From the Guidelines
Gout and pseudogout are crystal-induced arthropathies that require prompt diagnosis and management, with the most recent evidence from 2020 suggesting that joint aspiration with identification of monosodium urate crystals under polarized microscopy is the gold standard for gout diagnosis, while pseudogout is confirmed by finding calcium pyrophosphate crystals 1.
Diagnosis of Gout and Pseudogout
- The diagnosis of gout should be considered in any acute arthritis in an adult, with suggestive features including monoarticular involvement of a foot or ankle joint, previous similar acute arthritis episodes, rapid onset of severe pain and swelling, erythema, male gender, and associated cardiovascular diseases and hyperuricaemia 1.
- Synovial fluid aspiration and examination for crystals is strongly recommended in any patient with undiagnosed inflammatory arthritis, with a level of evidence of 3 and a grade of recommendation of C 1.
- The diagnosis of gout should not be made on the presence of hyperuricaemia alone, with a level of evidence of 2a and a grade of recommendation of B 1.
Management of Gout and Pseudogout
- Acute gout attacks should be treated with NSAIDs like naproxen 500mg twice daily, colchicine 1.2mg followed by 0.6mg one hour later, or corticosteroids such as prednisone 30-40mg daily with a 10-14 day taper, as recommended by the 2012 American College of Rheumatology guidelines for management of gout 1.
- For long-term management of gout, urate-lowering therapy is indicated for patients with frequent attacks, tophi, or urate nephropathy, with allopurinol as the first-line agent, starting at 100mg daily and titrating up to achieve a serum uric acid level below 6mg/dL, with febuxostat as an alternative for those who cannot tolerate allopurinol 1.
- Pseudogout management focuses on treating acute attacks similarly to gout, using NSAIDs, colchicine, or corticosteroids, with joint aspiration and drainage providing immediate relief in both conditions 1.
- Prophylaxis with low-dose colchicine (0.6mg daily) or NSAIDs may be used during the first 3-6 months of urate-lowering therapy to prevent flares, as recommended by the 2012 American College of Rheumatology guidelines for management of gout 1.
Lifestyle Modifications
- Lifestyle modifications for gout include weight loss, limiting purine-rich foods, reducing alcohol intake (especially beer), and avoiding high-fructose corn syrup, as recommended by the 2016 updated EULAR evidence-based recommendations for the management of gout 1.
- Pseudogout may be associated with underlying conditions like hyperparathyroidism or hemochromatosis, which should be investigated and treated accordingly, with a level of evidence of 1a and a grade of recommendation of A 1.
From the FDA Drug Label
Gout is a metabolic disorder which is characterized by hyperuricemia and resultant deposition of monosodium urate in the tissues, particularly the joints and kidneys. The etiology of this hyperuricemia is the overproduction of uric acid in relation to the patient's ability to excrete it If progressive deposition of urates is to be arrested or reversed, it is necessary to reduce the serum uric acid level below the saturation point to suppress urate precipitation. An increase in acute attacks of gout has been reported during the early stages of administration of allopurinol tablets, even when normal or subnormal serum uric acid levels have been attained.
The diagnosis and management strategies for Gout (Gouty Arthritis) include:
- Reducing serum uric acid levels below the saturation point to suppress urate precipitation
- Using medications such as allopurinol to inhibit the formation of uric acid
- Implementing lifestyle changes, such as increasing fluid intake to yield a daily urinary output of at least 2 liters
- Maintaining a neutral or slightly alkaline urine
- Using colchicine or anti-inflammatory agents to suppress gouty attacks in some cases
There is no information in the provided drug labels about the diagnosis and management strategies for Pseudogout (Calcium Pyrophosphate Deposition Disease). 2, 2, 2
From the Research
Diagnosis of Gout and Pseudogout
- Definitive diagnosis via synovial tap is recommended, as the clinical picture may not identify some cases 3, 4, 5, 6
- Synovial fluid aspiration and microscopic synovial fluid analysis under compensated polarized light should be done to confirm the suspicion of crystal-induced arthropathy 4, 6
- Identification of monosodium urate crystals in the presence of serum hyperuricaemia is responsible for gout, and calcium pyrophosphate dihydrate (CPPD) crystals are responsible for pseudogout 5, 6
Management Strategies for Gout and Pseudogout
- The acute pain and swelling of attacks, regardless of etiology, generally respond to treatment with nonsteroidal anti-inflammatory drugs and local or occasionally systemic corticosteroids 3, 7
- Uric-acid-lowering therapy may be indicated in a patient who has experienced recurrent attacks of gout 3
- Control of serum phosphate levels might be effective in some individuals with hyperphosphatemia and hydroxyapatite-associated periarthritis or arthritis 3
- Treatment includes the use of nonsteroidal anti-inflammatory drugs, colchicine, or corticosteroids 7
- Gout may be impacted by dietary factors, weight reduction, and avoidance of certain forms of alcohol; uric acid-lowering agents are effective for refractory or chronic tophaceous disease 7
Long-term Management and Prevention
- A plan for long-term management and prevention of recurrences may be devised once a causative crystal has been identified and a diagnosis established 3
- Identification and subsequent treatment of preventable or correctable underlying disorders may be one of the most gratifying aspects of managing crystal-induced arthropathies 3, 4
- Periodic review of the patient is stressed 5