Gout
Formal Definition
A crystal-induced inflammatory arthropathy caused by monosodium urate (MSU) deposition in joints and soft tissues due to hyperuricemia; characterized by acute attacks of severe monoarthritis (classically the first MTP joint — podagra), tophi formation, and potentially chronic gouty arthropathy; diagnosed by synovial fluid analysis demonstrating negatively birefringent needle-shaped MSU crystals.
How It's Used on the Ward
"Gout attack" or "gouty flare" — the acutely swollen, exquisitely tender joint that makes patients refuse to let anyone near it.
Example
""48-year-old man with acute onset right first MTP swelling, redness, warmth so severe he cannot bear bed sheet contact: classic podagra. Joint aspiration shows negatively birefringent crystals. Starting colchicine and naproxen; uric acid is 9.2. Plan for allopurinol once acute flare resolved.""
Clinical Context
Acute gout treatment: NSAIDs (if no contraindication), colchicine (within 36h of attack onset), or corticosteroids. Do NOT start allopurinol or urate-lowering therapy during an acute attack (paradoxically worsens/prolongs flare). Urate-lowering therapy (ULT): start 2–4 weeks after flare resolves; target uric acid <6 mg/dL. Allopurinol: XO inhibitor, first-line; titrate slowly (avoid SJS, especially in HLA-B*5801 carriers — screen in Southeast Asian populations). Febuxostat: alternative to allopurinol. Probenecid: uricosuric, use only in under-excretors with good renal function. Prophylaxis during ULT initiation: low-dose colchicine or NSAID for 3–6 months (prevents mobilization flares). Precipitants: alcohol, purine-rich foods, diuretics, dehydration, surgery.