Back to the Basics: Gout

The American Academy of Family Physicians Scientific Assembly (September 24-28, 2013, San Diego) features a comprehensive itinerary of sessions addressing several topics—including cardiovascular, endocrine, nephrologic and patient care. On Thursday, September 26, Benroe Blount, MD, MPH, FAAFP took the podium for a musculoskeletal lecture on gout and hyperuricemia. For those who couldn’t attend, here is a synopsis of the session.

Gout is characterized by recurrent attacks of acute inflammatory arthritis and appears as red, swollen, tender joints. Gout and pseudogout can present as monoarticular or polyarticular and asymmetric or symmetric. Although any joint pain is a possibility, approximately 50% of all cases affect the big toe or the first metatarsal joint—this condition is called podagra.

There are four stages of gout: asymptomatic hyperuricemia, acute flares of crystallization, intervals between flares, and advanced gout.

     Asymptomatic hyperuricemia. Most people with hyperuricemia never develop clinical gout. For those who do, hyperuricemia can last 20 years before the first attack. Onset before 35 often is related to an inherited defect.    

     Acute flares of crystallization. Acute gouty flares occur after abrupt onset of severe joint inflammation, often nocturnal. Symptoms include warmth, swelling, erythema and pain, as well as a possible fever. If untreated, gout can last for 3-10 days. However, Dr Blount says his personal experience is that untreated gout can last much longer—in many cases, as long as a year.      Crystallization can also occur in other joints, bursa, and tendons.

     Intervals between flares. Although asymptomatic, if left untreated, gout may advance. Intervals will shorten, crystals will enter asymptomatic joints, and the body urate stores will increase. “During flare intervals, the patient is getting silent tissue deposition and hidden damage,” said Dr Blount.

    Advanced gout. Characterized by chronic arthritis and joint damage visible on an x-ray, this condition involves polyarticular acute flares with upper extremities. The average time from initial attack to chronic gout is 11.6 years.

Tophi (solid urate deposits in tissues) develop; when more than one tophi is visible, the patient is in stage 4. “You can get rid of tophi, but you cannot get rid of joint damage unless you replace the joints,” said Dr Blount. Risk factors of tophi include a long duration of hyperuricemia, high serum urate, and long periods of active, untreated gout.       

Note: Calcified, overhanging edge on an x-ray is indicative of gout.        

Diagnosis

First, collect the patient’s history and complete a physical exam. The next step is a synovial fluid analysis, which is considered the gold standard. Note: Serum urate levels have no influence on gout diagnosis. However, it is useful to draw blood to measure the levels to know the baseline to target for treatment.

Risk Factors

Gout risk factors include: male or postmenopausal female, older, hypertension, DM, HLD, pharmaceuticals (diuretics, ASA, cyclosporine), transplant, alcohol intake (highest with beer, lowest with whiskey and does not increase with wine), high BMI/obesity, diet high in meat and seafood, and sugar-sweetened (not diet) drinks.

Treatment

Treatment goals start with rapidly ending acute flares, protect against future flares, and reduce the chance of crystal inflammation. Then prevent disease progression and lower urate serum levels.

Medical considerations include the use of NSAIDs. Pay attention to the interaction with warfarin and remember it is contraindicated for renal disease, peptic ulcer disease, GI bleeders, ASA-induced RAD, ASA-treated coronary artery disease, and congestive heart failure.

Also consider colchicine, which is not as affective “late” in the flare. It is the only agent on the U.S. market FDA-approved to prevent flares. Recommended dosage is 0.6 mg q per day or bid for six months. If patients are not prescribed NSAIDs or colchicine, the odds of a repeat flare are at 40% versus 3% with the treatment.

Finally, corticosteroids can be used for worse glycemic control, and may be used for patients who have contraindications to NSAIDs and colchicine. New guidelines say 10 mg/day, but Dr Blount said he believes it needs to be higher at ≤ 20 mg/day.

Future Prevention

 Finally, for protection against future flares, Dr Bount reviewed at least 6 months of colchicine at 0.6-1.2 mg/day and/or low doses of NSAIDs. Both decrease frequency and severity of flares, and prevent flares with the start of urate-lowering medication. 

Also, of note, cherry intake lowers the risk of gout flares by 35% and cherry extract intake lowers risk by 45%. Allopurinol alone reduces the risk by 53%, and combined with cherries, reduces the risk by 75%.

Dr Blount also touched on urate-lowering therapy (UTI), which is only to be started 1-2 weeks after an acute attack subsides. The goal is to lower urate to < 6.0 mg/dl.

For more information, visit http://www.aafp.org/events/assembly.html.