Gout investigations, Differential diagnosis, Diet and treatment

This is an approach to diagnosis and treatment of Gout , in which we are going to discuss the investigations, differential diagnosis and treatment of the disease .

Investigations to diagnose Gout 

- Serum uric acid > 7 mg/dl in males
                   or > 6 mg/dl in females
            (it may be normal)
Normal level is
3.5 - 7 mg/dl in males
2.5-6 mg/dl in females
• ESR +++
• TLC +++
• Aspiration of tophi : urate crystals (by polarized microscope).
• Uric acid in urine > 1100 mg / 24 hours = overexcertion.
Normal serum uric acid does not exclude the diagnosis of gout.
- Joint X-ray
In early disease -7 Normal, but narrowing of joint space with sclerosis may develop with time.
• Gouty erosions (bony tophi) occurring as para articular punched out defects with well defined borders.
• Tophi: eccentric soft tissue swellings.

Differential diagnosis of Gout 

- Rheumatic arthritis.
- Septic arthritis
- TB arthritis.
- Rheumatoid disease.
- Tendonitis.
- Osteoarthritis
Hyperuricemia is frequently associat§d with obesity, hypertension, D.M, hyperlipidemia (syndrome x) but still there is no relation between ++ uric add and hypertension, DM or atherogenesis.

Treatment of Gout

I. Asymptomatic hyperuricemia.
• There is controversy.
• 20 % of patients with asymptomatic hyperuricemia develop arthritis.
• So no treatment except with :
                                     - Family history of renal stone.
                                     - Urinary excretion> 1100 mg / day.
                                     - Serum uric acid> 11 mg/dl.
• It is treated by allopurinol (See below).
A. NSAIDs in large dose.
• Indomethacine 75mg immediately, then 50 mg 6-8 hourly
• Diclofenac 75-100 mg immediately then 50 mq 6-8 hourly
• After improvement (24-48) hours, use low dose for one week.
• In patients with renal impairment orwith history of peptic ulcer, it is better to use colchicines or steroids.

B. Colchicine 1 mg immediately then 0.5 mg/6 hour, it can be used in patients with gastritis

C. Short term corticosterolds can be used e.g predisolone 30mg/day
with tapering within 7 days, 1Mmethyl prednisolone can be used.
III. Long term management
By hypouricemic drug to keep uric acid < 7 mg % 
Prolonged hypouricaemic drug treatment is indicated for :
- Recurrent attacks of acute gout.
- Tophi
- Evidence of joint damage.
- Associated renal disease.
Allopurinol (zyloric )
 300 mg / day, lower doses (1OOmg/day) should be used in older patients or if renal function is impaired.
• It inhibits xanthine oxidase enzyme.
• Side effects - l' liver enzyme - Acute gouty arthritis.
- Diarrhea - B.M depression
- Allpurinol hypersensitivity syndrome (skin rash, eosinophilia, hepatic necrosis and renal failure).

Uricosuric drugs can achieve equivalent reduction in serum uric acid to allopurinol .These drugs should be taken with alkalinization of urine + plenty of fluid .
e.g Probencid ( 0.5-1 gm/12h) or Sulfinpyrazone ( 100mg/8h) .
IV. Gouty kidney
• Plenty fluids.
• Alkaline urine by sodium citrate.
• Allopurinol.

Recommended Diet in Gout 

(this can reduce serum urate by 15%)
• There is no need for severe dietary restrictions but excessive purine intake and alcohol should be avoided.
• Weight reduction, Severe caloric restriction must be
avoided as ++ lactic acid ++ uric acid.
Excessive meat intake ==> ++ risk of gout, but vegetable protein decreases risk of gout.
Important articles to understand Gout :
- Clinical presentations of Gout (Hyperuricemia manifestations)
Gout investigations, Differential diagnosis, Diet and treatment
Dr.Tamer Mobarak


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