Crystal arthropathy due to monosodium urate deposition; acute monoarthritis, often 1st MTP (podagra).
Etiology
- • Overproduction (purine intake, lysis)
- • Underexcretion (CKD, diuretics, alcohol)
Risk factors
- • Male, age >40, obesity, alcohol
- • Diuretics, ciclosporin
- • CKD, HTN, MetS
History taking
- • Sudden severe joint pain peaking 6–12 h
- • Triggers: alcohol, red meat, dehydration
- • Previous attacks, tophi
Examination
- • Hot swollen tender joint
- • Tophi over ears, elbows, Achilles
Red flags
- • Fever + joint → exclude septic arthritis
Differential diagnosis
- • Septic arthritis
- • Pseudogout (CPPD)
- • Cellulitis
- • Reactive arthritis
Recommended investigations
- • Serum urate (may be normal in acute)
- • Joint aspiration: negative birefringent needles
- • RFT, lipids, glucose
Diagnosis
- • Clinical diagnosis supported by targeted investigations
Initial treatment / management
- • Acute: NSAID / colchicine / steroid
- • Urate-lowering after attack settles
Drug therapy
- • Naproxen 500 mg BD 5–7 d
- • Colchicine 1 mg then 0.5 mg 1 h later, then 0.5 mg BD–TDS
- • Prednisolone 30–40 mg OD × 5 d if NSAID contraindicated
- • Allopurinol 100 mg OD, titrate to urate <360 µmol/L (300 µmol/L if tophi)
Lifestyle advice
- • Reduce alcohol, fructose, red meat, shellfish
- • Hydration ≥2 L/day
- • Weight loss
Follow-up advice
- • Review in 2–4 weeks or earlier if worsening
- • Monitor response to therapy and adverse effects
Patient counselling
- • Explain diagnosis and natural course in lay terms
- • Red-flag symptoms warranting urgent return
- • Adherence to medications and follow-up
Referral criteria
- • Refer if diagnostic uncertainty, complications, or failure of first-line therapy
Clinical pearls
- • Do NOT stop allopurinol during acute attack
- • Cover urate-lowering initiation with colchicine 0.5 mg BD for 3–6 months
References
- • Harrison's Principles of Internal Medicine, 21e
- • NICE / WHO guidelines (current edition)
Educational outpatient guide — verify against local guidelines before clinical use.
