GOUT Diagnosis, Treatment, and Prevention - Chio Yokose, MD MGH Rheumatology Fellow - Massachusetts General Hospital
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GOUT
Diagnosis, Treatment, and
Prevention
Chio Yokose, MD
MGH Rheumatology Fellow
May 2019
Disclosures • None
OUTLINE 1. Background – what is gout? 2. Symptoms of gout 3. Complications of gout 4. Diagnosis of gout 5. Short- and long-term treatment of gout
What is gout?
• Extremely painful type of
inflammatory arthritis
• Caused by crystals (monosodium urate)
that deposit in and around joints
• One of the first clinical entities
described
• Egypt, 2640 B.C.
• Often seen in association with many
metabolic conditions
• Metabolic syndrome, obesity, diabetes,
hypertension, kidney disease, heart
disease
Nuki et al., Arthritis Res Ther. 2006.
Historical Perspective • From Disease of Kings… • Lifestyle of indulgence • Triggered by rich foods and alcohol • To a Disease of Commoners • Gout does not discriminate
How common is gout?
• VERY common
• United States: approximately 4% of total population affected
• More common as you get older
Kuo et al. Nat Rev Rheumatol. 2015.
Who gets gout?
• VERY common
• More common as you get older
• Males > Females
Kuo et al. Nat Rev
Rheumatol. 2015.
What causes gout?
• Elevated levels of urate in the blood
• Condition known as hyperuricemia
Image source: https://www.verywellhealth.com/can-hepatitis-b-
cause-kidney-disease-4107525
Neogi. N Engl J Med. 2011.
URATE OUT:
• Volume status
What causes gout? • Medications
• Comorbidities
• Genetics
• Elevated levels of urate in the blood
• Condition known as hyperuricemia
URATE IN:
• Diet Image source: https://www.verywellhealth.com/can-hepatitis-b-
cause-kidney-disease-4107525
• Foods that are rich in purines
• Cell turnover
Neogi. N Engl J Med. 2011.
What causes gout?
• Elevated levels of urate in the blood
• Condition known as hyperuricemia
• Saturation level of urate in the blood stream
• Approximately 6.8 mg/dL Image source:
https://www.hss.edu/conditions_gout-risk-
factors-diagnosis-treatment.asp
Neogi. N Engl J Med. 2011.What are the symptoms of gout?
• Episodes of joint pain and
inflammation (gout flares)
• Return to normalcy in
between
• Sudden onset of joint pain
• Rapid escalation of pain
• Pain can be quite debilitating
• Worse with minimal
movement
• Present even at restWhat are the symptoms of gout?
• Associated with redness and swelling
• Usually one or few joints at a time
• Lower extremities > upper extremities
• Podagra = gout flare affecting base of the
big toe
• Severe flares can present with fevers and other
systemic symptoms (e.g., chills, sweats,
malaise)
Image source: ACR Image BankGout, in your own words… • ”I cannot walk on it or apply any weight. I cannot go to work until this subsides…” • “I put on a sock and it was excruciating.” • “Even the sheets hurt…I have to sleep with my foot poking out from the covers!” • “Doc, I’m in 13 out of 10 pain.”
What is a tophus?
• Collection of monosodium
urate crystals surrounded by
inflammatory cells and
connective tissue
• Can deposit under the skin, in
joints, around tendons…
• Can be painful and disfiguring
• Can interfere with normal
function
• Marker of more severe gout
• Associated with worse outcomes Image source: ACR Image Bank
Dalbeth et al. Arthritis Rheum. 2010.Why care about gout?
• Painful and debilitating flares of arthritis
• ↓ Quality of life
• ↓ Work productivity
• ↑ Activity impairment
• Bone erosions and permanent structural
damage
• Chronic joint inflammation
Eggebeen. Am Fam Physician. 2007.High blood pressure
Why care about gout? Chronic kidney disease
Obesity
Diabetes
Heart attack
Stroke
Gout
Hyperuricemia Increased risk of death,
primarily due to heart
disease
Worse outcomes in heart
disease and kidney disease
Bardin and Richette. BMC Medicine. 2017.How is gout diagnosed?
• Clinical history and exam
• Podagra
• Sudden onset of symptoms
• Redness, swelling, fluid in the
joints
• Labs
• Hyperuricemia: high urate level
in the blood stream
• Elevated inflammatory markers
(if in the middle of a flare)
Dalbeth. Lancet. 2016.How is gout diagnosed?
• Joint aspiration
• Insert a small needle into
a joint to sample joint fluid
• Can be performed in the
clinic
• Look for gout crystals
under microscope
• GOLD STANDARD
Dalbeth. Lancet. 2016.How is gout diagnosed? DUAL-ENERGY CT
Green = monosodium urate crystals!
• Imaging
• Not required, but can be helpful
• Plain X-rays
• If bony damage (e.g., erosions)
from gout present
• Musculoskeletal ultrasound
• Dual-energy CT
Dalbeth. Lancet. 2016.What are common triggers of gout? • Foods/beverages that are high in purines → converted into urate • Trauma • Dehydration • Medications • Diuretics • Hospitalization/surgery • Can also happen with no apparent trigger!
How are gout flares treated?
• Colchicine
• Inhibits activity of a type of
inflammatory cell implicated in
gout
• Non-steroidal anti-inflammatory
drugs (NSAIDs)
• Ibuprofen (Advil, Motrin)
• Naproxen (Aleve)
• Use with caution in those with
heart disease and kidney disease
Khanna et al. Arthritis Care Res. 2012.How are gout flares treated?
• Steroids
• By mouth → caution in those
with:
• Diabetes
• Mood disorders
• Stomach ulcers
• Injected into the joint
• RI(C)E
• Rest, ice, (compression), elevation
Image source: UpToDate, courtesy of Scott Koehler, MD
Start treatment at first sign of gout flare and may be able to prevent a
full flare! Sooner the better.
Khanna et al. Arthritis Care Res. 2012.Can gout be “cured”?
• YES!
• Only inflammatory arthritis with a theoretical “cure”
• How?
• We know what causes it
→ Urate crystals
• We know how to prevent urate crystals from forming
→ Lower urate levels in your blood
• What can be done?
• Lifestyle interventions
• Medications to lower serum urate levels in the bloodLifestyle Interventions
GOOD AVOID
• Healthy diet • Unhealthy diet
• DASH diet • Western diet
• Mediterranean diet • Sugar-sweetened beverages
• Low-fat dairy • High-fat dairy
• Vitamin C • Red meat, organ meats, shellfish
• Weight loss • Alcohol
• DiureticsMedications to “Cure” Gout • Most common: allopurinol, febuxostat • Xanthine oxidase inhibitor • Taken by mouth daily • Not only during a gout flare, but even when joints feel perfectly normal • Why? • Gout crystals always present, even if no symptoms!
“Treat-to-Target”
• American College of Rheumatology
• Target serum urate < 6 mg/dL for most people
• Tophus: target < 5 mg/dL
• Medication dose determined by serum urate levels
• NOT weight based, NOT one-size-fits-all
Repeat blood Increase dose
Start medicine
work in 2-4 until goal
at a low dose
weeks serum urate
• Once at goal, maintain that level long enough to allow existing
crystals to go away!
Khanna et al. Arthritis Care Res. 2012.Gout Flare Prevention
• WARNING (!!)
• Increased risk of gout flares when first starting medication to lower urate level
• Why?
• Any sudden fluctuations in the serum urate level (up or down) can cause a
flare
• What can be done?
• Take a medication (commonly colchicine) to prevent gout flares until serum
urate levels stabilizeTake-Home Points
• Gout is very common
• Older men, postmenopausal women
• Gout is caused by precipitation and deposition of urate crystals
in joints
• Sets off inflammatory cascade causing redness, swelling, and
extreme pain
• Gout is associated with many other chronic medical conditions
• Obesity, diabetes, chronic kidney disease, heart diseaseTake-Home Points
• Gout flares can be treated with anti-inflammatory medications
• Sooner the better
• Gout can be “cured”
• With long-term use of medications to lower urate levels in
the bloodstream
• If you or someone you know suffers from gout, talk to your
doctor!Thank You!
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