Gout

Triggers

• High Purine Foods: Shellfish, organ meats (liver, kidney), red meat

• Fructose-Rich Drinks: Soft drinks, fruit juices (particularly high-fructose corn syrup)

• Alcohol (beer, spirits)

• Trauma to Joints, systemic illness, or fever

• Dehydration

• Medications: Low-dose aspirin, thiazide/loop diuretics, cyclosporine

Clinical Features

Acute Gout

• Typically monoarticular (often the first metatarsophalangeal joint—podagra)

• Sudden onset of intense pain, erythema, swelling, and warmth

• Pain peaks within 24 hours, may have fever or malaise

• Can mimic septic arthritis (always consider joint aspiration if doubt)

Chronic Gout

• Recurrent or oligo-/polyarticular involvement

• Tophi: Urate crystal deposits (elbows, fingers, toes) → deformities

• Leads to chronic arthritis, possible joint destruction

• Associated with cardiovascular and renal co-morbidities

Diagnosis

• Joint Aspiration (Gold Standard):

  • Needle-shaped monosodium urate (MSU) crystals showing negative birefringence under polarised light

• Serum Uric Acid: May be normal during acute flares; more useful for chronic monitoring

• Imaging:

  • X-ray may show erosions or ‘punched-out’ lesions, tophi, joint damage in chronic cases

Acute Flare Management

First-Line

• Prednisolone: 15–30 mg PO daily for 3–5 days or short taper

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  Intra-articular Corticosteroids if 1–2 joints involved, under sterile technique

Second-Line

• Colchicine:

  • 1 mg stat, then 500 mcg 1 hour later (max 1.5 mg/day)

  • Lower doses if renal impairment or drug interactions

Non-Pharmacological Advice

• Hydration: 2–3 L fluid/day unless contraindicated

• Avoid high-purine foods, excessive alcohol, and sugary drinks

• Weight loss, regular exercise, smoking cessation

• For rapid relief in severe attacks, combination therapy with colchicine plus NSAIDs or low-dose prednisolone may be used carefully (avoid combining NSAIDs + steroids due to GI toxicity)

Long-Term Treatment

Urate-Lowering Therapy (ULT)

• Allopurinol:

  • Start at 50 mg daily, titrate every 2–4 weeks up to 900 mg/day as needed

  • Continue ULT during acute flares (do not stop abruptly)

  • Target serum urate <0.36 mmol/L (or <0.30 mmol/L if tophi present)

• Febuxostat: Alternative if allopurinol-intolerant or in case of allopurinol hypersensitivity

Prophylaxis (During ULT Initiation, Minimum 6 Months)

• Colchicine 500 mcg once daily

• NSAIDs (e.g. ibuprofen 200–400 mg TDS) if no contraindications

• Low-Dose Corticosteroids (5 mg prednisolone daily) in special scenarios under specialist advice

Patient Counselling

• Long-Term ULT is needed to prevent further flares, joint damage, and reduce cardiovascular risks

• Lifestyle modifications: diet (low purine), weight control, hydration, avoid triggers (alcohol, sugar-sweetened beverages)

• Do not stop allopurinol (or febuxostat) during acute flares; use prophylaxis to minimise flare frequency

• Emphasise adherence to reduce flares and help resolve tophi over time

Complications

• Chronic Gouty Arthritis → progressive joint deformity

• Tophaceous Gout: Large urate deposits in joints and subcutaneous tissues

• Renal: Urate nephropathy, kidney stones

• Cardiovascular Risk: Hyperuricaemia associated with hypertension, metabolic syndrome