Definition

Gout is the most common form of inflammatory arthritis in which there is

increase uric acid in the bloodstream and accumulation of uric crystals or
monosodium urate (gout) within the tissues in the body. These crystals deposit into
the joints causing inflammation and joint pain.

Its incidence increases with age and is three times more common in men. In a
study done by Singh (2008), it was found out that new-onset gouty arthritis is
common in the elderly population. This seems to be related to increasing lifespan,
and thus the age-related diseases such as hypertension and effects of associated
treatment as with diuretics.

Signs and Symptoms

Gout has four distinct stages:

1. Asymptomatic hyperuricemia
2. Acute gouty arthritis
3. Intercritical gout
4. Chronic tophaceous gout

Acute Gouty Arthritis

In an acute presentation, severe pain, redness, swelling, and warmth in one or more
joints will be noticed. Severe tenderness will be noted in involved joints. Symptoms
worsen within the first 24 hours. Joint involvement includes the joints in the toes, the
instep/forefoot, the ankle, the knee, the wrist, and the fingers. Untreated acute gout
usually resolves within 1-3 weeks.

Intercritical Gout
This is the period between two attacks of gout. Approximately 60% of patients have
a second attack within the first year, and 78% have a second attack within 2 years.
Only 7% of patients do not have a recurrence within a 10-year period, (Singh, 2008).

Chronic Tophaceous Gout

Tophaceous disease is more likely to occur in patients with multiple joint

involvement, a serum urate level higher than 9.0 mg/dL, and a younger age at
disease onset (40.5 years or younger). The rate of urate deposition and,
consequently, the rate of tophi formation (crystalline deposits accumulating in
articular, osseous, and soft tissue as well as the cartilage), correlate with the
duration and severity of hyperuricemia. The most common sites include the joints of
the hands and feet. The helix of the ear, the elbow, and the Achilles tendon are
classic, though less common, locations for tophi. Additionally, urate deposition in
kidneys could lead to nephrolithiasis.

Risk Factors

Predisposing Factor

 Age- Higher incidences of gouty arthritis are reported among elderly clients
specifically 60 years and above. According to healthtalk.org, gouty arthritis
increases with age and frequent attacks happen more often this is because
the kidneys which are responsible for the excretion of this waste material in
the body had a decreased function due to aging process.
 Gender- Men tend to develop gouty arthritis earlier than women because men
considered to have high levels of uric acids in their bodies. On the other hand,
women in their postmenopausal years begin to have the same levels of uric
acid level as of those in men since there is already a decline in their hormone
estrogen. Based on the study of McCLory and Said (2009), serum uric acid
levels is regulated by estrogen, a hormone that is predominant among
women, since it enhances renal uric acid excretion.
 Race: African-American are at a higher risk of developing gouty arthritis.
According to Singh(2014), African-american had this genetic marker that is
associated with hyperuricemia that places them at increased risk of having
gouty arthritis.

Predisposing Factor

 Alcohol Consumption- Increased amount of alcohol consumption can increase

the risk of having gouty arthritis considering that older people have decreased
kidney function. These beverages have actually contained large amounts of
purines thus higher incidence of gouty attacks happen after large
consumption of alcoholic beverages.
  Medication- specific medication can affect levels of uric acids in the body this
includes diuretics. Diuretics can increase urination does the available fluid in
the body becomes more concentrated, thus an increase build-up of crystals in
the joints increase. Also, other diuretic medication can affect the excretion of
urate, a component of uric acid.

 Consumption of frustose rich beverages- Sweetened beverages are not

known to contain a lot of purines but drinks rich in fructose, which a
carbohydrate known to increase uric acid levels. According to a study,
consumption of two or more sugars a day specifically fructose contained soda
can increase up 85 percent risk of developing gouty arthritis.

 Diet: High in purine diet can increase the risk among older people to develop
gouty arthritis. These food include internal organs of animals, beans , meat,
poultry and etc. because this kind of food are rich in purine, which are
substances converted into uric acid in our body.

Treatment

Medications used to treat Gout:

 Nonsteroidal anti-inflammatory drugs (NSAIDs)

o Examples include indomethacin (Indocin), ibuprofen (Advil),
and naproxen(Aleve). Newer drugs such as celecoxib (Celebrex) can
also be used. Aspirin should not be used for this condition.
o High doses of anti-inflammatory medications are used to control the
inflammation and can be tapered off within a couple of weeks.
o Tell a doctor about other health problems, particularly if one has a
history of peptic ulcer disease or intestinal bleeding, if one is
taking warfarin(Coumadin), or if one has problems with kidney function.
o The primary complications of these medications include upset
stomach, bleeding ulcers, and decreased kidney function.
 Colchicine (Colcrys)
o This medication is given in two different ways, either to treat the acute
attack of arthritis or to prevent recurring attacks.
 o To treat the hot, swollen joint, colchicine is given rapidly (generally, two
tablets at once followed by another tablet an hour later).
o To help prevent an attack from coming back, colchicine can be given
once or twice a day. While the chronic use of colchicine can reduce the
attacks of gout, it does not prevent the accumulation of uric acid that
can lead to joint damage even without attacks of hot, swollen joints.
o Tell a doctor if experiencing any problems with kidney or liver function.
 Corticosteroids
o Corticosteroids such as prednisone (Meticorten, Sterapred, Sterapred
DS) are generally given when a doctor feels this is a safer approach
than using NSAIDs.
o When given by mouth, high-dose corticosteroids are used initially and
tapered off within a couple of weeks. It is important to take these
medications as prescribed to avoid problems.
o Some complications with the short-term use of corticosteroids include
altered mood, elevated blood pressure, and problems with control of
glucose in patients with diabetes.
o Corticosteroids can also be injected into the swollen joint. Resting the
joint temporarily, after it is injected with steroids, can be helpful.
o Occasionally, corticosteroids or a related
compound, corticotropin (ACTH), can also be injected into the muscle
or given intravenously.

In addition to low-dose colchicine, other medicines used to prevent further attacks of

gout and lower the level of uric acid in the blood include the following:

 Probenecid (Benemid)
o This medication helps the body eliminate excess uric acid through the
kidneys and into the urine.
o Individuals should drink at least 2 liters of fluid a day while taking this
medication (to help prevent uric acid kidney stones from forming).
o Advise a doctor if one has kidney problems or a history of kidney
stones or if taking aspirin. One may need to take allopurinol (see
below) instead.
 o There are a number of drug interactions with probenecid, so advise a
doctor of other medications. If prescribed a new medication, let a
doctor know that you are taking probenecid.
 Allopurinol
o This medication decreases the formation of uric acid by the body and is
a very reliable way to lower the blood uric acid level. Allopurinol is
currently the gold standard of maintenance therapy.
o Advise your doctor if you have kidney problems. Allopurinol can be still
used, but the dose may need to be adjusted.
o Common side effects include stomach pain, headache, diarrhea,
and rash.
o Discontinue allopurinol if you develop a rash or a fever, and call your
doctor.
o A very rare risk of allopurinol hypersensitivity exists. This problem can
cause a severe skin rash, fever, kidney failure, liver failure, bone
marrow failure, and can be fatal.
o Advise your doctor if you are taking azathioprine (Azasan, Imuran), 6-
mercaptopurine, or cyclophosphamide (Cytoxan, Cytoxan
Lyophilized, Neosar); dose adjustments of allopurinol may be needed.
o Ampicillin (Principen) is more likely to cause a rash if you are taking
allopurinol.
 Febuxostat (Uloric)
o Febuxostat is first new medication developed specifically for the control
of gout in over 40 years.
o Febuxostat decreases the formation of uric acid by the body and is a
very reliable way to lower the blood uric acid level.
o Febuxostat can be used in patients with mild to moderate kidney
impairment.
o Febuxostat should not be taken with 6-mercaptopurine (6-MP), or
azathioprine.
 Pegloticase (Krystexxa)
o Pegloticase is a PEGylated uric acid-specific enzyme given
intravenously that is indicated for the treatment of chronic gout in adult
patients refractory to conventional therapies described above.
 o Pegloticase should be avoided if you have G6PD enzyme deficiency.
o Serious allergic reactions can occur with pegloticase, including life-
threatening anaphylaxis.

Nursing Interventions and Rationales

Desired Outcome:

Treat the acute attack, prevent future flare ups/attacks, lower excess stores of urate.

Nursing Interventions and Rationales:

1. Treat pain: administer medications, apply warm or cool compresses, positioning.

Rationale: Patients in an acute attack will experience pain and require appropriate
pain control and interventions.

2. Assist with mobility.

Rationale: Patients may have an impaired ability to mobilize due to inflammation and
pain; assist for safe ambulation and transfer especially in elderly.

3. Closely monitor amount of inflammation at joint.

Rationale: Enables you to know if symptoms are worsening or resolving (therefore

telling you if interventions are working)

4. Promote adequate intake of fluids.

Rationale: Prevents dehydration and aides in the excretion of uric acid

5. Assist with Active ROM or Passive ROM.

Rationale: Prevents joint stiffness and immobility.

6. Cluster care; maximize rest.

Rationale: Prevents fatigue; enables patient to participate inasmuch self-care as

possible.

7. Educate about dietary and lifestyle changes. (Decreasing alcohol intake, foods high
in purines, foods/drinks sweetened with fructose, weight reduction, and adequate
hydration)

Rationale: Doing so decreases the likelihood of future flare ups and/or attacks.

8. Initiate fall precautions/prevent injury.

Rationale: Joint pain, particularly in the foot, will put them at higher risks for fall and
injury due to their impaired mobility.

Sources:

 Hinkle, J, & Cheever, K. (2014). Textbook of Medical-Surgical Nursing 13th

ed. Vol. 1. Chapter 39.

 Singh, H. (2008). Diagnosis and Management of Gout in the Long-term Care

Setting. Retrieved from
https://www.managedhealthcareconnect.com/article/7335 on Sept. 6,
2018.

 McCLory, J. & Said, N. (2009) Gout in Women retrieved September 6, 2018

from http://rimed.org/medhealthri/2009-11/2009-11-363.pdf

 Singh, J. (2013) Racial and Gender Disparities in Patients with Gout retrieved
September 6, 2018 from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3545402/

 Shiel, W. (2018) Gout treatments and medications, emedicinehealth, retrieved

September 6, 2018 from
https://www.emedicinehealth.com/gout/article_em.htm#can_dietary_changes_
prevent_gout
 Nursing Care Plan for Gout. (2017, June 30). Retrieved from
https://www.nrsng.com/care-plan/gout/