Delivered during the 4th SLU Dept of Medicine Postgraduate Course Center for the Culture and the Arts St. Louis University Baguio City 01 July 2016

1. Gout Ba or OA Lang?
Allan D. Corpuz, MD, FPCP, DPRA
01 July 2016
St. Louis University CCA

3. Objectives
• Summarize the approach to the diagnosis of patients
with musculoskeletal disease in 4 easy steps
• Use the 2015 Gout Classification Criteria with
confidence
• Understand the value of uric acid for both gout and
OA
• Ask the appropriate questions to be able to screen
patients with gout
• Be confident about urate lowering therapy and
concomitant prophylaxis of gout

4. Disclosures
• Sub-investigator for Clinical Trials: BASE and
AURINIA
• Speaker for Pfizer, LRI-Therapharma, Otsuka

5. CASE
• A 54 y.o male family driver consults for pain in the
left knee on going up and down the stairs, for 2
years now.About 2 months ago, after driving long
distance, the pain got worse and he now limps
when walking.There is no fever or malaise.
• Joint PE: left knee is swollen, warm, + bulge sign.
There is 2+ tenderness and limited flexion and
extension.The right knee appears normal, but is
positive for fine crepitations.

6. CASE
• A 48 y.o businessman came home from a party the
night prior to consult and woke up with an
inflamed right big toe. He was feverish and could
not walk. He admitted to drinking beer and had
“pulutan” of kilawin. He had a similar episode 4
years prior, lasting 2 days.
• Joint PE: Swollen, erythematous, warm and
exquisitely tender right 1st MTP joint.

7. CASE
• A 45 y.o. housewife consulted for swelling and
pain of both wrists and small hand joints of 4
months duration. Pain is worse in the morning,
associated with stiffness lasting for 1 hour. She
takes Alaxan tablets as needed, with temporary
pain relief.
• Joint PE: Swelling , warmth and tenderness of
both wrists, and 1st and second PIPs of both
hands. Other joints and systemic PE are normal

8. CASE
• A 35 y.o. female PA of a famous celebrity consulted
for swelling and pain of the R wrist and 4 weeks
duration. Pain is worse at the end of the day,
especially after a long day of writing, texting and
carrying her boss’ stuff. She takes Arcoxia tablets as
needed, with temporary pain relief.
• Joint PE: Tenderness of R wrist, with pain on thumb
flexion, digit flexion and sharp ulnar deviation of the
wrist. No Pain on PROM. Other joint PE are normal

9. THE FUNDAMENTALS: KNOWING WHAT
TO ASK

10. Back to the Basics
• A
• C
• I
• N

11. A: Is it Articular or Non-Articular?
• Active ROM
• Passive ROM
• PAIN
– Articular: +AROM,
+ PROM
– Non-articular:
+AROM, -PROM
• Both OA and Gout
have articular
manifestations
• Gout may be non-
articular in the
case of gouty
bursitis

12. C: Is is Chronic or Acute?
• Chronic: >= 6
weeks
• Acute <6 weeks
• OA: usually
chronic (pain on
most days of the
week)
• Gout: Acute,
episodic; may be
chronic if with
tophi

13. I: Is it Inflammatory or Non-Inflammatory
• Inflammatory:
calor, rubor, dolor,
tumor, loss of
function (LOM)
• OA: non-
inflammatory,
except when in
flare (rare)
• Gout:
inflammatory

14. N: How Many (Number) Joints are
Involved?
• 1: monoarticular
• 2-3: oligoarticular
• >3: polyarticular
• OA: usually polyarticular
– hand, knee, hip, lumbar
spine
• Gout: usually starts as
mono- or oligoarticular,
eventually becomes
polyarticular

15. CLASSIFICATION CRITERIA

16. Gout Criteria (1977)

17. Gout Criteria (2014)
• Male sex = 2pts
• Previous patient-reported arthritis attack = 2 pts
• Onset within 1 day = 0.5 pt
• Joint redness = 1 pt
• MTP1 involvement = 2.5pts
• HTN or ≥ 1 CV diseases = 1.5 pts
• Serum Uric acid >5.88mg/dL = 3.5 pts
Kienhorst, LB et al.The Validation of a diagnostic rule for gout without joint fluid analysis: a
prospective study. Rheumatology (Oxford) 2014; 16

18. Gout Criteria (2014)
SCORE INTERPRETATION APPLICATION
<=4 Non gout in 95% Consider a different Dx such as CPPD, Reactive
Arthritis, Septic Arthritis, Rheumatoid Arthritis,
OA, or Psoriatic Arthritis
>4-8 Uncertain Perform joint fluid aspiration and analysis w/
polarization microscopy for the presence of
crystals; if not possible or available, then
extensive follow-up of the patient
>=8 Gout in 87% Manage the patient as having gout, including
care for CV risks
Kienhorst, LB et al.The Validation of a diagnostic rule for gout without joint fluid analysis: a
prospective study. Rheumatology (Oxford) 2014; 16

19. ACR/EULAR 2015
• ENTRY Criterion
• SUFFICIENT Criterion
• CLINICAL Criteria
• LAB Criteria
• IMAGING Criteria

20. STEP 1: Entry Criterion
• At least one episode of swelling, pain or
peripheral tenderness in a peripheral joint or
bursa

21. STEP 2: Sufficient Criterion
• Presence of MSU Crystals in a symptomatic joint or
bursa (ie Synovial Fluid) or tophus

22. STEP 3: Criteria
• CLINICAL
• LABORATORY
• IMAGING

23. CLINICAL CRITERIA
Pattern
• Ankle or midfoot (w/o MTP1) = 1 pt
• MTP1 = 2 pts
Characteristics
• Erythema = 1 pt
• Can’t bear touch or pressure = 1 pt
• Great inability in walking or inability to use joint = 1 pt
Time Course
• Time to maximal pain <24h
• Resolution <= 14days
• Complete resolution to baseline level between symptomatic episodes
• 1 typical episode = 1 pt / Recurrent typical episodes = 2 pt
Tophus
• Draining or chalk-like subcutaneous nodule under transparent skin, often
with overlying vascularity, located in typical locations: joints, ears, olecranon
bursae, finger pads, tendons (e.g.,Achilles) = 4 pts

25. LABORATORY CRITERIA
• SERUM URATE
– <4 mg/dL (<0.24 mmol/L) = -4pts
– 6-8 (0.36-0.48) = 2pts
– 8-10 (0.48-0.60) =3pts
– >10 (>0.60) =4pts
*Ideally not on ULT, >4wks from start of episode (if
practicable, retest under those conditions)
• SF Analysis (of Symptomatic joint or bursa)
– By trained observer

26. IMAGING CRITERIA
• Urate deposition =
4pts
– Ultrasound:
double contour
sign
– DECT: deposition
of urate
• Gout related
damage = 4 pts
– At least 1 erosion
on hands and/or
feet Xray

28. MAX SCORE = 23
THRESHOLD SCORE = 8

29. Comparison of Classification
2015 vs 2014 vs 1977
Criteria Sensitivity/
Specificity
Advantage/Disadvantage
1977 100% SEN
51% SPEC
Gold standard / Criteria + in a other
rheumatic conditions
2014 95% SEN
87% SPEC
Appropriate for clinical settings / Still need
SF aspiration and microscopy if uncertain
2015 92% SEN
89% SPEC
Incorporates imaging modalities;
appropriate for clinical setting if SFA
cannot be done; can be a “clinical-only”
version in settings where lab and imaging
criteria are impossible to fulfill

30. CLINICAL PRESENTATION: GOUT

32. Initial Presentation
• Podagra = 50%
• Mono to Oligoarticular =90%
• Rarely involves the shoulder
• Polyarticular in 10%
Puig JG, Michan AD, Jimenez ML, et al. Female gout. Clinical spectrum and uric acid metabolism. Arch Intern Med. 1991 Apr. 151(4):
726-32.
Meyers OL, Monteagudo FS. Gout in females: an analysis of 92 patients. Clin Exp Rheumatol. 1985 Apr-Jun. 3(2):105-9
Macfarlane DG, Dieppe PA. Diuretic-induced gout in elderly women. Br J Rheumatol. 1985 May. 24(2):155-7

33. Differential Diagnosis of Gout

34. ROLE OF URIC ACID

35. =
≠
GOUT
HYPERURICEMIA GOUT
HYPERURICEMIA

36. HOW MANY WILL PROGRESS?

37. HOW MANY WILL PROGRESS?

38. HOW MANY WILL PROGRESS?

40. Uric acid levels correlate with OA severity
• Uric acid (UA) is known to activate the NLRP3
• NLRP3 (also known as NALP3) inflammasome à IL-18 and IL-1β.
• Synovial fluid uric acid was strongly correlated with synovial fluid IL-18
and IL-1β.
• Synovial fluid uric acid and IL-18 were strongly and positively associated
with OA severity as measured by both radiograph and bone scintigraphy
• Synovial fluid IL-1β was associated with OA severity but only by
radiograph.
• Synovial fluid IL-18 was associated with a 3x change in OA severity, on
the basis of the radiograph.
• Synovial fluid uric acid is a marker of knee OA severity.
• There is potential involvement of the innate immune system in OA
pathology and OA progression.

41. OA Pathogenesis by Phenotype

42. IN A NUTSHELL, WHAT SHOULD I ASK?

43. Threee clinical clues/questions
(you should ask)
• EPISODIC
• EXQUISITE PAIN/TENDERNESS
• EXACERBATING FACTORS
– Diuretics, IV Heparin,
Cyclosporine
– Trauma, alcohol ingestion,
surgery, dietary excess,
hemorrhage, foreign protein
therapy, infections, radiographic
contrast exposure
– 20% of hospitalized patients
develop a gout attack (esp if
with previous Hx)

44. EPISODIC: Sample Questions
• Ang pagsakit po ba ng kasukasuan nyo: tuloy-
tuloy o pasulpot-sulpot lang?
• Ang sakit po ba ay araw-araw o umaatake lamang?
• Pag sumakit po ba, bumabalik sa normal pag
nakainom kayo ng gamot o pagkalipas ng ilang
araw kahit walang gamot?
• May mga araw po ba na walang sakit at normal
lang o walang limitasyon ang galaw ng
kasukasuan nyo?

45. EXQUISITE PAIN: Sample Questions
• Pag sumakit or umatake ang sakit, nahihirapan ba
kayong igalaw yun masakit na kasukasuan?
• Hindi nyo na ba naigagalaw or hindi na ba kayo
nakakalakad sa mga araw na inaatake ng sakit?
• Malubha po ba ang sakit na nagkakaroon ng
pagkakataon na ayaw nyong pahipo o pahawakan
yun masakit na bahagi? Masakit ba kahit mahipan
o madampian lang?

46. EXACERBATING FACTORS:
Sample Questions
• May nakain o nainom ka ba bago mo
naramdaman yun sakit?
• Nangyari na ba ito dati?
• Umiinom po ba kayo ng gamot para sa high blood
(diuretics) , sa sakit sa puso (Aspirin), o sa gout
(Allopurinol or Febuxostat)?
• Naospital po ba kayo kamakailan?
• Malakas ba kayo uminom ng alak o soft drinks?

47. REVIEW OF THE CASES

48. CASE 1
• A 54 y.o male family driver
consults for pain in the left knee
on going up and down the stairs,
for 2 years now.About 2 months
ago, after driving long distance,
the pain got worse and he now
limps when walking.There is no
fever or malaise.
• Joint PE: left knee is swollen,
warm, + bulge sign.There is 2+
tenderness and limited flexion
and extension.The right knee
appears normal, but is positive for
fine crepitations.
• A: Articular
• C: Chronic
• I: Inflammatory
• N: Monoarticular

49. CASE 2
• A 48 y.o businessman came
home from a party the night
prior to consult and woke up
with an inflamed right big
toe. He was feverish and
could not walk. He admitted
to drinking beer and had
“pulutan” of kilawin. He had
a similar episode 4 years
prior, lasting 2 days.
• Joint PE: Swollen,
erythematous, warm and
exquisitely tender right 1st
MTP joint.
• A: Articular
• C: Acute
• I: Inflammatory
• N: Monoarticular

50. CASE
• A 45 y.o. housewife consulted
for swelling and pain of both
wrists and small hand joints
of 4 months duration. Pain is
worse in the morning,
associated with stiffness
lasting for 1 hour. She takes
Alaxan tablets as needed,
with temporary pain relief.
• Joint PE: Swelling , warmth
and tenderness of both wrists,
and 1st and second PIPs of
both hands. Other joints and
systemic PE are normal
• A: Articular
• C: Chronic
• I: Inflammatory
• N: Polyarticular

51. CASE
• A 35 y.o. female PA of a famous
celebrity consulted for swelling
and pain of the R wrist and 4
weeks duration. Pain is worse at
the end of the day, especially
after a long day of writing,
texting and carrying her boss’
stuff. She takes Arcoxia tablets as
needed, with temporary pain
relief.
• Joint PE: Tenderness of R wrist,
with pain on thumb flexion, digit
flexion and sharp ulnar deviation
of the wrist. No pain on PROM.
Other joint PE are normal
• A: Non-Articular
• C: Acute
• I: Non-inflammatory
• N: Mono

52. APPROACH TO URATE LOWERING
THERAPY AND PROPHYLAXIS

54. INDICATIONS FOR ULT
• At least 2 flares per
year
• Presence of tophi
• Radiographic changes
of arthropathy
• Nephrolithiasis
• Comorbid conditions
that may complicate
treatment of gout
(CKD, CVD)

56. TREAT TO TARGET: SUA in GOUT

58. SUMMARY
• Always go back to the basics: A-C-I-N
• The 2014 and 2015 Classification Criteria have
excellent SEN/SPEC and are appropriate for
settings where lab and imaging are difficult
• Gout is almost always associated with
hyperuricemia but hyperuricemia in itself rarely
leads to gout

59. SUMMARY
• High uric acid is a predictor for more severe OA.
SUA is not indicated for all arthritis Pxs but may be
helpful in explaining prognosis in Pxs with OA
• Gout affects joints previously damaged by OA.
Gout, when recurrent, and in the long term, may
cause secondary OA
• Asking the thrEEE questions can be helpful in
diagnosing gout and differentiating it from OA

60. RheumaHelper App
(Itunes and Google Play)

61. Don’t let patients suffer too long…
CONSULT YOUR RHEUMATOLOGISt J