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Gout
The Clinical Advisor, 09/18/09

Brier M – Disorder with a heterogeneous group of clinical presentations resulting from tissue deposition of monosodium urate crystals.
Testing:

• Synovial fluid analysis/culture needed to exclude septic arthritis if patient is febrile and has leukocytosis
• Serum uric acid ( >6.8 mg/dL [404 micromol/L] is sufficient for crystal precipitation; level often normal during acute attack).
• X–ray may help confirm.
• 24–hour urine uric acid level as adjunctive test for 1) Identifying/excluding overproducers of urate 2) Patients being considered for uricosuric therapy
• Blood culture to rule out infection

Treatment of acute attack:

• Oral nonsteroidal anti–inflammatory drugs (NSAIDs) at maximum dose for one to two weeks (drugs of choice for symptomatic relief)
• Colchicine effective but slower to work than NSAIDs
• Corticosteroids, especially in patients with contraindications to NSAIDs
• Rest, ice packs, joint elevation ("Bed cage" may keep bedclothes off inflamed joint.)
• Avoid alcohol; ensure adequate fluid intake (>2 L water daily).
• Allopurinol should not be started or discontinued during acute attack (avoid sudden changes in serum urate levels).
• Consider discontinuation of diuretics.

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