CLINICAL PRINTABLE
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A one-page Gout clinical reference is on the way.
1 · Recognition / Alarm Features
- Acute gout flare: sudden onset (often overnight) of severe joint pain, swelling, warmth, and erythema. Monoarticular in most cases. First MTP joint (podagra) is classic — also ankle, knee, wrist, and small joints of the hand. Resolves spontaneously in 7–14 days without treatment.
- Serum uric acid during an acute flare: may be normal or low — do not use to rule out gout during a flare. Uric acid shifts into the joint during acute inflammation. Check uric acid 2–4 weeks after the flare resolves for accurate baseline.
- Diagnosis: clinical diagnosis in classic presentation (podagra, hyperuricemia, rapid response to colchicine). Joint aspiration with polarized light microscopy (negatively birefringent needle-shaped monosodium urate crystals) is the gold standard — especially when diagnosis is uncertain or septic arthritis must be excluded.
- Triggers: dietary (red meat, shellfish, fructose-sweetened beverages, alcohol — especially beer), medications (diuretics, low-dose aspirin, cyclosporine, niacin), dehydration, acute illness, surgery, and rapid changes in uric acid level (starting or stopping urate-lowering therapy).
- Chronic tophaceous gout: urate crystal deposits in soft tissue (tophi), joint destruction, chronic arthropathy. Occurs with prolonged hyperuricemia. Urate-lowering therapy (ULT) is essential to dissolve tophi and prevent joint damage.
2 · Differential / Secondary Causes
Septic arthritis
Fever, systemic toxicity, joint effusion, elevated WBC. Cannot be excluded clinically — joint aspiration is required when septic arthritis is possible. Gram stain and culture of synovial fluid. Do not treat empirically for gout if septic arthritis is on the differential.
Pseudogout (calcium pyrophosphate deposition, CPPD)
Clinically similar to gout. Knee, wrist, and ankle most common. Positively birefringent rhomboid-shaped crystals on polarized microscopy. Chondrocalcinosis on X-ray. Treat acute flare the same as gout (NSAIDs, colchicine, steroids). No urate-lowering therapy.
Cellulitis
Overlying skin erythema, warmth, and swelling can mimic gout. Cellulitis typically has diffuse skin involvement without joint effusion. Gout may have overlying skin changes. Joint aspiration distinguishes the two when uncertain.
Reactive arthritis
Asymmetric oligoarthritis following GI or genitourinary infection. Associated with urethritis, conjunctivitis (classic triad). HLA-B27 association. NSAIDs for symptom control.
3 · Treatment Pathway
Acute flare — colchicine (first-line)
Colchicine 1.2 mg at onset, then 0.6 mg 1 hour later (total 1.8 mg). Most effective when started within 24–36 hours of flare onset. Dose-reduce in renal impairment (CrCl <30: avoid or use 0.3 mg once daily). Drug interactions: strong CYP3A4 inhibitors (clarithromycin, cyclosporine) increase colchicine toxicity — reduce dose significantly.
Acute flare — NSAIDs
Indomethacin 50 mg TID or naproxen 500 mg BID for 5–7 days. Effective when started early. Avoid in renal impairment, GI disease, or cardiovascular risk. Add PPI for GI protection.
Acute flare — corticosteroids
Prednisone 30–40 mg/day for 5–7 days (taper over 10–14 days for severe flares). Preferred when NSAIDs and colchicine are contraindicated (renal failure, anticoagulation). Intra-articular triamcinolone for monoarticular flare. Do NOT start urate-lowering therapy during an acute flare — it can prolong or worsen the flare.
Urate-lowering therapy (ULT) — indications
Indications: ≥2 flares per year, tophi, urate nephropathy, uric acid nephrolithiasis, or chronic kidney disease. Target serum uric acid <6 mg/dL (or <5 mg/dL with tophi). Start ULT 2–4 weeks after the acute flare resolves — not during the flare.
Urate-lowering therapy — agents
Allopurinol: first-line. Start low (100 mg/day), titrate to target uric acid. Dose-reduce in renal impairment. HLA-B*5801 testing before starting in patients of Southeast Asian or African descent (risk of severe cutaneous reactions). Febuxostat: alternative to allopurinol; avoid in cardiovascular disease (increased CV mortality). Probenecid: uricosuric; avoid in nephrolithiasis or CrCl <50.
Flare prophylaxis during ULT initiation
Starting or adjusting ULT can trigger a flare due to rapid uric acid shifts. Prescribe prophylactic colchicine 0.6 mg daily (or BID if tolerated) for 3–6 months when initiating ULT. NSAIDs or low-dose prednisone are alternatives.
4 · Expected Response
- Acute flare with colchicine or NSAIDs: significant improvement within 24–48 hours. Complete resolution in 7–10 days.
- Urate-lowering therapy: uric acid reaches target in weeks to months with dose titration. Tophi may take months to years to resolve. Flare frequency decreases as uric acid is maintained below target.
- Flares may paradoxically increase in the first 3–6 months of ULT initiation — reassure patients and continue prophylaxis.
5 · Escalation
- Suspected septic arthritis: joint aspiration, Gram stain, culture, and cell count. Do not treat empirically for gout if septic arthritis cannot be excluded clinically.
- Refractory or polyarticular gout not responding to standard therapy: rheumatology consultation. Pegloticase (IV uricase) for refractory tophaceous gout.
- Colchicine toxicity (GI symptoms, myopathy, bone marrow suppression): dose-reduce or discontinue. Check for drug interactions (CYP3A4 inhibitors).
Apply It · Change One Detail
APPLY IT
A 52-year-old man on hydrochlorothiazide presents with sudden onset severe right first MTP joint pain, swelling, and erythema that woke him from sleep. Uric acid is 5.8 mg/dL. This is a classic gout flare — normal uric acid during a flare does not rule out gout. Treat with colchicine 1.2 mg then 0.6 mg 1 hour later. Check uric acid in 4 weeks. Discuss switching from HCTZ to a non-thiazide antihypertensive. If he has ≥2 flares/year, start allopurinol after the flare resolves.
CHANGE ONE DETAIL
Change one detail — the same patient has a fever of 38.8°C and the joint is exquisitely tender with a large effusion. Septic arthritis cannot be excluded clinically. Joint aspiration is required before treating for gout. Send synovial fluid for cell count, Gram stain, culture, and crystal analysis. Do not assume gout and skip the aspiration when fever and systemic toxicity are present.
Bottom Line
Serum uric acid can be normal during an acute gout flare — do not use it to rule out gout. Treat the flare first, then start urate-lowering therapy 2–4 weeks after resolution. Never start allopurinol during an acute flare.
EVIDENCE & REFERENCES
- FitzGerald JD, et al. 2020 American College of Rheumatology Guideline for the Management of Gout. Arthritis Care Res. 2020;72(6):744-760. doi:10.1002/acr.24180
- Richette P, Bardin T. Gout. Lancet. 2010;375(9711):318-328. doi:10.1016/S0140-6736(09)60883-7
- Terkeltaub RA. Clinical practice. Gout. N Engl J Med. 2003;349(17):1647-1655. doi:10.1056/NEJMcp030733