Overview
Acute Gout
1. Clinical Overview
Summary
Acute gout is intensely painful inflammatory arthritis from MSU crystal deposition (classic: 1st MTP "podagra"). Serum urate may be NORMAL during attack. Diagnosis: joint aspiration showing negatively birefringent crystals. Acute: NSAIDs/colchicine/steroids. Do NOT start allopurinol during acute attack.
Key Facts
- Cause: MSU crystal deposition in joints
- Classic presentation: Acute monoarthritis of 1st MTP (podagra)
- Diagnosis: Joint aspiration showing negatively birefringent crystals
- Acute treatment: NSAIDs, colchicine, or corticosteroids
- Long-term: Urate-lowering therapy (allopurinol, febuxostat)
Clinical Pearls
Serum urate may be NORMAL during an acute flare — don't use it to exclude gout
Always exclude septic arthritis if doubt — aspirate the joint
Do NOT start allopurinol during an acute attack (can prolong/worsen flare)
Why This Matters Clinically
Gout is the most common inflammatory arthritis. Acute attacks are extremely painful. Proper treatment of acute attacks and long-term urate-lowering therapy prevents joint damage and recurrence.
2. Epidemiology
Visual assets to be added:
- MSU crystal under polarised microscopy
- Podagra clinical photo
- Gout vs septic arthritis comparison
- Acute gout management algorithm
Epidemiology
Incidence
- 1-2% of adults in Western countries
- Increasing prevalence
- Most common inflammatory arthritis
Demographics
- Male predominance (3:1)
- Peak age: 40-60 in men; post-menopausal in women
- Rare in premenopausal women
Risk Factors
| Factor | Notes |
|---|---|
| Hyperuricaemia | Major risk factor |
| Diet | Red meat, seafood, fructose |
| Alcohol | Especially beer |
| Obesity | |
| Renal impairment | Reduced urate excretion |
| Diuretics | Thiazides, loop diuretics |
| Metabolic syndrome | |
| Family history |
3. Pathophysiology
Mechanism
- Hyperuricaemia (overproduction or underexcretion of urate)
- MSU crystal formation in joints
- Crystal phagocytosis by macrophages
- NLRP3 inflammasome activation → IL-1β release
- Acute inflammatory response
Uric Acid Metabolism
- End product of purine metabolism
- Excreted by kidneys (2/3) and gut (1/3)
- Hyperuricaemia: Over 420 μmol/L (men) or over 360 μmol/L (women)
Crystal Characteristics
- Monosodium urate crystals
- Needle-shaped
- Negatively birefringent under polarised light
4. Clinical Presentation
Acute Attack
Common Sites
| Site | Notes |
|---|---|
| 1st MTP joint (podagra) | Most common (50%) |
| Ankle | Common |
| Knee | Common |
| Wrist, fingers | Less common initially |
Symptoms
Signs
Red Flags
| Finding | Significance |
|---|---|
| Fever with monoarthritis | Exclude septic arthritis |
| Immunocompromise | Higher septic risk |
| Prosthetic joint | Urgent aspiration |
| No response to treatment | Reconsider diagnosis |
Rapid onset (often overnight)
Common presentation.
Severe pain — exquisitely tender
Common presentation.
Swelling, redness, warmth
Common presentation.
Peak at 12-24 hours
Common presentation.
Resolves in 7-14 days untreated
Common presentation.
5. Clinical Examination
Joint
- Swelling
- Erythema
- Warmth
- Tender to touch and movement
General
- Fever possible
- Look for tophi (ears, fingers, elbows, Achilles)
Cardiovascular Risk Assessment
- Check BP, weight
- Gout associated with metabolic syndrome
6. Investigations
Joint Aspiration — Gold Standard
| Finding | Gout |
|---|---|
| Appearance | Cloudy/turbid |
| Crystals | Needle-shaped, negatively birefringent |
| WCC | Elevated (usually 10,000-50,000) |
| Gram stain/culture | Negative (excludes septic) |
Blood Tests
| Test | Notes |
|---|---|
| Serum urate | Often NORMAL during attack; check 2-4 weeks later |
| CRP, ESR | Elevated |
| FBC | WCC may be elevated |
| U&E | Renal function (affects drug choice) |
Imaging
| Modality | Findings |
|---|---|
| X-ray | Normal early; later: punched-out erosions, tophi |
| Ultrasound | "Double contour sign" on cartilage |
| Dual-energy CT | Detects urate deposits |
Classification & Staging
By Presentation
- Acute gout (flare)
- Intercritical gout (between attacks)
- Chronic tophaceous gout
By Severity
- Monoarticular
- Oligoarticular
- Polyarticular
7. Management
Acute Flare — Treat Early
First-Line Options:
| Agent | Dose | Notes |
|---|---|---|
| NSAIDs | Naproxen 500mg BD or indomethacin 50mg TDS | Avoid if renal impairment, heart failure, GI risk |
| Colchicine | 500mcg BD-TDS (max 6mg/course) | Low-dose preferred; GI side effects |
| Corticosteroids | Prednisolone 30-40mg OD for 5 days | If NSAIDs/colchicine contraindicated |
Intra-articular steroid:
- If single large joint
- Triamcinolone 40mg
Ice:
- Apply to affected joint
Do NOT Start Urate-Lowering Therapy During Acute Attack
- Can prolong/worsen flare
- Start 2-4 weeks after attack settles
- If already on ULT → continue
Prophylaxis While Starting ULT
- Colchicine 500mcg OD-BD for 3-6 months
- Prevents mobilisation flares
Long-Term Urate-Lowering Therapy (ULT)
Indications:
- 2 or more attacks per year
- Tophi
- Chronic kidney disease
- Uric acid stones
| Agent | Starting Dose | Target |
|---|---|---|
| Allopurinol | 100mg OD (50mg if renal impairment), titrate monthly | Urate under 360 μmol/L (under 300 if tophi) |
| Febuxostat | 80mg OD | Alternative if allopurinol not tolerated |
Lifestyle Modification
- Weight loss
- Reduce alcohol (especially beer)
- Reduce red meat, shellfish
- Avoid fructose-sweetened drinks
- Stay hydrated
8. Complications
Joint
- Chronic tophaceous gout
- Joint destruction
- Deformity
Renal
- Uric acid nephrolithiasis
- Chronic urate nephropathy
Cardiovascular
- Associated with increased CV risk
9. Prognosis & Outcomes
Prognosis
- Excellent with treatment
- Untreated: Recurrent attacks, chronic joint damage
ULT Outcomes
- Reduces flares
- Tophi can resolve over time
10. Evidence & Guidelines
Key Guidelines
- BSR Guideline on Management of Gout
- EULAR Recommendations for Gout
Key Evidence
- Low-dose colchicine is as effective and safer than high-dose
- Treat-to-target ULT improves outcomes
11. Patient/Layperson Explanation
What is Gout?
Gout is a type of arthritis caused by uric acid crystals building up in joints. It causes sudden, severe pain and swelling.
Symptoms
- Sudden severe joint pain (often big toe)
- Swelling and redness
- Joint feels hot
Treatment
- Anti-inflammatory medication for attacks
- Long-term medication to lower uric acid levels
Lifestyle Changes
- Lose weight if overweight
- Reduce alcohol (especially beer)
- Reduce red meat and shellfish
- Drink plenty of water
Resources
12. References
Primary Guidelines
- Hui M, et al. The British Society for Rheumatology Guideline for the Management of Gout. Rheumatology. 2017;56(7):e1-e20. PMID: 28549177
Key Reviews
- Dalbeth N, et al. Gout. Lancet. 2016;388(10055):2039-2052. PMID: 27112094
- Richette P, et al. 2016 updated EULAR evidence-based recommendations for the management of gout. Ann Rheum Dis. 2017;76(1):29-42. PMID: 27457514