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Gout is a common type of inflammatory arthritis that causes severe pain, discomfort and
damage to joints
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Uric acid is formed from the breakdown of purine nucleotides from internal or ingested
sources
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The shedding of crystals can be triggered by direct trauma, dehydration, rapid weight loss,
illness and surgery
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Risk factors
The kidney excretes about two-thirds of the uric acid that is produced by the body
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Factors that increase the uric acid level in the body: lifestyle factors (alcohol), medical
conditions (untreated hypertension, diabetes, hyperlipidaemia), some medications (thiazide
diuretics and low-dose aspirin), family history of gout, age and sex
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Tophi aren’t usually painful, but get swollen and become tender during gout attacks
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Medications can help reduce the risk of kidney stones
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Medicines used in the management of an acute flare-up of gout; NSAIDs, colchicine and
corticosteroid
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a) NSAIDs
NSAIDs should be used as first-line treatment and should be started immediately at high
doses, which are then tapered 24 hours after complete resolution of the attack
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At present there is no convincing evidence that an NSAID is more effective than others
for the management of acute gout
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It arrests the assembly of microtubules in neutrophils and inhibits many cellular
functions
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Dose: 500mcg two-four times a day until symptoms are relieved
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Excessive doses may cause profuse diarrhoea, GI haemorrhage, rash, renal and hepatic
damage
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The dose
of colchicine should be reduced in mild-to-moderate renal impairment (500mcg twice
daily)
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Preferred in patients with heart failure, because unlike NSAIDs, does not induce fluid
retention
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c) Corticosteroids
Used when NSAIDs or colchicine are contraindicated or ineffective
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Intra-articular corticosteroid injections are highly effective in treating acute gout for
patients with only one affected joint
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Corticosteroids may cause fewer adverse events than other acute treatments when used
short term, particularly in the elderly
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However, if pts have one or more acute attacks within 12 months of an initial attack, uric
acid lowering therapy is needed to prevent further flare-ups
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The aim of prophylactic treatment of gout; to maintain serum uric acid levels below the
saturation point of monosodium urate; if serum urate is maintained below this level, crystal
deposits dissolve
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Should never be started during an acute attack
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An NSAID or colchicine should be used as a prophylactic treatment and continued for at
least one month after the hyperuricaemia has been corrected, at the start of the treatment,
one may have an acute attack due to the shift in the plasma uric acid concentration
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It inhibits synthesis of uric acid by competitively inhibiting xanthine oxidase, which
is the enzyme catalysing the hypoxanthine-xanthine-uric acid reaction
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Serum urate should be reduced within a couple of days of starting allopurinol, with a
peak effect at seven to ten days
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3%-5% of pts treated with allopurinol may have adverse reaction- hypersensitivity within
the first two months of treatment
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b) Febuxostat (Adenuric) is recommended by NICE for pts with chronic hyperuricaemia
who are intolerant to allopurinol or whom allopurinol is contraindicated
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Licensed to treat chronic hyperuricaemia for conditions where urate deposition has
already occurred, including a history or presence of a tophus, gouty arthritis, or both
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It has a faster onset of action than allopurinol and serum uric acid levels can be tested
two weeks after starting the treatment
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The dose of febuxostat does not need to be adjusted for pts with mild to moderate renal
therapy, but there are no current recommendations for pts with severe renal
impairement
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Adverse effects; respiratory infection, nausea, diarrhoea, headache, liver function
abnormalities
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Febuxostat is not recommended for pts taking mercaptopurine or azathioprine
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Examples; sulphinpyrazone and probenecid
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Uricosuric medicines are only prescribed to pts with adequate renal function and fluid
intake (2-3 litres dly)
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Sulphinpyrazone can be given instead of allopurinol or in conjunction with it
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Lifestyle modifications of gout; weight loss, moderate physical exercise, avoid shellfish,
reduce alcohol intake, dairy products lower serum uric acid and eating yoghurt on alternate
days helps to reduce levels too

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