“Clinical state in which hyperuricaemia and monosodium urate crystal deposition in joints causes pain, inflammation and potential joint destruction

Risk Factors
  • Modifiable:
    • Consumption of red meat
    • Seafood intake
    • Alcohol
    • Obesity
  • Non-Modifiable:
    • Sex (male, 30-50y/o typically)
    • Heart disease
    • Metabolic syndrome
    • Genetic susceptibility
Aetiology

Elevated uric acid levels in the body (due to risk factors) predisposes to deposition of monosodium urate crystals in joints.

Pathophysiology

Overproduction/underexcretion of uric acid → saturated synovial fluid → uric acid precipitates → deposition of crystals → phagocytic immune response causes chemokine stimulation, leukocyte infiltration and inflammation → pain and joint destruction

Clinical Presentation
  • Acutely inflamed hot, swollen and painful joint → most severe in first 6-12 hours
    • Usually first metatarsophalangeal (MTP) joint affected
    • Other joints e.g. knee, elbow and fingers can also be affected
  • Lingering discomfort lasts for days to weeks after
  • Gouty tophi = masses of soft tissue swelling from urate crystal deposition
  • Gouty arthritis = bulgy, deformed joints
Investigations
  1. Clinical Diagnosis
    • Acute monoarthritis affecting the first MTP is the typical initial presentation
  2. Arrange synovial fluid aspiration (gold standard)
    • Presence of urate crystals that are negatively birefringent needle-shaped on polarised light exposure
  3. Blood tests
    • Elevated serum urate level (>7mg/dl)
  4. Joint X-ray
    • Periarticular punched out erosions
Management
  • Acute Gout Attacks
    • NSAIDS – Anti-inflammatory action
    • Colchicine – Anti-inflammatory by inhibiting phagocyte activity
    • Oral steroids – If these are contraindicated e.g. renal disease
  • Prophylaxis
    • Allopurinol – Hypouremic agent. Inhibits xanthine oxidase and prevents uric acid formation.
    • Febuxostat – Same mechanism but more selective inhibition. For allopurinol intolerant px.
Complications
  • Tophi
  • Joint damage and deformity
  • Kidney stones
  • Kidney disease and failure

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