Hyperuricemia and gout

1. Big picture

Gout is crystal-induced arthritis caused by monosodium urate crystal deposition due to chronic hyperuricemia. It is one of the most exam-friendly metabolic diseases because the clinical picture is very characteristic:

Middle-aged/older man + metabolic syndrome/CKD/diuretics
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sudden severe red hot swollen joint, often 1st MTP joint
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think acute gout
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confirm with monosodium urate crystals if uncertain/severe/first attack

The examiner usually wants five things:

1. Most common cause: decreased renal uric acid excretion.
2. Acute attack treatment: NSAID, colchicine, or glucocorticoid.
3. Do not use allopurinol as acute pain treatment.
4. Definitive diagnosis: synovial fluid monosodium urate crystals.
5. Long-term treatment: urate-lowering therapy with treat-to-target serum urate.

Modern gout management uses a treat-to-target urate strategy, with allopurinol as preferred first-line urate-lowering therapy and a serum urate goal usually <6 mg/dL / <360 μmol/L. ([PMC][1])

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