DIAGNOSIS



DIAGNOSISRapidly developing pain in any of… big toe, midfoot, ankle, knee, small finger jts, wrist elbow.Tender +++INVESTIGATIONSUrate checked 4-6w after attack (can be normal during!)TREATMENTNSAIDS (+PPI if over 65)If this doesn’t work add or replace with colchicine 500 mcg tds for 2-3 daysIf this doesn’t work add or replace with prednisoloine 15mg 5 days.If this doesn’t work consider IM or IA steroids.LONG TERM MANAGEMENTPrimary Gout (FH may be present)Avoid alcohol (beer)Avoid purine rich foods– red meat, liver, kidneys, seafood, fructose and sugar sweetened drinks. Encourage Mediterranean diet; complex carbs, vegetables, maintain hydration (really impt). Consider Urate lowering foods – coffee (in moderation), blueberries, strawberries, fresh cherries, other red-blue berries.Beware: associated with metabolic syndrome (Any three of 1. Obesity 2. Triglyceridaemia(>1.7), 3. low HDL (<1.03 men 1.29 women), 4. HTN or BP>130/85 , 5. DM or fasting sugar >5.6)Secondary GoutElderly, due to medication like thiazides, renal disease; affects upper and lower limbs more evenlyGouty tophi +++ (with or without gout attacks)Rx – change diuretic , optimise renal fx (control BP, manage sugars), urate lowering therapy (ULT)ULTIndications: If >2 attacks per year, or gouty tophi present, or renal damage or joint damageAllopurinol may trigger acute attack. Always cover 2-3w NSAID, colchicine or steroids when starting. Start Allopurinol 100mg, then build up (to avoid hypersensitivity – rash, renal/liver damage)Febuxostat if allopurinol not toleratedMonitor urate levels - keep on Allopurinol until it urate <360 (may take 6m!!!)Gout can recur up to a year after the urate has normalised!Do not stop allopurinol during an acute attack if patient established on treatment.Gout can take several months to settled! Gouty tophi can take 2y to settle! Bloods Not only do urate 4—6w after attack but also for metabolic syndromeHBA1C for diabetesFasting lipidsU&Es – renal impairmentFBC – myeloproliferative disordersCheck BPWeight and waist circumference ................
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