Gout or pseudogout suspected? (Tables 97.1 and 97.2)

End

Frequent attacks 3/yr.
Difficult to treat gout
Clinical or X-ray evidence of tophi
Urate overproduction

Diagnosis of gout still possible, if hyperuricaemia present, or consider pseudogout if chondrocalcinosis on X-ray
Consider other aetiology

Aspirate joint (Chapter 124), perform synovial fluid culture, Gram stain, microscopy and crystal analysis (see Fig. 28.1 for the assessment of the patient with acute arthritis)

Urate crystals detected, culture negative

CPPD crystals detected, culture negative

Crystals analysis negative, culture negative

NSAID (ibuprofen 400 mg 8-hrly PO or naproxen 500 mg 12-hrly PO for 5 days) (if renal function satisfactory)
OR
Colchicine 500 µgm 8-hrly PO for 7 days; 500 µgm once daily if eGFR < 30)
OR
Prednisolone 30-40 mg once daily PO for 7 days or intramuscular methyl prednisolone 120 mg stat or intra-articular steroids

Assess if hyperuricaemia is 1° or 2°
Assess for urate overproduction vs under excretion

Low dose prophylactic colchicine + urate lowering therapy when acute gout resolves

NSAID (ibuprofen 400 mg 8-hrly PO or naproxen 500 mg 12-hrly PO for 5 days) (if renal function satisfactory)
OR
Colchicine 500 µgm 8-hrly PO for 7 days; 500 µgm once daily if eGFR < 30)
OR
Prednisolone 30-40 mg once daily PO for 7 days or intramuscular methyl prednisolone 120 mg stat or intra-articular steroids

Rule out 2° causes of chondrocalcinosis (serum Ca²⁺, PO₄^–, Mg²⁺, serum Fe, ferritin TIBC, TSH)

Frequent attacks of pseudogout 3/yr.

Low dose daily prophylactic colchicine