Gout

Question 1

What type of arthritis is gout and how do its episodes typically present?

Answer 1

Gout is an inflammatory arthritis where episodes last several days, reach maximal intensity within 12 hours, and patients are symptom-free between attacks.

Question 2

What are the cardinal clinical features of an acute gout flare?

Answer 2

Severe pain, swelling, and erythema of the affected joint.

Question 3

Which joint is most commonly affected in the first presentation of gout?

Answer 3

The 1st metatarsophalangeal (MTP) joint (podagra), accounting for ~70% of first attacks.

Question 4

Which other joints are commonly affected in gout?

Answer 4

Ankle, wrist, and knee.

Question 5

What can untreated recurrent attacks of gout lead to?

Answer 5

Chronic joint damage and persistent joint disease.

Question 6

What serum uric acid result supports a diagnosis of gout according to NICE?

Answer 6

Uric acid ≥ 360 µmol/L.

Question 7

What should be done if uric acid is < 360 µmol/L during a flare but gout is strongly suspected?

Answer 7

Repeat uric acid at least 2 weeks after the flare has settled.

Question 8

What is the characteristic finding on synovial fluid analysis in gout?

Answer 8

Needle-shaped, negatively birefringent monosodium urate crystals under polarised light.

Question 9

List the classic radiological features of gout.

Answer 9

Joint effusion, well-defined punched-out erosions with sclerotic margins, overhanging edges, preserved joint space until late disease, eccentric erosions, absence of periarticular osteopenia, soft-tissue tophi.

Question 10

What causes gout at the pathophysiological level?

Answer 10

Deposition of monosodium urate crystals due to chronic hyperuricaemia (>0.45 mmol/L).

Question 11

What conditions or drugs reduce uric acid excretion and predispose to gout?

Answer 11

Diuretics, chronic kidney disease, lead toxicity.

Question 12

Which conditions increase uric acid production and predispose to gout?

Answer 12

Myeloproliferative or lymphoproliferative disorders, cytotoxic therapy, severe psoriasis.

Question 13

What is Lesch-Nyhan syndrome and how does it relate to gout?

Answer 13

X-linked recessive HGPRT deficiency causing gout, renal failure, neurological deficits, learning difficulties, and self-mutilation.

Question 14

Does low-dose aspirin significantly raise urate levels?

Answer 14

No — aspirin 75–150 mg/day does not significantly affect urate and should be continued if needed for cardiovascular prophylaxis.

Question 15

What are the first-line treatments for an acute gout attack?

Answer 15

NSAIDs or colchicine.

Question 16

How long should the maximum NSAID dose be continued during a gout flare?

Answer 16

Until 1–2 days after symptoms have resolved.

Question 17

What is the mechanism of action of colchicine?

Answer 17

Inhibits microtubule polymerisation, reduces neutrophil motility and activity, interferes with mitosis.

Question 18

What is the main side effect of colchicine?

Answer 18

Diarrhoea.

Question 19

How should colchicine be used in renal impairment according to the BNF?

Answer 19

Reduce the dose if eGFR 10–50 mL/min; avoid if eGFR < 10 mL/min.

Question 20

What are alternatives if NSAIDs and colchicine are contraindicated?

Answer 20

Oral prednisolone (15 mg/day) or intra-articular steroid injection.

Question 21

Should allopurinol be continued during an acute gout attack?

Answer 21

Yes — allopurinol should be continued.

Question 22

What is the current BSR recommendation for offering urate-lowering therapy?

Answer 22

Offer ULT to all patients after their first gout attack.

Question 23

Give four specific indications where ULT is particularly recommended.

Answer 23

≥2 attacks in 12 months; tophi; renal disease; uric acid renal stones; prophylaxis if on cytotoxics or diuretics.

Question 24

What is the first-line long-term treatment for gout?

Answer 24

Allopurinol.

Question 25

What is the initial dose of allopurinol and how is it titrated?

Answer 25

100 mg once daily, titrated every few weeks to target uric acid < 360 µmol/L.

Question 26

When is a lower uric acid target (<300 µmol/L) recommended?

Answer 26

In patients with tophi, chronic gouty arthritis, or persistent flares despite uric acid < 360 µmol/L.

Question 27

How should allopurinol be started in renal impairment?

Answer 27

Use a lower initial dose.

Question 28

What prophylaxis is recommended when initiating allopurinol?

Answer 28

Colchicine cover (or NSAIDs if colchicine intolerant), continued for up to 6 months.

Question 29

What is the second-line agent when allopurinol is not tolerated?

Answer 29

Febuxostat (xanthine oxidase inhibitor).

Question 30

Which therapy is used in severe refractory gout?

Answer 30

Pegloticase (IV uricase) every two weeks.

Question 31

Which lifestyle factors reduce flares of gout?

Answer 31

Reduce alcohol, avoid alcohol during an attack, lose weight, avoid purine-rich foods (organ meats, seafood, oily fish, yeast products).

Question 32

Which antihypertensive has a uricosuric effect and may benefit patients with gout?

Answer 32

Losartan.

Question 33

What dietary factor may help reduce uric acid levels?

Answer 33

Increased vitamin C intake.