Gout is a prevalent condition, especially as age increases. It affects a significant portion of the older population, with up to 7% of men over 65 and 3% of women over 85 experiencing this form of inflammatory arthritis. Elevated serum uric acid levels are a major risk factor, and the likelihood of developing gout rises substantially with increasing uric acid. Lifestyle factors also play a crucial role; alcohol consumption and diets rich in purines, such as red meat and seafood, are significant contributors to the incidence of gout. Certain medications like loop and thiazide diuretics are also linked to an increased risk. Gout is frequently observed alongside metabolic syndrome, highlighting the interconnectedness of metabolic health and gout development. Furthermore, dehydration, rising creatinine levels, and surgical procedures are known triggers for acute gout flares.
Acute gout attacks are characterized by sudden, severe joint pain that escalates rapidly, reaching peak intensity within hours. Gout has a predilection for the joints of the lower extremities. The first metatarsophalangeal joint is often the initial site, a condition commonly known as podagra. Other frequently affected areas include the tarsal and subtalar joints, ankle, knee, wrist, small joints of the hands, Achilles tendon, and olecranon bursae. The affected joint typically presents with intense heat, redness, swelling, and extreme tenderness. Skin erythema may also be present in the overlying skin.
The definitive diagnosis of gout relies on the identification of monosodium urate (MSU) crystals in the synovial fluid obtained from an inflamed joint or from tophi. It’s important to note that hyperuricemia alone is not sufficient to diagnose or exclude gout. Many individuals with hyperuricemia remain asymptomatic, and paradoxically, serum uric acid levels often decrease during acute gout attacks.
For the management of acute gout flares, short-acting Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) are the first-line treatment option, used at the maximum recommended dose, provided there are no contraindications. In patients with an elevated risk of gastrointestinal complications, it is advisable to co-prescribe a proton pump inhibitor or consider using COX-2 selective agents to mitigate GI risks. Colchicine can be particularly beneficial in patients with heart failure where NSAIDs are contraindicated; however, it should be avoided in patients with severe renal impairment. Joint aspiration followed by intra-articular steroid injection is a highly effective method for treating acute monoarthritic gout, providing rapid local relief.
Urate-lowering therapy (ULT) is generally recommended for patients who experience two or more gout attacks within a year. Many rheumatologists may also initiate ULT in hyperuricemic patients after a particularly severe first attack or in cases of polyarticular gout to prevent future episodes and long-term complications.
