8- GOUT

• Defect in urate metabolism

  Hyperuricemia and sodium urate deposition
• Overproduction of uric acid (breakdown of purines)

  1. Increased de-novo purine (lesch-nyhan)

  2. Increased turnover

  3. Polycythemia vera (myeloproliferative)

  4. Leukemia (lymphoprolipherative)
• Renal underexcretion


  1. CKD

  2. Thiazides

  3. HTN

  4. High lactic acid (alcohol, starvation, exercise)

  5. Hypothyroid

  6. Hyperparathyroidism
• Idiopathic primary gout


  Most common cause
• Acute gout attack (acute sodium urate synovitis)


  • Mostly middle-aged males (5x more common)
  • MTP of big toe
  • Sudden severe pain, swelling, tenderness
  • Fever is common, may give impression of cellulitis
  • Precipitated by; dietary/alcohol excess, dehydration, thiazide diuretic
• Other forms of gout


  • Chronic interval gout
  • Chronic polyarticular gout: elderly women; long-term diuretics
  • Chronic tophaceous gout
• Chronic tophaceous gout


  • Tophi: large smooth white deposition in skin and around joints
  • Ears, fingers, Achilles tendon, bone, kidney
  • Tissue deposits of urate crystals with foreign body reaction
• Uric acid renal stone formation is common in all types
• Investigations


  • CBC, ESR, CRP, RFT; urea & creatinine (can cause renal problems)
  • Serum uric acid (can be normal, high, or low in acute setting à not used to rule out)
  • X-ray to rule out trauma
  • Joint fluid microscopy à most specific & diagnostic
• Joint fluid microscopy


  • Negatively birefringent long needle-shaped crystals
• Acute attack treatment


  1. High dose NSAIDs (indomethacin) is first line

  2. Intraarticular steroids if no response or contraindication for NSAIDs

  3. Colchicine if both can't be used
• Chronic treatment


  1. Weight loss, limiting alcohol and high purine foods. Avoiding thiazides, aspirin, and niacin

  2. Low dose colchicine

  3. Allopurinol to decrease production of uric acid

  4. Febuxostat if allopurinol contraindicated