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CE/CME

Gout
A Clinical Overview
Bonnie Dadig, EdD, PA-C, Anna Everett Wallace, PA-S
Gout, a metabolic disorder that affects more than six
million people in the United States, most commonly
presents as an acute inflammatory arthritis—usually
manifesting in an acutely painful, tender, and inflamed
joint. Because gout can affect every organ system,
however, patients with gout are vulnerable to other
Uric acid crystals from an inflamed gouty joint, significant pathologies that may also require timely
shown on light microscopy.
intervention.

CE/CME INFORMATION
TARGET AUDIENCE: This activity has been de- ACCREDITATION STATEMENT: CECourses.aspx, follow links to the posttest for this
signed to meet the educational needs of physician PHYSICIAN ASSISTANTS activity, and provide payment information via our se-
assistants and nurse practitioners in primary care This program has been reviewed and is approved cure server; 4) complete the 10-question posttest by
with adult patients who may by susceptible to hyper- for a maximum of 1.0 hour of American Academy of recording the best answer to each question; and 5)
uricemia and gout. Physician Assistants (AAPA) Category I CME credit record their response to each of the additional evalu-
• Original Release Date: July 2011 by the Physician Assistant Review Panel. Approval is ation questions.
• Expiration Date: July 31, 2012 valid for one year from the issue date of July 2011. If you have any questions, e-mail CR.evaluations
•E stimated Time to Complete This Activity: 1 Participants may submit the self-assessment at any @qhc.com. Upon successful completion of an on-
hour time during that period. line posttest, with a score of 70% or better, and the
• Medium: Printed journal and online CE/CME This program was planned in accordance with completion of the online activity evaluation
AAPA’s CME Standards for Enduring Material Pro- form, a statement of credit will be made available
PROGRAM OVERVIEW: The primary objective grams and for Commercial Support of Enduring immediately.
of this educational initiative is to provide clinicians in Material Programs.
primary care with the most up-to-date information Successful completion of the self-assessment is DISCLOSURE OF UNLABELED USE: This
regarding diagnosis and management of gout. required to earn Category I CME credit. Successful educational activity may contain discussion of pub-
completion is defined as a cumulative score of at lished and/or investigational uses of agents that are
EDUCATIONAL OBJECTIVES: After com- least 70% correct. not indicated by the FDA. AAPA, The NPA, and
pleting this activity, the participant should be better Quadrant HealthCom Inc. do not recommend the
able to: ACCREDITATION STATEMENT: use of any agent outside of the labeled indications.
• Explain the pathogenesis of hyperuricemia and NURSE PRACTITIONERS The opinions expressed in this educational activ-
its relationship to gout. This program has been approved by the Nurse ity are those of the faculty and do not necessarily
• Enumerate the serious comorbidities often pres- Practitioner Association New York State (The NPA) represent the views of AAPA, The NPA, or Quad-
ent in patients with gout that may also require for 1.0 contact hour. rant HealthCom Inc. Please refer to the official pre-
intervention. scribing information for each product for discussion
• Discuss the “gold standard” for diagnosis of gout, DISCLOSURE OF CONFLICTS OF INTER- of approved indications, contraindications, and
in addition to diagnostic criteria commonly used EST: The faculty reported the following financial warnings.
to identify the condition. relationships or relationships to products or devices
• Explain methods for ruling out alternate diagno- they or their spouse/life partner have with commer- DISCLAIMER: Participants have an implied re-
ses in patients who have risk factors for gout but cial interests related to the content of this CME ac- sponsibility to use the newly acquired information
a non-classic presentation. tivity: Bonnie Dadig, EdD, PA-C, and Anna Everett to enhance patient outcomes and their own profes-
• Describe the components of conventional gout Wallace, PA-S, reported no significant financial rela- sional development. The information presented in
management, in addition to newer medications tionship with any commercial entity related to this this activity is not meant to serve as a guideline for
now available. activity. patient management. Any procedures, medications,
or other courses of diagnosis or treatment discussed
FACULTY: Bonnie Dadig, EdD, PA-C, is the Chair METHOD OF PARTICIPATION: The fee for or suggested in this activity should not be used by
and Program Director of the Georgia Health Sciences participating and receiving CME credit for this activ- clinicians without evaluation of their patient’s con-
University (GHSU) Physician Assistant Department ity is $10.00. During the period July 2011 through ditions and the possible contraindications or dan-
and a PA in the GHSU Department of Family Medi- July 31, 2012, participants must 1) read the learning gers in use, review of any applicable manufacturer’s
cine outpatient clinic, Augusta. Anna Everett Wal- objectives and faculty disclosures; 2) study the educa- product information, and comparison with recom-
lace, PA-S, is a student in the PA program at GHSU. tional activity; 3) go to www.clinicianreviews.com/ mendations of other authorities.

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July 2011 • Vol 21, No 7
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CE/CME Gout: A Clinical Overview

G
outy arthritis is a 30% between 1990 and 1999,
TABLE 1
common form of while prevalence among those
inflammatory ar- older than 75 almost doubled
Factors Associated With Urate Underexcretion and
thritis, occurring during this same period.14 Urate Overproduction1,15,26,30-33
more frequently in men than in Numerous factors appear to Urate underexcretion Urate overproduction
women. The condition has a contribute to these trends, in-
Medications/drugs Aspirin (low-dose) Cytotoxic drugs
male–female ratio of 3 or 4 to 1, cluding aging of the population,
although that ratio narrows as dietary trends (ie, increased con- Cyclosporine Ethanol
adults age; because the uricosu- sumption of red meat, organ Ethambutol Fructose (overconsumption)
ric effects of estrogen decline food, game, and shellfish and re-
with menopause, the risk for duced consumption of low-fat Ethanol Purine (excess)
gout increases in postmenopaus- dairy products), presence of cer- Levodopa Vitamin B12
al women.1,2 Mean age at disease tain comorbid conditions (ie, hy-
Loop diuretics Warfarin
onset is 40 to 60 in men,3,4 with pertension, dyslipidemia, diabe-
onset in women averaging seven tes, metabolic syndrome, Nicotinic acid
years later.5 end-stage renal disease), the in- Pyrazinamide
Apart from the pain and loss creasing prevalence of obesity in
of function associated with this younger adults, use of specific Thiazides
disorder of purine metabolism6 prescription medications, and Other factors Chronic renal failure Glycogen storage disorders
and the risk for a chronic form increased incidence of organ
Dehydration Hypertriglyceridemia
of the disease, gout is almost transplantation.1,7,8,15-19
universally linked with serious The body’s underexcretion or Hyperparathyroidism Lymphoproliferative disorders
comorbidities that require time- overproduction of uric acid (a by-
Obesity Myeloproliferative disorders
ly intervention. These ­include product of purine metabolism12)
hypertension, dyslipidemia, hy- can lead to hyperuricemia. This Hypertension Obesity
perglycemia and ­diabetes, obesi- condition, defined as a serum Hypothyroidism Psoriasis
ty, metabolic syndrome, cardio- urate level exceeding 7.0 mg/dL
Polycythemia
vascular disease (CVD), renal in men or 6.0 mg/dL in wom-
insufficiency, and coronary heart en20,21 (levels above 9.0 mg/dL are Lactic acidosis
disease (CHD).2,3,7 The presence considered very high22), is the
Elevated insulin levels
of gout is independently associ- primary risk factor for gout.8,23,24
ated with a risk for acute myo- As with gout, the incidence of Polycystic kidney disease
cardial infarction (AMI) and in- hyperuricemia has increased in Sarcoidosis
creased rates of all-cause recent years,20 with researchers
mortality.3,8-10 attributing the trend to world- Toxemia of pregnancy

wide popularization of the West- Sources: Bhole et al. Arthritis Rheum. 20101; Weaver. Cleve Clin J Med. 200815; Zhang et al. Ann
Rheum Dis. 200626; Harris et al. Am Fam Physician. 199930; Schlesinger. Curr Pharm Des. 200531;
EPIDEMIOLOGY ernized diet (particularly use of Ning and Keenan. Curr Opin Rheumatol. 201032; Menon et al. Clin Chem. 1986.33
In 2007, the National Arthritis high-fructose corn syrup20,25)
Data Workgroup11,12 estimated and increased use of certain the MSU deposits is gout.20 Genetic variants are current-
that about three million US medications, including thiazide In addition to hyperuricemia, ly being investigated to possibly
adults had had “self-reported diuretics, cyclosporine, and low- risk factors for gout include a identify a predisposition to
gout” in the previous year. An dose aspirin.2,20,25,26 high-purine diet, habitual alco- gout. The most significant ge-
estimated six million US adults As serum urate levels rise, the hol consumption (especially beer netic factors appear to involve
have been diagnosed with patient with hyperuricemia may and fortified wines27), diuretic mechanisms that regulate se-
gout,2,11 and its incidence and experience urate supersatura- therapy (particularly in patients rum uric acid levels—particu-
prevalence are increasing. The tion, often followed by crystal- with heart failure or renal insuf- larly urate underexcretion.23
incidence of primary gout more lization of the excess urate into ficiency), obesity, hypertension, Other factors that contribute to
than doubled between 1977-1978 monosodium urate (MSU) and high levels of fructose con- underexcretion or overproduc-
and 1995-1996,13 especially af- crystals. Subsequently, circulat- sumption.7,28 Additionally, cyclo- tion of uric acid are shown in
fecting the aging population. ing MSU crystals may deposit sporine use in an organ trans- Table 1.1,15,26,30-33
The prevalence of gout among in body tissues, especially in the plant recipient, poorly controlled A dynamic relationship exists
1,000 managed care patients joint spaces. The body’s ensu- uric acid levels, and a long histo- between gout and a number of
ages 65 to 74 increased by at least ing inflammatory response to ry of gout increase the patient’s pathologic processes. According
risk for chronic tophaceous to researchers investigating
Bonnie Dadig is the Chair and Program Director of the Georgia Health Sciences
University (GHSU) Physician Assistant Department and a PA in the GHSU Depart-
gout.24,29 Tophi may be more nearly 178,000 patients with
ment of Family Medicine outpatient clinic, Augusta. Anna Everett Wallace is a PA common in a patient with a his- gout in a managed care database,
student at GHSU. tory of organ transplantation.16 36% had hypertension, 27% had

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July 2011 • Vol 21, No 7
30
dyslipidemia, and 15% had dia- at risk for the deposition of
betes.8 In a smaller cohort study MSU crystals into body tissues FIGURE 1
conducted in Spain and Mexico, and the potential associated or-
it was demonstrated that 93% of gan damage—even patients
patients with gout had one or without symptoms. There is
more associated diseases, in or- currently no evidence-based
der of decreasing frequency: hy- method to determine which pa-
pertriglyceridemia, obesity, hy- tients with asymptomatic hy-
pertension, metabolic syndrome, peruricemia will experience dis-
hyperglycemia, chronic renal ease progression.16
failure, diabetes, and ischemic Acute gout develops when de-
heart disease.3 position of MSU crystals in the
Of particular clinical impor- joints initiates an inflammatory
tance in this study was a finding response. In the typical history,
that the first gout attack gener- the patient experiences sudden-
ally preceded the diagnosis of onset severe pain, swelling, and In about half of patients with monoarticular gout, the attack
the associated diseases.3 Thus, a erythema. The pain often starts occurs in the metatarsophalangeal joint (podagra).
diagnosis of gout should lead the in the middle of the night or ear-
primary care provider to discuss ly morning,34 waking the patient joints may become stiff and Because such a large propor-
modifiable risk factors with the from sleep and peaking within swollen, and subcutaneous nod- tion of patients have the classic
patient—but also to investigate 24 hours of onset. At this time, ules or whitish-yellow intrader- presentation of rapid-onset
for comorbid illnesses that may the patient is often unable to mal deposits may be present un- warmth, redness, and tender-
require timely management.2 bear weight comfortably on the der taut skin, anywhere in the ness at the MTP, knee, or ankle
In a 12-year-long prospective affected joint. The patient may body.16 and surrounding soft tissue,
study of more than 50,000 men also report fever and flu-like cases with a differing presenta-
participating in the Health Pro- malaise resulting from the re- PATIENT PRESENTATION AND tion are likely to be misdiag-
fessionals Follow-Up Study,9 it lease of interleukin 1-b (IL-1b), HISTORY nosed or overlooked, or a cor-
was found that men with gout IL-1 receptor, ­cytokines, and Typically, a patient with gout rect diagnosis is delayed.26 In
had a 28% increased risk for all- prostaglandins.16,24,35 Usually in will present with a chief com- many documented cases, gout
cause mortality, a 38% in- these early attacks, symptoms re- plaint of a painful, tender, in- was the ultimate diagnosis—but
creased risk for CVD-related solve spontaneously within three flamed joint (classically de- one that was reached only inci-
death, and a 55% increased risk to 14 days.16,24 scribed in Latin as calor, rubor, dentally because of unusual
for CHD-related death, com- After resolution of an acute dolor, et tumor6). However, clini- clinical presentation, ranging
pared with men who did not attack, the patient enters the in- cians must also be aware of un- from entrapment neuropathy to
have gout (excluding other risk tercritical stage, another asymp- usual presentations and consider a pancreatic mass.32
factors).9 Similarly, researchers tomatic stage that may last for gout in the differential whenever The presence of hyperurice-
for the Multiple Risk Factor In- months or years—or indefinite- a patient with a history of gout mia and other risk factors must
tervention Trial10 demonstrated ly. During the intercritical or pertinent risk factors presents be investigated. Also relevant in
a clinically significant associa- stage, MSU crystal deposition with unexplained clinical find- the history of an acute gout at-
tion between gout and an in- continues, adding crystals in ings.32 The history of present ill- tack may be a preceding event
creased risk for AMI: 10.5% of and around the affected joint or ness will vary according to the that has caused damage or stress
men with gout, compared with joints, possibly continuing to stage of the disease. to the joint, such as infection,
8.43% of men without gout, had inflict damage (in some patients, About 90% of recognized ini- trauma, or surgery. Other pos-
an AMI during mean follow-up substantial), and in many cases tial attacks of gout are monoar- sible triggers for an attack in-
of 6.5 years.10 resulting in additional attacks ticular, usually occurring in one clude alcohol ingestion, acidosis,
and pain.16 Any subsequent of the lower extremities.16 While use of IV contrast media, diuret-
THE STAGES acute gout attacks the patient the first metatarsophalangeal ic therapy, chemotherapy, recent
The four stages of gout are may experience are likely to last (MTP) joint is affected in about hospitalization or surgery, and
­asymptomatic hyperuricemia, longer than the initial attack 50% of gout cases (podagra, the initiation or termination of
acute gout, intercritical gout, and and to involve additional joints Greek term for gout),2,35 eventu- urate-lowering therapy with the
chronic tophaceous gout.20 or tendons.24 ally patients with gout have a xanthine oxidase inhibitor allo-
Only a small percentage Some patients, especially 90% chance of involvement with purinol.2,30 According to Prima-
(0.5% to 4.5%) of patients with those who do not receive ade- the MTP joint (see Figure 1). testa et al,8 the risk for flares is
asymptomatic hyperuricemia will quate treatment for hyperurice- According to Zhang et al,26 pa- increased in patients with car-
develop acute gout.28 Neverthe- mia,2 progress to develop chronic tients with hyperuricemia and an diometabolic comorbidities.
less, any patient with serum tophaceous gout. This is a deform- affected MTP joint have an 82% The medication history of a
urate greater than 6.8 mg/dL is ing disease process in which the chance of having gout.2,26 patient with gout may include

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July 2011 • Vol 21, No 7
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CE/CME Gout: A Clinical Overview

TABLE 2 the comorbidities associated The gold standard for gout di-
Comparison of Criteria for Diagnosis with gout. In addition to the agnosis is detection of MSU
of Gout21,34,38,39 conditions mentioned previous- crystals in a sample of synovial
ly, patients with a history of fluid aspirated from the affected
ACR/ARA preliminary criteria34 polycystic kidney disease, dehy- joint or from a tophus and exam-
MSU monohydrate crystals in synovial fluid dration, lactic acidosis, hyper- ined by polarized light micros-
parathyroidism, toxemia of copy.24 This is of significant im-
or
pregnancy, hypothyroidism, or portance to the clinician who is
at least six of the following: sarcoidosis may have elevated faced with a questionable diag-
• More than one attack of acute arthritis urate levels due to underexcre- nosis.16 However, crystal visual-
• Maximum inflammation within 24 hours tion—and thus may be vulnera- ization is not ordinarily available
• Monoarthritic attack ble to gout.30 History of gout in to the primary care clini-
a first-degree relative is associ- cian,2,17,40 and it is not always
• Redness apparent over the joints
ated with an increased risk for necessary if a careful history and
• Pain or swelling in the first MTP joint gout.36 physical exam are conducted in a
• Unilateral first MTP joint attack The social history should ad- patient with hyperuricemia or
• Unilateral tarsal joint attack dress alcohol use or abuse. The other risk factors for gout. A
• Suspected or confirmed tophus clinician should also inquire presumptive diagnosis may be
about how gout is impacting the acceptable in a patient with the
• Hyperuricemia
daily life of the patient. Diet and classic presentation of acute
• Radiographic evidence of asymmetric swelling in a joint exercise habits should be as- gout: rapid onset of severe pain
• Radiographic evidence of subcortical cysts with no erosions sessed37 (see “Patient Educa- in a swollen, erythematous joint
• Negative organism findings in synovial fluid culture tion,” below). and symptoms peaking within
24 hours. The presence of tophi
• Attack starting at night
PHYSICAL EXAMINATION is pathognomonic for chronic
New York criteria 38 The physical exam begins with tophaceous gout.41
evaluation of the skin and ex- In cases of questionable or un-
MSU crystals in synovial fluid or tissue or tophus
tremities for the classic features usual manifestation of gout,
or of gout. Affected joints will be however, various imaging tech-
at least two of the following: exquisitely tender, and patients niques and crystal visualization
• History or observation of at least two attacks of painful may be febrile. Most cases are may be indicated.32
limb swelling, remitting within one week monoarticular, but polyarticular In order to compare the effec-
• History or observation of podagra involvement is likely in patients tiveness of the latter technique
• Tophi with advanced disease (and can, with conventional diagnostic
particularly in women, be mis- criteria for gout, Malik et al39
•H
 istory or observation of a good response to colchicine
(ie, major reduction in objective signs of inflammation within taken for rheumatoid arthri- conducted a pilot study involv-
24 hours of therapy onset) tis).2,16 In patients with chronic ing 82 patients who had under-
tophaceous gout, there may be gone synovial fluid analysis with
Rome criteria21 whitish-yellow skin deposits, polarized light microscopy. Pa-
At least two of the following criteria: subcutaneous nodules, and areas tients were surveyed about the
• History of attacks of painful, swollen joints, with abrupt onset of taut skin. The lower-extremi- clinical features of their disease,
and initial remission within one to two weeks ty joints and tendons, as well as as listed in the three standard
• Serum uric acid level > 7.0 mg/dL in men or > 6.0 in women
the wrists, fingers, and elbows, sets of criteria for diagnosis of
are commonly affected16 (see gout. Compared with the “gold
• Tophi Figure 2, page 33). standard” of urate crystal detec-
• MSU crystals in synovial fluid or tissues tion (which is one of the Rome
Abbreviations: ACR/ARA, American College of Rheumatology/American Rheumatism Association;
DIAGNOSIS criteria38), the study authors
MSU, monosodium urate; MTP, metatarsophalangeal. Diagnostic criteria that are cur- found the ACR/ARA prelimi-
Sources: Kellgren et al. Epidemiology of Chronic Rheumatism. 196321; Wallace et al. Arthritis rently available (and have long nary criteria,34 the New York
Rheum. 197734; Bennett and Wood. Third International Symposium. 196838; Malik et al. J Clin
Rheumatol. 2009.39
been in use) include the Ameri- criteria,21 and the Rome crite-
can College of Rheumatology/ ria38 generally unsatisfactory.
low-dose aspirin (but not stan- tionally, ethambutol, pyrazin- American Rheumatism Associa- In the study, among patients
dard-dose aspirin, which is uri- amide, levodopa, nicotinic acid, tion (ACR/ARA) preliminary with confirmed presence of
cosuric2), diuretics, cyclospo- didanosine, niacin, and warfarin criteria,34 the New York crite- MSU crystals:
rine, cytotoxic agents, and may raise uric acid levels.15,30,33 ria,21 and the Rome criteria.38 • 87% reported more than
vitamin B12, which may contrib- Medical history should in- The specifics of each are listed one attack of acute arthritis
ute to hyperuricemia.24 Addi- clude a thorough assessment of in Table 2.21,34,38,39 (ACR/ARA34)

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July 2011 • Vol 21, No 7
32
mimic rheumatoid arthritis in ap- progression, but further studies
FIGURE 2 pearance and joint distribution, are needed to more clearly de-
and patients affected by either fine the role of these techniques
condition may develop a posi- in management of gout.45 Plain
tive rheumatoid factor. Exami- radiographic evidence of asym-
nation of synovial fluid for MSU metric swelling in a joint (one of
crystals and radiographic imag- the ACR/ARA preliminary cri-
ing will be of value in making a teria34) was shown to have a 60%
distinction. positive predictive value for a di-
Osteoarthritis is usually evi- agnosis of gout.39 Late in the dis-
denced by joint space narrowing ease process, an affected joint
on x-ray.42 may be affected by characteristic
Bacterial cellulitis will present “punched out” intra-articular le-
similarly to gout, but the ery- sions, with a normal amount of
thema of bacterial cellulitis will joint space.45
more likely extend beyond the Ultrasound is a safe and inex-
involved joint.16 pensive test that can reveal soft
Tophi in the finger joints of a patient with gout. Sarcoid arthropathy often pre­ tissue edema and increased vas-
sents as a polyarthritis, as in ad- cularity during an acute gout at-
• 86% reported monoarthritis highest specificity and highest vanced gouty arthritis. Howev- tack. Chronic changes include
attack (ACR/ARA34) positive predictive value, per- er, in sarcoid arthropathy, serum the double contour sign and to-
• 89% had hyperuricemia haps making them most helpful calcium and angiotensin-con- phus-like lesions surrounded by
(ACR/ARA34 and Rome,38 for clinicians who lack access to verting enzyme will likely be el- a thin, anechoic rim.45
with the latter giving effec- synovial fluid analysis. evated.43 Synovial or tendon CT will also show tophi and
tive, specific parameters) sheath biopsy will show non-ca- bony erosion. While CT is more
• 100% had negative results DIFFERENTIAL DIAGNOSIS seating granulomas, which are specific than other techniques, it
on joint fluid culture (ACR/ Conditions to be considered and the hallmark for sarcoid disease. is also more expensive and ex-
ARA34) ruled out before a diagnosis of Additionally, joint fluid analysis poses the patient to increased ra-
• 90% reported an attack gout can be made are: will demonstrate a predomi- diation. MRI can help monitor
starting at night (ACR/ • Pseudogout nance of mononuclear or poly- the complications of gout, espe-
ARA34). • Septic arthritis morphonuclear cells.43 cially entrapment neuropathies.45
The positive predictive values • Psoriatic arthritis
for these signs and symptoms • Rheumatoid arthritis Diagnostic Tests TREATMENT/MANAGEMENT
are 38%, 39%, 74%, 50%, and • Erosive osteoarthritis Diagnostic tests to consider are According to current evidence,
45%, respectively, according to • Bacterial cellulitis analysis and culture of the syno- treatment is not indicated for
Malik et al.39 The presence of • Sarcoid arthropathy.16,28,42,43 vial fluid, complete blood count asymp­tomatic hyperuricemia.16
tophi (cited by all three sets of Unlike gout (in which com- (CBC), blood urea nitrogen
criteria but “proven or suspect- pensated polarized light micros- (BUN), creatinine, radiography, Acute Gout Management
ed” in the ACR/ARA 34) had the copy reveals needle-shaped urate ultrasonography, serum uric Pharmacologic treatments avail-
highest positive predictive value crystals with strong negative bi- acid, and blood culture if septic able for an acute gout attack in-
for gout (91%) and a likelihood refringence), pseudogout is char- arthritis is suspected.28 While clude NSAIDs, colchicine, and
ratio of 15.56, which was at least acterized by calcium pyrophos- serum urate levels may be nor- local or systemic corticoste-
three times higher than any of phate dihydrate crystals; these mal during an acute gout attack, roids.24,46 At the onset of an at-
the other listed criteria. A veri- are rhomboid-shaped, with weak measurement may still be help- tack, patients should start high-
fied response to colchicine, one positive birefringence.42 Addi- ful for comparison, since eleva- dose NSAID therapy, and
of the New York criteria,21 had tionally, radiographic imaging tion is a likely finding two weeks continue for two to three days
the second highest positive pre- will reveal soft tissue swelling after an attack—if the patient after symptoms are resolved.6
dictive value at 86%.39 and chondrocalcinosis of the was, in fact, experiencing an Oral indomethacin (50 mg tid)
In summary, the ACR/ARA,34 joint in pseudo­gout.44 acute gout attack.42 or oral ibuprofen (800 mg tid)
the New York,21 and the Rome The patient with septic arthri- Since renal dialysis increases are both reasonable options.6 It
criteria38 had specificity of 79%, tis, most likely affecting the the risk for gout, pseudogout, may be prudent to consider a
83%, and 89%, respectively; knee, will have a white blood and septic arthritis, synovial flu- proton pump inhibitor (eg,
sensitivity of 70%, 70%, and cell (WBC) count exceeding id analysis is essential in patients omeprazole) to protect the gas-
67%, respectively; and positive 50,000/mm3 and a positive cul- undergoing renal dialysis.42 tric mucosa in patients who are
predictive values for gout of ture of the synovial fluid, with Various imaging techniques susceptible to gastrointestinal
66%, 70%, and 77%, respective- absence of crystals.28 may aid in confirming a diagno- problems.27
ly. The Rome criteria38 had the Chronic tophaceous gout can sis of gout and monitoring its In addition to high-dose

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CE/CME Gout: A Clinical Overview

NSAID therapy, adding colchi- tients with chronic tophi, pa- tients did not achieve the target- of an acutely tender, inflamed
cine (1.2 mg by mouth at onset tients with radiographically ed response (ie, serum urate < 6.0 joint, but since gout is a systemic
of symptoms, followed by 0.6 demonstrated joint damage,47 or mg/dL), and 77% of patients ex- disorder, the clinician must also
mg one hour later) has proven to patients with a documented state perienced gout flares.52 Infusion consider the possibility of gout
be effective in relieving the of uric acid overproduction.29 reactions occurred in 26% to in almost any organ system.
symptoms of gout, but its serious Allopurinol dosage should be 31% of patients, and Reinders Gout is a common disease, and
gastrointestinal adverse effects, adjusted based on creatinine and Jansen52 recommended the its diagnosis can alert the astute
particularly diarrhea, must be clearance; dosing as high as 800 clinical evaluation of glucocorti- clinician to investigate for cer-
considered.6,47 mg/d has been recommended in coids and other anti-inflammato- tain metabolic disorders requir-
In patients with monoarticu- patients with normal renal func- ry agents to prevent the forma- ing intervention. Hyperlipid-
lar gout who cannot tolerate tion.2 Again, allopurinol should tion of antibodies involved in emia, metabolic syndrome,
NSAIDs, intra-articular aspira- never be started or discontinued these reactions. hypertension, chronic kidney
tion and corticosteroid injec- during an acute attack,27 because The second agent, rasburi- disease, obesity, cardiovascular
tions may provide relief. abrupt fluctuations in uric acid case, has been approved for disease, and diabetes are all con-
Long-acting triamcinolone, ad- levels may heighten the inflam- treatment and prevention of ditions associated with gout.
ministered by intra-articular in- mation. The target serum urate acute hyperuricemia in adult Recognizing the opportunity
jection, has been found to relieve level is 6.0 mg/dL.29 cancer patients. Rasburicase is to offer preventive care mea-
pain and inflammation in pa- Febuxostat, which received now being investigated for use in sures and recommend lifestyle
tients with gout. Septic arthritis FDA approval in 2009, was the patients with nonresponsive to- modifications to the patient
must be ruled out by way of joint first oral urate-lowering treat- phaceous gout.53-55 It can be ad- with gout allows the clinician to
aspiration and culture before in- ment to be approved since the ministered in the form of play an important role in the pa-
jection of corticosteroids.47 1960s. Like allopurinol, this monthly infusions.54 tient’s care. CR
Oral or IM-administered nonpurine xanthine oxidase in-
corticosteroids may be consid- hibitor blocks uric acid synthe- Patient Education
ered for patients with polyartic- sis.48,49 In a trial reported by Educating the patient about Our CE/CME
ular involvement. Prednisone Becker et al,50 67% of patients modifiable risk factors, such as posttest can be
(60 mg/d, tapered over 10 days) who took febuxostat 80 mg/d diet, alcohol consumption, and taken or viewed at
is an appropriate option for out- reached the target serum urate adherence to the medication
patients or inpatients; methyl- level (ie, < 6.0 mg/dL), compared regimen, should be a priority. www.Clinician
prednisone (80 to 120 mg IM) with 45% of those who took 40 Patients should be encouraged Reviews.com.
may be suitable for inpatients.6 mg/d of febuxostat and 42% of to target and maintain an ideal
Again, septic arthritis must be those taking 300 mg/d of allopu- body weight, through diet and
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