Gout — KFP-style written assessment

KFP 1 (10 marks)

A 52-year-old overweight publican wakes at 2 am with severe pain in his right first MTP joint. By mid-morning he cannot bear a sock on it. He drinks four beers most evenings. A locum last year told him 'it's just arthritis'. Serum urate today is 0.47 mmol/L; renal function normal. ^{[20] [3]}

1. What is the clinical diagnosis and what would definitively confirm it? (3) ^[20]
2. Outline first-line acute management with exact regimens, choosing sensibly for his occupation and preferences. (5) ^{[1] [3] [16]}
3. How should his alcohol intake feature in the consultation now? (2) ^[12]

Model answers

1. Acute gout (podagra): rapid-onset exquisitely tender first MTP synovitis in a middle-aged man with hyperuricaemia. Definitive confirmation is polarised-light microscopy of synovial fluid showing needle-shaped negatively birefringent MSU crystals; the 2015 ACR/EULAR criteria (92% sensitivity/89% specificity) formalise clinical diagnosis when aspiration is not feasible. ^[20]
2. Treat early with one of the strongly recommended classes: low-dose colchicine (1 mg then 500 µg one hour later, then 500 µg daily–twice daily) — CLEAR showed efficacy equal to high-dose with placebo-like safety; an NSAID plus PPI (e.g., naproxen or indomethacin until 24h after resolution); or oral prednisolone 30-40 mg for 4-5 days (equivalent analgesia to indomethacin, fewer early adverse events). Intra-articular steroid is ideal if he prefers avoiding systemic tablets. NSAIDs carry GI risk in a drinker — weigh carefully. ^{[1] [3] [16] [5]}
3. Address beer specifically: UK Biobank data show beer/cider carries the strongest beverage-gout association (HR 1.60 per pint/day in men). Frame reduction as part of flare prevention alongside weight loss, but be clear diet alone will not replace urate-lowering therapy if he meets its indications. ^{[12] [19]}