Acute Gout Treatment Protocol
Erika Payne
History & Physical Exam
Risk factors: male gender (men > women 20:1), older age (40-60 years), high
purine diet, alcohol intake, family history, obesity, medication use (ASA,
nicotinic acid, diuretics, cyclosporine, chemotherapy)
- Acute joint pain, swelling, stiffness accompanied by erythema & warmth
- Metatarsophalangeal joint of first toe is most common, but may involve other
joints including tarsal area, ankle, wrist, or finger joints
- Usually monoarticular (75% of time) or oligoarticular (<4 joints)
- Symptoms begin abruptly, often at night & wakes the patient up from sleep
- Lack of trauma to joint
- The physical examination may reveal limited range of motion of the joint due
to pain and stiffness accompanied by exquisite pain with palpation of the joint
- Fatigue, fever, & chills may be present due to inflammatory process
- Subsequent attacks may persist longer and involve several joints
- Chronic gout can lead to tophi, or firm swellings, of the hands, elbows, or ears
Diagnostics
Diagnosis of gout is often made by a history and physical exam. However, a
definitive diagnosis is achieved through an arthrocentesis with synovial fluid
analysis to determine the presence of urate crystals.
- A uric acid level is not beneficial for diagnosis as it may be normal or low
during an acute gout attack. Obtain 2 weeks after symptoms resolve. Elevated
Uric Acid: >7mg/dL in men, >6mg/dL in women.
- Consider ultrasonography. A double-contour sign is highly specific for
diagnosis of gout.
- An x-ray may be normal or show soft tissue swelling; after multiple episodes
tophi and degenerative changes may be present.
- A WBC and ESR are usually elevated during an acute attack.
**Red Flags: Increasing pain, worsening inflammatory symptoms, &
fever/chills - must consider bacterial infection.
Prevention Education: Avoid contributing substances, good hydration, regular exercise, dietary modifications, and eliminate tobacco use.
If frequent recurrent episodes, prophylactic therapy may be indicated. Consider rheumatology evaluation.
Abbreviated References: (Badlissi, 2019), (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2017), (Hollier, 2018)
Differentials
- Septic Arthritis: Occurs in both sexes at any age; risk factors for infection
(immunocompromised, IV drug user). Symptoms progressively get worse and can
lead to negative outcomes. **Must not be missed.
- Pseudogout (calcium pyrophosphate deposition disease): Presents identical to gout,
but more likely to affect knees and wrists.
- Rheumatoid Arthritis: RA is usually symmetric with gradual onset. Tophi may be
misdiagnosed as rheumatoid nodules.
- Trauma: History of trauma, usually less erythema or warmth than gout.
- Other differentials: Cellulitis, psoriatic arthritis, muscular or ligament strain.
*Differentials can be ruled out by synovial fluid analysis from arthrocentesis, if
indicated.
Management Strategies
Non-Pharmacologic
- Avoid activity to the joint, ice the joint (20 minutes, 4-6 times a day, with skin
barrier), avoid contributing substances (alcohol, purine), increase fluid intake to 3L
per day, weight reduction (if indicated)
- Acute attacks usually subside without treatment in 1-2 weeks
Pharmacologic
- First line therapy: NSAIDS. Indomethacin 50mg PO TID until pain is resolved.
*Best if initiated within 24 hours of onset
- Alternative: Colchicine. Take 1.2mg tablet PO followed by 0.6mg tablet 1 hour
later. Take 0.6mg tablet BID during initial flare. Do not exceed 3mg/day.
- Corticosteroids: Intra-articular injection for monoarticular acute gout or PO for
polyarticular acute gout (Prednisone 30-40mg daily during flare, then taper over 7-
10 days)
- If mild-moderate, monotherapy is appropriate. If severe polyarticular, combination
therapy is indicated.
- Evaluate response to therapy for acute attack within a few days.