Question

Mr Jones is a 55-year-old man who comes to the clinic with complaints of pain in his right great toe. He tells you that the pain woke him up in the middle of the night and had a hard time sleeping. His toe is very swollen, tender to touch, warm and red. Mr Jones just returned from Las Vegas where he states he ate and drank quite a bit. His diet consists of some vegetables, but he states he eats quite a bit of red meat, especially beef and enjoys red wine.

1. What are the risk factors for gout?

2. What are the clinical manifestations of gout?

3. What education and treatment is effective for Mr Jones?

Answer 1

2. Gout clinical presentation :-

- intense pain

(usually starts at night, peaks within a few hours; lasts about 3-10 days)

- inflammation

(affecting big toe (podagra), plus knee, elbows, wrists, fingers)

- redness, warmth and shininess over affected joint

- tiredness, lack of appetite, mild fever

1. Risk factors for gout

- male (higher urate levels)

- obesity

- family history (20% of cases)

- alcoholic intake (increases urate levels)

- fructose (increases urate levels)

- co-morbidities (ie CVD, HTN (thiazides), renal impairment, diabetes)

- renal insufficiency (reduces excretion of uric acid)

3. Acute management of gout

- do NOT initiate allopurinol

- NSAIDS, colchicine (rarely used), steroids

Long-term management of gout

1. ADDRESS hyperuricaemia

- lifestyle advice (wt loss, exercise, hydration)

- review any other drug therapy (ie diuretics)

2. ASSESS LIKELIHOOD of RECURRENCE

. consider prophylaxis with allopurinol, sulfinpyrazone or probenecid, IF

a) more than 3 attacks/year

b) evidence of damage

c) fam Hx

d) if on thiazide diuretic with other risk factors

3. DON'T START prophylactic therapy until acute attack (lasts 7-10 days) has resolved (uaually 2-3 weeks after)

4. Risk of acute attack of gout being precipitated at start of treatment (give additional prophylactic therapy for about 3 mos)--> NSAIDs, low dose colchicine