Crystalize your knowledge of gout and stop flares in their tracks with tips from expert, Tuhina Neogi MD, PhD, Professor of Medicine at Boston University School of Medicine. On this first of two gout episodes we learn to diagnose gout with or without arthrocentesis, how to treat flares, and how to counsel patients about gout, which apparently involves fire fighting and bathtubs. Don’t miss next week’s episode on urate lowering therapy, gout guidelines controversy, and answers to your gout questions from social media.
Gout is caused by an elevation of uric acid in the blood combined with genetic factors and patient comorbidities. Hyperuricemia is present in over 20% of the population, but only about four percent of the population has gout (Zhu Arthritis Rheumatism 2011). Two-thirds of urate is excreted by the kidneys and one third via the GI tract. Chronic kidney disease promotes urate underexcretion and predisposes patients to gout (Sidari Prim Care Clin Office Pract 2018).
The first metatarsal phalangeal joint (1st MTP) is most commonly affected. Other commonly affected joints include: insteps of the feet, heels, ankles, and knees. Less common sites include the wrists, elbows, and even small joints of the fingers (Sidari Prim Care Clin Office Pract 2018).
Gout flares can be explained to patients as a joint being “on fire” as the body develops an inflammatory response to the monosodium urate (MSU) crystals in the joint. Steroids, NSAIDS, or colchicine can be used to put out the fire.
Dr Neogi’s bathtub analogy explains gout as a process whereby the bathtub (i.e. the body and joints) becomes overflowed with water (i.e. urate and uric acid). When the water level gets to high, it spills over and causes an electrical short/fire (i.e. gout flare). To treat gout we can:
In practice a clinical diagnosis is most common. Arthrocentesis remains the gold standard for diagnosis, and while a crystal proven diagnosis is uncommon due to logistics, it should be pursued if possible. MSU crystals are needle-shaped, and yellow if parallel, but blue if perpendicular to the light polarizer. MSU crystals can even be found in the joints between flares!
Classification criteria are used to enroll a homogenous population for clinical trials. These should not be substituted for a clinician’s diagnostic reasoning, but can be helpful in identifying the key features of gout when considering this diagnosis (Calculator http://goutclassificationcalculator.auckland.ac.nz). –Dr Neogi
The 2016 EULAR gout guidelines recommend a pill-in-pocket strategy for “fully informed” patients to promote prompt self management of gout flares (Richette Ann Rheum Dis. 2017). Dr Neogi notes that evidence suggests that patients are better at managing their own flares.
Colchicine is less effective if started after 24 hours into a flare. Give 1.2 mg at first sign of flare followed in one hour by another 0.6 mg (Lexicomp). Continue colchicine at 0.6 mg twice daily until the flare resolves, usually up to 14 days (Dr Neogi’s expert opinion). Be careful with concomitant use of CYP3A4 inhibitors like diltiazem.
Start at 30 mg prednisone daily and decrease the dose by 5 mg every two days (12 day course). Higher dose may be used for polyarticular gout. –Dr Neogi’s expert opinion.
Start ibuprofen 800 mg three times daily for 3 days, then give 400 mg three times daily for the remaining 7-10 days (Dr Neogi’s expert opinion). No specific NSAID is recommended over others (Sidari Prim Care Clin Office Pract 2018).
Goal: Listeners will develop a both a practical and evidence based approach to the diagnosis and management of gout flares.
After listening to this episode listeners will…
Disclosures: Dr Neogi reports no relevant financial disclosures. The Curbsiders report not relevant financial disclosures.
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