Ver el código de «Gout and pseudogout»

==Pathophysiology==
*Primarily an illness of middle-aged males and elderly adults
**Gout in females usually occurs only after menopause
*Gout is most common form of inflammatory joint disease in men >40yr
*Presence of crystals does not exclude septic arthritis

===Precipitants===
*Trauma
*Surgery
*Medication ([[allopurinol]], thiazide/loop [[diuretics]], [[ASA]])
*[[Alcohol]] consumption
*Meat/Seafood consumption 
*Dehydration
*Lower body temperature

==Clinical Features==
[[File:Gout2018.jpg|thumb|Acute gout affecting the first MP joint (podagra)]]
[[File:PMC3117776 1757-1146-4-13-2.png|thumb|Tophaceous gout affecting the right great toe and finger interphalangeal joints. Note the asymmetrical swelling and yellow-white discoloration]]
[[File:PMC3117776 1757-1146-4-13-1.png|thumb|Distribution of joints typically affected by gout]]
*Joint pain may develop over period of hours
*Primarily involves first MTP, knee, ankle

==Differential Diagnosis==
{{Differential Diagnosis Monoarthritis}}

==Evaluation==
*Synovial fluid aspiration
**Gout = Negatively birefringent, needle-shaped monosodium urate crystals
**Pseudogout = Positively birefringent, rhomboid-shaped, calcium pyrophosphate crystals
*Serum uric acid levels are not helpful (30% of patients with gout attack have normal levels)
**Uric acid during attacks can be low due to the precipitation of gout crystals
**High uric acid is >6.8 
*ESR may be elevated
*'''No bacteria on [[Gram Stain]]'''
*Pseudogout: X-ray of joint space may show radiolucent calcium pyrophosphate crystals
{{Arthrocentesis diagnostic chart}}

==Management==
''Patients usually only require [[opioid]] and [[NSAID]] treatment in the ED with continued [[NSAID]] treatment as an oupatient. However any combination of the following treatments are acceptable<ref>Khanna D. et al. 2012 American College of Rheumatology guidelines for management of gout. Part 2: Therapy and antiinflammatory prophylaxis of acute gouty arthritis. Arthritis Care Res. Oct 2012;64(10):1447-61</ref>''

===All patients===
*Hold [[diuretics]]
*Consider starting [[losartan]] to replace diuretic (has modest uricosuric effect)
*Alcohol and dietary counseling
*Continue uric acid-lowering agents if already on prophylactic regimen (do not start)
*Follow up with Primary Doctor or Rheumatology if having continued flares

===[[NSAIDs]]===
*Do not give to patients with renal insufficiency (use [[opioids]] instead)
*Substantial pain relief should occur within 2hr
*Options:
**[[Indomethacin]] 50mg po TID x3-5d, OR
**[[Naproxen]] 500mg po BID x3-7d, OR
**[[Ibuprofen]] 800mg PO TID x 3-5d

===Other options===
====[[Colchicine]]====
*Can be used as alternative agent to NSAIDs in patient with normal renal/hepatic function
*1.2mg PO (load), followed by 0.6mg one hour later x 1 <ref>Terkeltaub RA et al. High versus low dosing of oral colchicine for early acute gout flare: Twenty-four-hour outcome of the first multicenter, randomized, double-blind, placebo-controlled, parallel-group, dose-comparison colchicine study. Arthritis Rheum. 2010;62(4):1060.</ref>
*May use to maximum of x3 doses, with more aggressive regimens totaling max dose up to 6mg<ref>GlobalRPH. http://www.globalrph.com/gout.htm*colchicine</ref>
*Wait at least x3 days before starting another round of colchicine therapy
*Renal impairment not absolute contraindication for acute flare but may consider dose reduction.
*Dose adjustments for CYP3A4 inhibitors (HARRT, Calcium Channel Blockers, fluconazole, erythromycin, clarithromycin)  
*Colchicine should not be administered intravenously

Initial: 0.6-1.2mg, followed by 0.6 every 1-2 hours; some clinicians recommend a maximum of 3 doses; more aggressive approaches have recommended a maximum dose of up to 6mg. Wait at least 3 days before initiating another course of therapy

====[[Steroids]]====
*[[Prednisone]] 30 to 50mg initially, and gradually tapered over 10 days, results in clinical resolution without rebound pain or complications<ref>Groff GD et al. Systemic steroid therapy for acute gout: a clinical trial and review of the literature. Semin Arthritis Rheum. 1990;19(6):329</ref><ref>Janssens H. et al. Use of oral prednisolone or naproxen for the treatment of gout arthritis: a double-blind, randomised equivalence trial. Lancet. 2008;371(9627):1854.</ref>

====Glucocorticoid injection====
*Even if gout has been diagnosed in the past, be cautious with glucocorticoid joint injection if the current clinical picture is uncertain since a [[Septic Arthritis|septic joint]] can coexist with gout and a steroid injection would then worsen the patient's clinical status.


====Other Therapies====
*[[Anakinra]]
**Disease-modifying agent; Interleukin-1 Receptor Antagonist
**Reserve use for patients who have frequent flares and in whom first-line therapies are ineffective, contraindicated, or not tolerated
**100 mg subq once daily until symptom improvement; usual duration: 3 to 5 days
**NOT routinely used in the ED.


==Medication Dosing==
{{MedicationDose
| drug = Indomethacin
| dose = 50mg TID x 3-5 days
| route = PO
| context = First-line NSAID option for acute gout
| indication = Gout and pseudogout
| population = Adult
| notes = Avoid in renal insufficiency
}}
{{MedicationDose
| drug = Naproxen
| dose = 500mg BID x 3-7 days
| route = PO
| context = First-line NSAID option for acute gout
| indication = Gout and pseudogout
| population = Adult
| notes = Avoid in renal insufficiency
}}
{{MedicationDose
| drug = Ibuprofen
| dose = 800mg TID x 3-5 days
| route = PO
| context = First-line NSAID option for acute gout
| indication = Gout and pseudogout
| population = Adult
| notes = Avoid in renal insufficiency
}}
{{MedicationDose
| drug = Colchicine
| dose = 1.2mg load, then 0.6mg 1 hour later
| route = PO
| context = Alternative to NSAIDs if normal renal/hepatic function
| indication = Gout and pseudogout
| population = Adult
| notes = Max 3 doses; wait 3 days before another course
}}
{{MedicationDose
| drug = Prednisone
| dose = 30-50mg initially, taper over 10 days
| route = PO
| context = Alternative when NSAIDs and colchicine contraindicated
| indication = Gout and pseudogout
| population = Adult
}}

==Disposition==
*Generally outpatient treatment

==See Also==
*[[Joint Pain]]
*[[Monoarticular Arthritis]]
*[[Knee Diagnoses]]

==References==
<references/>
[[Category:Orthopedics]]
[[Category:Rheumatology]]