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Gout

Now the festive season is here, Dr Louise Warburton, a GPSI in musculoskeletal medicine, gives essential tips on spotting the telltale signs of gout

Now the festive season is here, Dr Louise Warburton, a GPSI in musculoskeletal medicine, gives essential tips on spotting the telltale signs of gout

1 Associated conditions and causes of gout

Gout is a common cause of arthritis in men over 40 and post-menopausal women. In an RCGP national morbidity survey in 1981/2, 2.7/1,000 patients visited their GP with an episode of gout.

The incidence of gout is rising due to the explosion of obesity in the population, so be prepared to see more of it, especially at Christmas.

2 The classical symptoms of gout – and the less classical symptoms

Classically gout presents as an attack in the early hours of the morning, causing pain and swelling in the first metatarsal joint (70 per cent of attacks occur in this joint). But it is worth remembering that gout can affect the ankle, knee and joints of the foot as well.

So, in the case of an elderly patient with a red, hot swollen foot, the differential diagnoses can be infection and gout. I have also seen gout in the wrist joint, especially in elderly women.

3 How acute gout affects the patient

An acute attack of gout will cause a fever, anorexia and malaise. Blood tests will reveal a raised ESR and CRP, sometimes a thrombocytosis and raised white cell count. In elderly patients it can be difficult to differentiate between cellulitis and gout, even on blood tests.

4 Remember one normal uric acid level test does not exclude gout

Diagnosis can be problematic if uric acid levels are measured as well. We all know that gout is caused by deposition of urate crystals in joints. Usually this happens because of hyperuricaemia, but can happen in individuals with a normal urate level.

In fact, one study found the prevalence of patients with acute gout who had normal uric acid levels at diagnosis was 12 per cent, but 81 per cent of these patients subsequently developed raised uric acid levels, at a median of one month after diagnosis.

So we cannot rely on a single uric acid level to help us with diagnosis, but a level taken at the time of attack and another a month later can be more helpful.

5 Avoid aspirating the joint unless you are an expert

Classically the textbooks tell us to aspirate joint fluid from the inflamed joint and look for uric acid crystals which are negatively birefringent under polarised light microscopy.

But how many of us have actually managed to do that? The joint fluid has to be still fresh and taken straight to the laboratory if the crystals are to be seen.

In my own experience, I have only once managed to aspirate fluid (from an ankle joint) in general practice and get a result back that showed crystals of uric acid. It was very satisfying, though!

My advice would be to avoid aspirating unless you are an expert and can access the lab quickly.

6 Other pointers to help in diagnosis

Other clues to a possible diagnosis of gout are co-morbid factors which can co-exist with hyperuricaemia.

Hyperuricaemia occurs in the metabolic syndrome and in those with renal failure; therefore the risk factors for gout include: ageing, male sex, hyperuricaemia, family history, hypertension, central obesity, alcohol consumption, renal insufficiency, trauma, metabolic syndrome and treatment with diuretics.

To aid diagnosis, look for these co-existing morbidities. With GMS2 and the QOF, most of our patients will have had their blood pressure measured and a large proportion of those with hypertension will have had lipids and glucose checked as well.

Conversely, in a patient with a new diagnosis of gout, look for these other co-morbidities. If they haven't already been checked, arrange for fasting glucose, lipids and blood pressure, weight and waist measurement.

Gout can be a marker for cardiovascular disease and diabetes.

7 Treatment options include NSAIDs and corticosteroids

The mainstay of drug treatment is NSAIDs – initially at the highest licensed dose and tapering off as the attack settles. All textbooks mention colchicine. In my patients I find it works but has a high level of unpleasant side-effects (diarrhoea and vomiting).

Corticosteroids work very well and are more pleasant to take. Injections of corticosteroid into an affected joint or bursa can work quickly and very effectively.

I use 40mg to 80mg of methylprednisolone in an ankle or knee, or 25mg hydrocortisone in a smaller joint such as the MTP.

Oral steroids at a dose of 20mg of prednisolone daily, for four to five days, are also effective.

8 Conservative treatment options include changing diet and weight loss

Dietary restrictions that result in loss of weight will lead to a reduction in gout. Low purine diets (reduction in meats, patés, fish roe and herrings and some oily fish) are effective to some extent.

I give my patients a copy of the Arthritis Research Campaign's patient booklet on gout, available online at www.arc.org.uk or by post.

This booklet contains useful dietary advice and an explanation of the condition. Apparently cherries can help to relieve acute gouty attacks because they contain anthocyanins, which have a similar effect to Cox-2 inhibitors.

9 Long-term treatment means cutting uric acid levels

Treatment of gout in the long-term involves reducing uric acid levels and the drug of choice is allopurinol. I usually start this in patients with more than three attacks of gout per year or very high urate levels.

Remember to always use an NSAID when allopurinol is started as it can precipitate an acute attack of gout. I usually ask patients to take an NSAID for about two weeks when the allopurinol is started.

I use doses of 50mg to 300mg of allopurinol in most patients to reduce urate levels to normal, increasing to 600mg in exceptional cases. I always start at a low dose of 50mg in severe renal impairment and titrate up the dose of allopurinol until normal urate levels are achieved.

10 Gout may be chronic and mimic inflammatory arthritis

Don't forget that gout can turn into a chronic condition which mimics inflammatory arthritis. The patient will experience chronic joint pain in many areas of the body, with no pain-free intervals and acute synovitis. Look for gouty tophi to diagnose this and differentiate from late-onset rheumatoid.

Louise Warburton is a GP in Ironbridge, Shropshire, a GPSI in musculoskeletal medicine in Telford and has also worked as a rheumatology clinical assistant

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