Compare conditions

Put any two — or three — conditions side by side, adult or pediatric, to spot the look-alike differences fast, row by row.

Gout

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In one line

·Too much uric acid in the blood forms needle-sharp crystals in joints, causing sudden severe pain and swelling.

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Normal physiology

·Your body constantly breaks down purines — building blocks found in red meat, organ meat, seafood, beer, and your own cells — into uric acid, a waste product. Normally, about two-thirds of uric acid leaves through your kidneys in urine, and one-third leaves through your intestines in stool. This keeps blood uric acid (serum urate) safely below 6–7 mg/dL. At that level, uric acid stays dissolved in blood like salt in water.

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What goes wrong

·Gout happens when uric acid in the blood climbs so high that it crosses the solubility threshold — the point where it can no longer stay dissolved — and crystallizes into needle-shaped monosodium urate crystals inside joints, especially the big toe.

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Hallmark signs

·Sudden, severe pain in one joint — often the big toe, ankle, or knee — that comes on at night or early morning
·The joint becomes hot, red, and swollen; the skin may look shiny and tight
·The joint is so tender that even a bedsheet touching it can hurt
·Pain and swelling usually peak within 12 to 24 hours
·Attacks are triggered by alcohol (especially beer), red meat, shellfish, sugary drinks, water pills (diuretics), hospital stay, surgery, or starting uric-acid-lowering medicine
·Firm, chalky lumps (tophi) under the skin near joints or on the ears
·Fever and feeling generally unwell during a severe attack
·Multiple joints flaring at once, or an attack that won't go away

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Red flags · escalate now

·Fever above 100.4°F (38°C) with joint pain — could be a joint infection, not gout
·Joint pain in more than two joints at once, or pain that spreads quickly
·Severe pain that doesn't improve at all after three days of treatment
·Red, hot, swollen joint in someone with a weakened immune system (on steroids, chemotherapy, or HIV)

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Workup

·Arthrocentesis (joint aspiration) with synovial fluid analysis under polarized microscopy
·Serum uric acid (urate) level
·Serum creatinine and estimated glomerular filtration rate (eGFR)
·24-hour urine uric acid (optional, if considering probenecid or recurrent stones)
·X-ray or ultrasound of the affected joint (if diagnosis is uncertain or to look for chronic damage)
·Complete blood count (CBC) and inflammatory markers (ESR, CRP) if infection is a concern

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Treatment

·Colchicine (1.2 mg, then 0.6 mg one hour later, then 0.6 mg once or twice daily), NSAIDs (indomethacin 50 mg three times daily or naproxen 500 mg twice daily), or corticosteroids (prednisone 30–40 mg daily for 5 days, or intra-articular injection)
·Allopurinol (start 100 mg daily, increase slowly to 300–800 mg daily, target urate < 6 mg/dL) or febuxostat (start 40 mg daily, increase to 80 mg if needed)
·Probenecid (start 250 mg twice daily, increase to 500–1000 mg twice daily)
·Preventive (Prophylactic) colchicine (0.6 mg once or twice daily) or low-dose NSAID (naproxen 250 mg twice daily) for 3 to 6 months when starting or adjusting urate-lowering therapy
·Lifestyle changes: cut alcohol (especially beer and liquor), avoid purine-rich foods (red meat, organ meat, shellfish, high-fructose corn syrup drinks), lose weight if overweight, drink 2+ liters of water daily, avoid dehydration
·Pegloticase (IV infusion 8 mg every 2 weeks)

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NCLEX trap

·Never start or stop urate medicine during a flare. It can make the flare worse because crystals shift around when urate levels change suddenly. Stop the flare first with NSAIDs, colchicine, or steroids. Then start urate medicine 2–4 weeks later when the joint is calm and quiet.
·Urate can actually drop during a flare because crystals are leaving the bloodstream and piling into the joint. Wait 2–4 weeks after the flare to check serum urate. That is when you see the true baseline, not the snapshot taken during the storm.
·Always do arthrocentesis (poke the joint with a needle) to get synovial fluid and look for bacteria and crystals under the microscope. Gout and septic arthritis (infection in the joint) can look identical at the bedside. Do not guess—get the fluid. Infection is a danger frame you must rule out before you call it gout.
·Gout can hit any joint, but the big toe (first metatarsophalangeal joint, or MTP) is most common because it is the coldest and lowest spot in the body, which makes crystals form more easily. Ankle, knee, wrist, and elbow gout all happen. Do not anchor on one location and miss the diagnosis.
·Gout flares come and go, but the underlying break—too much urate in the blood—stays. Long-term urate-lowering medicine (allopurinol, febuxostat, or probenecid) prevents future flares, stops tophi (lumpy urate deposits) from forming, and protects the kidneys from crystal damage. One flare treated is not the same as gout cured.
·Pegloticase (an IV enzyme that breaks down urate) can cause severe allergic reactions and infusion reactions, especially if urate drops too fast. It is a last-resort drug for severe, refractory gout when other medicines have failed or when the patient has big tophi or advanced disease. Watch the patient carefully during the infusion and have emergency equipment ready.

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