Gout, acute

M10.00-09/M10.90-99

DESCRIPTION

A metabolic disease in which uric acid crystals are deposited in joints and other tissues. Characterised by recurrent attacks of an acute arthritis that often affects one joint which is very painful, tender, swollen, red and hot to the touch. The inflammation may extend beyond the joint.

In many patients the 1st metatarso-phalangeal joint is initially involved. The instep, ankle, heel, and knee are also commonly involved. Bursae (such as the olecranon) may be involved.

Gout commonly occurs in men > 40 years of age and in postmenopausal women.

INVESTIGATIONS

Increased serum uric acid level.

However, the serum uric acid level may be normal during acute attacks, and therefore best estimated after the acute symptoms have subsided.

GENERAL MEASURES

  • Immobilise the affected joint during the acute painful attack.
  • Increase (high) fluid intake.
  • Avoid alcohol.
  • Avoid aspirin.

MEDICINE TREATMENT

Initiate treatment as early as possible in an acute attack.

  • NSAIDs, e.g.:
  • Ibuprofen, oral, 400 mg,8 hourly with or after a meal for the duration of the attack.

CAUTION: NSAIDS
Concomitant use of more than one oral NSAID has no additional clinical benefit and only increases toxicity.
Chronic use of all NSAIDs is associated with increased risks of gastrointestinal bleeding, renal failure, and cardiovascular events (stroke and myocardial infarction).
NSAIDs should be used judiciously at the lowest effective dose for the shortest duration. Explore and manage exacerbating factors for pain. See: Pain.
Do not use NSAID in pregnancy and breastfeeding.

LoEIII [6]

If NSAIDS are contraindicated, e.g. peptic ulceration, warfarin therapy and renal dysfunction, or heart failure:

LoEIII [7]

  • Corticosteroids (intermediate-acting) e.g.:
  • Prednisone, oral, 40 mg daily for 5 days (Doctor prescribed).

LoEII [8]

REFERRAL

  • No response to treatment.
  • For confirmation of diagnosis, if in doubt.
  • Patients with chronic kidney disease.
  • Patients with suspected secondary gout (e.g. haematological malignancies).

Note:

  • Gout may be secondary to other medical conditions, e.g. haematological malignancies.
  • Gout may co-exist with hypertension, diabetes mellitus (as a risk factor for degenerative vascular disease) and chronic kidney disease. The pharmacological treatment of these conditions could precipitate gout.