformities

Tophaceous Gout

• Solid, chalky white masses of uric acid commonly around joints and soft tissues
• Predilection - extensor surfaces of elbows, distal Achilles tendon, finger proximal interphalangeal (PIP), cartilaginous portion of ears

Renal impairment (due to hyperuricemia and NSAIDS chronic use)

Complications and Referral Criteria

• Not responding to first line ULT (Allopurinol)
• Presence of comorbid conditions