A 40-year-old man presented in OPD with sudden onset of severe pain and redness of great toe

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A 40-year-old man presented in OPD with sudden onset of severe pain and redness of great toe. On asking he told last night he had a meal of fried red meat and drank a number of beer in a party with friends. His uric acid level was ordered. Results showed elevated uric acid and a diagnosis of acute gout is made. Following statement about acute gout is True?

    1. Usually affects young females
    1. Usually affects middle-aged males
    1. Allopurinol is the best treatment for acute Attack
    1. Thiazide diuretic is an effective treatment

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Answer: Usually affects middle-aged males

Description:

  • Gout is a male dominant disease with a male and female ratio of 3:1.
  • It usually has an onset at the age of 30-60 Years

Option A:

  • In females, estrogen promotes renal uric acid secretion so young females are less affected by gout
  • However, this is not true for postmenopausal women as they are more likely to develop gout due to the decline of estrogen level

Option C:

  • Allopurinol is a Xanthine oxidase inhibitor and it is the ist-line treatment in chronic gout/however it should not be given for the first 2 weeks of acute gout as it can worsen the symptoms by forming urate crystals.
  • Tip: Exact reason for this effect is not clear but it is suggested that it might be due to rapid change in serum uric acid levels that results in precipitation or remodelling of deposits of uric acid in joints. This remodelling or mobilization of deposits of uric acid is responsible for worsening of symptoms

Option D:

  • Thiazide diuretics decrease uric acid excretion, which is the most common cause of secondary hyperuricemia
  • Tip: Most common cause of secondary hyperuricemia is decreased uric acid excretion.

Study Notes

What is Gout?

Gout is a most common inflammatory arthritis is men characterized by deposition of monosodium urate MSU crystals into the joints and other tissues. This cause not only pain but sweeling of joints.

Gout may b primary or secondary.

Primary Gout:

  • Idiopathic (most common)
  • Partial deficiency of enzyme Hypoxanthine guanine phophoribosyl transferase(HGPRT)

Secondary Gout:

  • Uric acid Over production:
    • In alcoholism
    • Myeloproliferative disorders
    • Lesch-Nyhan syndrome
    • High protein diet
  • Uric acid under-excretion: (most common)
    • Dehydration
    • Decreased renal function
    • Medications (thiazide or loop diuretics, aspirin, niacin, pyrazinamide)

What are the risk Factors?

  • Ageing
  • Male dominant
  • Obesity
  • Heavy alcohol intake
  • Diet rich in red meat and fructose
  • Diet low in vitamin C or coffee
  • Saturnine gout – lead poisoning

How to treat this patient?

  • Best initial therapy is NSAIDS
  • Alternative to NSAIDs is Colchine
  • Short course of steroids are also effective in acute attacks. However, rule out infection first befot

How to prevent acute attack?

In order to prevent acute attack in pateints of chronic gout start with Urate lowering drugs and pharmacological prophylaxis.

Phrmacological prophylaxis includes:

  • Colchicine-agent of choice
  • NSAIDs- less effective
  • Low dose steroids