NCLEX Review Guide: Gout

Understanding Gout

• Gout is a metabolic disorder caused by hyperuricemia (elevated uric acid levels >7 mg/dL), leading to uric acid crystal deposits in joints and tissues.
• Primary gout results from genetic defects in purine metabolism, while secondary gout occurs due to medications or medical conditions that increase uric acid production or decrease excretion.
• The first metatarsophalangeal joint (big toe) is the most commonly affected site, known as podagra.

Acute Gout Attack

• Sudden onset of severe, excruciating pain typically occurring at night or early morning, often described as "crushing" or "throbbing."
• Affected joint becomes red, hot, swollen, and extremely tender to touch - even bed sheets can cause unbearable pain.
• Attacks usually last 3-10 days and resolve spontaneously, but frequency increases without treatment.

Laboratory & Imaging Studies

• Synovial fluid analysis is the gold standard - shows monosodium urate crystals and elevated WBC count (>2000/μL).
• Serum uric acid levels >7 mg/dL confirm hyperuricemia, but levels may be normal during acute attacks due to inflammatory response.
• 24-hour urine collection helps determine if patient is an overproducer (>800 mg/day) or underexcretor (<600 mg/day) of uric acid.

Acute Attack Management

1. NSAIDs are first-line therapy - Indomethacin 50mg TID or Ibuprofen 800mg TID for 7-10 days
2. Colchicine 1.2mg initially, then 0.6mg one hour later (maximum 1.8mg in 24 hours)
3. Corticosteroids (prednisone 40-60mg daily) if NSAIDs contraindicated
4. Apply ice to affected joint and maintain strict bed rest

Chronic Management

• Allopurinol (xanthine oxidase inhibitor) is first-line prophylaxis, starting at 100mg daily and titrating to achieve uric acid <6 mg/dL.
• Febuxostat is an alternative xanthine oxidase inhibitor for patients intolerant to allopurinol.
• Never start uric acid-lowering therapy during acute attack as it can worsen symptoms.

Dietary Modifications

• Limit high-purine foods: organ meats, shellfish, sardines, anchovies, and beer (highest purine content).
• Encourage low-fat dairy products, which have uricosuric properties and may reduce gout risk.
• Maintain adequate hydration and limit alcohol consumption, especially beer and spirits.

Potential Complications

• Chronic tophaceous gout develops with repeated attacks, causing joint deformity and functional impairment.
• Uric acid nephropathy and kidney stones occur in 10-25% of patients with gout.
• Increased cardiovascular risk due to association with metabolic syndrome and hypertension.