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Clinical Findings
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A Symptoms and Signs
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Acute gouty arthritis is characterized by its sudden onset, frequently nocturnal, either without apparent precipitating cause or following rapid fluctuations in serum urate levels
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Arthritis & Musculoskeletal Disorders
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Either increases or decreases in the serum urate level can precipitate a gout attack Common precipitants are alcohol excess (particularly beer), changes in medications that affect urate metabolism, and in the hospitalized patient fasting before medical procedures The MTP joint of the great toe is the most susceptible joint ( podagra ), although others, especially those of the feet, ankles, and knees, are commonly affected Gouty attacks may develop in periarticular soft tissues such as the arch of the foot Hips and shoulders are rarely affected More than one joint may occasionally be affected during the same attack; in such cases, the distribution of the arthritis is usually asymmetric As the attack progresses, the pain becomes intense The involved joints are swollen and exquisitely tender and the overlying skin tense, warm, and dusky red Fever is common and may reach 39 C Local desquamation and pruritus during recovery from the acute arthritis are characteristic of gout but are not always present Tophi may be found in the external ears, hands, feet, and olecranon and prepatellar bursae They usually develop years after the initial attack of gout Asymptomatic periods of months or years commonly follow the initial acute attack After years of recurrent severe monarthritis attacks of the lower extremities and untreated hyperuricemia, gout can evolve into a chronic, deforming polyarthritis of upper and lower extremities that mimics rheumatoid arthritis
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may be necessary to distinguish tophi from rheumatoid nodules An x-ray appearance similar to that of gout may be found in rheumatoid arthritis, sarcoidosis, multiple myeloma, hyperparathyroidism, or Hand-Sch ller-Christian disease Chronic lead intoxication may result in attacks of gouty arthritis (saturnine gout); abdominal pain, peripheral neuropathy, renal insufficiency, and basophilic stippling of red cells are clues to the diagnosis
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Treatment
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A Asymptomatic Hyperuricemia
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Asymptomatic hyperuricemia should not be treated; uric acid lowering drugs need not be instituted until arthritis, renal calculi, or tophi become apparent
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B Acute Attack
Arthritis is treated first and hyperuricemia weeks or months later, if at all Sudden reduction of serum uric acid often precipitates further episodes of gouty arthritis 1 NSAIDs These drugs (see Table 5 3) are the treatment of choice for acute gout Traditionally, indomethacin has been the most frequently used agent, but all of the other newer NSAIDs are probably equally effective Indomethacin is initiated at a dosage of 25 50 mg orally every 8 hours and continued until the symptoms have resolved (usually 5 10 days) Active peptic ulcer disease, impaired renal function, and a history of allergic reaction to NSAIDs are contraindications For patients at high risk for upper gastrointestinal bleeding, a cyclooxygenase type 2 (COX-2) inhibitor may be an appropriate first choice for management of an acute gout attack Long-term use of COX-2 inhibitors is not advised because of the association with increased risk of cardiovascular events, which has led to the removal of some drugs from the US market (eg, rofecoxib and valdecoxib) 2 Colchicine Neither oral nor intravenous colchicine is any longer recommended for the treatment of acute gout flares The use of oral cochicine during the intercritical period to prevent gout attacks is discussed below 3 Corticosteroids Corticosteroids often give dramatic symptomatic relief in acute episodes of gout and will control most attacks They are most useful in patients with contraindications to the use of NSAIDs If the patient s gout is monarticular, intra-articular administration (eg, triamcinolone, 10 40 mg depending on the size of the joint) is most effective For polyarticular gout, corticosteroids may be given intravenously (eg, methylprednisolone, 40 mg/d tapered over 7 days) or orally (eg, prednisone, 40 60 mg/d tapered over 7 days) Gouty and septic arthritis can coexist, albeit rarely Therefore, joint aspiration and Gram stain with culture of synovial fluid should be performed before corticosteroids are given
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