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Referral and warning signs
When to refer
Referral to Rheumatologist/Specialist for: Diagnostic uncertainty, Severe/frequent attacks, Chronic tophaceous gout, Intolerance/contraindication to standard therapy, Consideration for advanced therapies, Gout with significant renal impairment.
Red flags
- Suspicion of septic arthritis (requires urgent aspiration)
- Severe skin reaction (potential allopurinol hypersensitivity)
- Rapidly worsening renal function
Signs and symptoms
- Acute Gout Attack: Sudden onset excruciating joint pain (often peaks 12-24h). Intense inflammation (red, hot, swollen, tender). Podagra (1st MTP) most common initial site. Also midfoot, ankle, knee, wrist, fingers. Fever/malaise possible. Resolves over days-weeks.
- Intercritical Period: Asymptomatic between attacks.
- Chronic Tophaceous Gout: Tophi (MSU crystal deposits) - firm nodules on ear helix, joints, tendons. Chronic Gouty Arthritis (pain, stiffness, deformity). Kidney stones (uric acid). Chronic kidney disease.
Risk factors
- Hyperuricemia
- Male gender
- Increasing age
- Genetics
- Diet (high purine - red meat/seafood, alcohol - esp. beer, sugary drinks)
- Obesity / Metabolic syndrome
- Hypertension
- Chronic kidney disease
- Medications (diuretics, low-dose aspirin, ciclosporin, pyrazinamide)
Diagnosis
Clinical assessment
Suspect acute gout with rapid onset severe monoarthritis (esp. podagra). Suspect chronic with recurrent attacks/tophi. Rule out septic arthritis urgently in acute monoarthritis.
Investigations
- Synovial Fluid Analysis (Arthrocentesis): Gold standard. Polarized microscopy shows negatively birefringent needle-shaped MSU crystals. Perform cell count, Gram stain, culture (rule out sepsis).
- Serum Uric Acid Level: Often elevated, but can be normal/low during acute attack. Useful baseline/monitoring.
- Blood tests: CBC (leucocytosis), ESR/CRP (elevated acutely).
- Imaging: X-ray (normal early; chronic shows 'rat-bite' erosions). Ultrasound ('double contour sign'). DECT (detects urate).
Diagnostic criteria
Definitive: MSU crystals in synovial fluid/tophus. Clinical diagnosis often based on characteristic features + hyperuricemia.
Management
Non-pharmacological management
- Acute Attack: Rest, elevation, ice packs.
- Chronic/Prevention: Lifestyle (Weight loss, diet - limit purines/alcohol/sugary drinks, hydration), review medications.
Pharmacological treatment
- Acute Attack Treatment (Start ASAP): NSAIDs (high dose, e.g., Indomethacin, Naproxen), Colchicine (low dose regimen), Corticosteroids (Oral Prednisolone, Intra-articular injection, IM/IV).
- Urate-Lowering Therapy (ULT) - Chronic Prevention (Indications: ≥2 attacks/yr, tophi, joint damage, CKD ≥2): Start AFTER acute attack resolves, continue if already on. Goal: Uric acid <0.36 mmol/L (<6 mg/dL) or <0.30 (5) if tophi.
- - First-line: Xanthine Oxidase Inhibitors (Allopurinol - start low, titrate up; Febuxostat).
- - Uricosurics (Probenecid).
- - Pegloticase (refractory).
- - Prophylaxis during ULT Initiation: Low-dose Colchicine or NSAID for 3-6 months.
Monitoring
Monitor serum uric acid when titrating/maintaining ULT. Monitor attack frequency, tophi. Monitor medication side effects (esp. allopurinol hypersensitivity).
Complications
- Recurrent attacks
- Chronic gouty arthropathy / Joint destruction
- Tophi
- Uric acid kidney stones
- Chronic kidney disease
- Increased cardiovascular risk
Prevention
- Lifestyle modifications.
- Long-term ULT if indicated.
- Avoid trigger medications if possible.
Patient education
- Explain gout as crystal arthritis.
- Difference between acute attack treatment & long-term prevention (ULT).
- Managing acute attacks promptly.
- Lifestyle/dietary advice.
- If starting ULT: Goal, need for prophylaxis, adherence, side effects (allopurinol rash).
- Do not stop ULT during attack.
Uganda-specific notes
Prevalence increasing. Diagnosis often clinical. Access to microscopy, uric acid tests, ULT limited. NSAIDs common for acute attacks.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 10, Section 10.2.2