Gout — গাউট: ক্লিনিক্যাল বাংলা নোট + Bangladesh Brand Guide
নোট: নিচের ডোজগুলো adult guideline-based educational dosing। রোগীর eGFR/CKD, LFT, peptic ulcer, anticoagulant use, CVD risk, pregnancy, drug allergy দেখে dose adjust করতে হবে। Serum uric acid normal থাকলেও acute flare-এ gout বাদ যায় না।
1) Definition — গাউট কী?
Gout হলো monosodium urate crystal deposition disease, যেখানে রক্তে uric acid বেশি থাকার কারণে joint/soft tissue-তে urate crystal জমে acute inflammatory arthritis হয়। সবচেয়ে classic presentation হলো 1st metatarsophalangeal joint-এর sudden severe pain — যাকে podagra বলা হয়।
2) Cause / Etiology — কেন হয়?
A. মূল কারণ: Hyperuricemia
রক্তে urate বেশি হলে crystal তৈরি হয়। Hyperuricemia থাকলেই সব রোগীর gout হবে না, কিন্তু gout-এর প্রধান biochemical ভিত্তি এটিই। NICE অনুযায়ী serum urate ≥6 mg/dL / 360 µmol/L gout diagnosis-কে support করে; তবে flare চলাকালীন urate কম/normalও থাকতে পারে।
B. Uric acid under-excretion — সবচেয়ে common mechanism
কিডনি দিয়ে uric acid কম বের হলে gout হয়।
- CKD / renal impairment
- Dehydration
- Diuretics: thiazide, loop diuretic
- Low-dose aspirin
- Cyclosporine / tacrolimus
- Pyrazinamide, ethambutol
- Obesity, metabolic syndrome, hypertension, diabetes, dyslipidemia
C. Uric acid over-production
শরীরে purine breakdown বেশি হলে uric acid বেশি তৈরি হয়।
- Myeloproliferative disease
- Hemolysis
- Tumor lysis syndrome
- Psoriasis
- High purine diet: red meat, organ meat, seafood
- Alcohol, especially beer/spirits
- Fructose-rich sugary drinks
D. Pathophysiology — সহজ ভাষায়
Purine metabolism থেকে xanthine oxidase enzyme uric acid তৈরি করে। Uric acid বেশি হলে ঠান্ডা peripheral joint-এ crystal জমে। Crystal immune system activate করে, বিশেষ করে NLRP3 inflammasome → IL-1β → neutrophil inflammation, তাই joint হঠাৎ লাল, গরম, ফুলে ও প্রচণ্ড ব্যথাযুক্ত হয়।
3) Symptoms — লক্ষণসমূহ
Acute gout flare
- হঠাৎ severe joint pain, অনেক সময় রাতে শুরু হয়।
- Joint red, hot, swollen, tender হয়।
- Bedsheet touch করলেও অসহ্য ব্যথা হতে পারে।
- ব্যথা সাধারণত 12–24 ঘণ্টার মধ্যে peak করে।
- Common joints:
- 1st MTP joint — big toe, podagra
- Ankle
- Midfoot
- Knee
- Wrist
- Elbow
- Finger joints
- Mild fever, malaise থাকতে পারে।
Intercritical gout
- Flare-এর মাঝখানে রোগী symptom-free থাকতে পারে।
- কিন্তু crystal deposition চলতে পারে।
Chronic tophaceous gout
- দীর্ঘদিন uncontrolled gout থাকলে tophi হয়।
- Tophi দেখা যায়:
- Ear pinna
- Olecranon bursa
- Finger
- Toe
- Achilles tendon
- Joint deformity, stiffness, chronic pain হতে পারে।
Renal symptoms
- Uric acid stone হলে:
- Flank pain
- Hematuria
- Dysuria
- Recurrent renal colic
4) Clinical Diagnosis — clinically কীভাবে diagnosis করবেন?
Strong clinical clue
- Adult male/postmenopausal female
- Sudden onset monoarthritis
- 1st MTP involvement
- Recurrent similar attack
- Hyperuricemia risk factor
- Rapid response to colchicine/NSAID
Gold standard diagnosis
Synovial fluid microscopy: needle-shaped, negatively birefringent monosodium urate crystals দেখা গেলে gout confirm। Diagnosis uncertain হলে NICE synovial fluid microscopy recommend করে।
Important clinical warning
Septic arthritis must be excluded if fever, toxic look, first attack, immunosuppression, prosthetic joint, or very high inflammatory marker থাকে। Septic arthritis and gout একসাথেও থাকতে পারে।
5) Investigations — specific work-up
| Test | কেন করবেন |
| Serum uric acid | Diagnosis support ও treatment target monitoring। Acute flare-এ normal হতে পারে; সন্দেহ থাকলে flare settle হওয়ার ≥2 সপ্তাহ পরে repeat। |
| Synovial fluid analysis | MSU crystal confirm; WBC count, Gram stain, culture দিয়ে septic arthritis exclude। |
| CBC, ESR, CRP | Inflammation/sepsis suspicion assess। |
| Serum creatinine, eGFR, electrolytes | NSAID/colchicine/allopurinol/febuxostat dosing ও renal risk assessment। |
| LFT | Febuxostat/allopurinol/steroid safety monitoring। |
| Fasting glucose/HbA1c, lipid profile, BP | Metabolic syndrome screening। |
| Urinalysis ± urinary uric acid | Stone, hematuria, recurrent/young/severe gout evaluation। |
| X-ray | Chronic gout: punched-out erosion, overhanging edge। Early gout-এ normal হতে পারে। |
| Ultrasound | Double contour sign, tophus, crystal deposition। |
| DECT | Urate deposition detect; aspiration possible না হলে useful। NICE uncertain diagnosis-এ X-ray/US/DECT consider করতে বলে। |
6) Differential Diagnosis
- Septic arthritis
- CPPD disease / pseudogout
- Cellulitis
- Trauma/fracture
- Reactive arthritis
- Rheumatoid arthritis flare
- Psoriatic arthritis
- Osteoarthritis flare
- Bursitis/tendinitis
7) Complications — রোগের জটিলতা
- Recurrent acute flare: বারবার joint pain, disability, work loss।
- Chronic gouty arthritis: joint cartilage ও bone damage হয়ে deformity।
- Tophi: skin ulceration, infection, nerve compression, cosmetic deformity।
- Renal stone: uric acid stone → renal colic, hematuria।
- CKD progression risk: uncontrolled urate burden ও comorbidity-এর সাথে renal deterioration।
- Functional disability: walking difficulty, hand function loss।
- Medication complications: NSAID-induced GI bleeding/AKI, colchicine toxicity, steroid-induced hyperglycemia, allopurinol hypersensitivity।
8) Treatment / Management
A. Acute gout flare — general principle
- Pain শুরু হওয়ার যত দ্রুত সম্ভব treatment শুরু।
- Rest, affected joint elevation, ice pack।
- Acute flare-এ সাধারণত একটি anti-inflammatory strategy:
- Colchicine, অথবা
- NSAID, অথবা
- Oral/intra-articular corticosteroid
- Patient আগে থেকেই allopurinol/febuxostat খেলে flare-এর সময় বন্ধ করবেন না।
- ULT নতুন করে শুরু সাধারণত flare settle হওয়ার 2–4 সপ্তাহ পরে; frequent flare হলে prophylaxis দিয়ে flare চলাকালেও শুরু করা যায়। NICE ULT usually lifelong এবং treat-to-target approach recommend করে।
B. Acute flare drugs — Bangladesh prescription-used list
1) Colchicine
| Point | Details |
| Generic name | Colchicine |
| Therapeutic category | Anti-gout medicine |
| Pharmacological class | Microtubule inhibitor; neutrophil migration/inflammation কমায় |
| Purpose — কেন used হয় | Acute gout flare-এর pain/inflammation কমাতে; ULT শুরু করলে flare prophylaxis হিসেবেও used হয়। DailyMed colchicine-কে acute flare treatment ও prophylaxis—দুই indication-এই উল্লেখ করেছে। |
| Adult acute dose | 0.6 mg tablet হলে: 1.2 mg stat, then 0.6 mg after 1 hour; max 1.8 mg/course। 0.5 mg tablet হলে practical equivalent: 1 mg stat, then 0.5 mg after 1 hour। |
| Prophylaxis dose | 0.5/0.6 mg once or twice daily, usually 3–6 months during ULT titration; ACR prophylaxis at least 3–6 months recommend করে। |
| Duration | Acute: usually 1 day loading, এরপর প্রয়োজন হলে 0.5/0.6 mg OD–BD short course। Prophylaxis: 3–6 months or until urate target stable। |
| Side effects | Diarrhea, abdominal pain, nausea/vomiting; serious toxicity: myopathy, neuropathy, bone marrow suppression, multiorgan toxicity। |
| Major interactions | Clarithromycin/erythromycin, azole antifungal, HIV protease inhibitor, verapamil/diltiazem, cyclosporine, tacrolimus, statin। Strong CYP3A4/P-gp inhibitor + renal/hepatic impairment হলে colchicine contraindicated/toxic risk high। |
| Bangladesh available brand name | Colimax 0.6 mg, Coluric 0.6 mg, Colut 0.6 mg, Kolchin 0.5 mg, Kolchin 0.6 mg। MedEx therapeutic class: Drugs used in Gout। |
2) Naproxen
| Point | Details |
| Generic name | Naproxen |
| Therapeutic category | Analgesic, anti-inflammatory |
| Pharmacological class | NSAID; non-selective COX inhibitor |
| Purpose — কেন used হয় | Acute gout flare-এ pain, swelling, inflammation দ্রুত কমাতে। |
| Adult dose | MedEx acute gout dose: 750 mg initially, then 250 mg every 8 hours until attack passed। Common practice: 500 mg BD short course। |
| Duration | Usually 3–5 days; severe flare-এ 7 days পর্যন্ত, clinical response অনুযায়ী। |
| Side effects | Dyspepsia, gastritis, GI bleeding, AKI, fluid retention, hypertension, headache, dizziness। |
| Major interactions | Warfarin/DOAC/aspirin/SSRI → bleeding risk; ACEi/ARB + diuretic → AKI risk; methotrexate/lithium toxicity; other NSAID avoid। MedEx naproxen interaction list-এ ACE inhibitor, aspirin, diuretic, methotrexate, warfarin, SSRI উল্লেখ আছে। |
| Avoid/caution | Peptic ulcer/GI bleed, CKD, heart failure, uncontrolled HTN, anticoagulant use, late pregnancy। |
| Bangladesh available brand name | Napro 250/500 mg, Napro-A 250/500 mg, Naprosyn 250/500 mg, Naprox 250/500 mg, Naproxin 250/500 mg, Napryn 250/500 mg, Napsod 275/550 mg। |
3) Etoricoxib
| Point | Details |
| Generic name | Etoricoxib |
| Therapeutic category | Analgesic, anti-inflammatory |
| Pharmacological class | Selective COX-2 inhibitor NSAID |
| Purpose — কেন used হয় | Acute gouty arthritis-এর pain/inflammation কমাতে; nonselective NSAID-এর তুলনায় platelet/GI effect কম, কিন্তু CV risk বেশি গুরুত্বপূর্ণ। |
| Adult dose | 120 mg once daily, acute gout trial duration up to 8 days। |
| Duration | Shortest possible; usually 3–8 days। |
| Side effects | Hypertension, edema, palpitation, dyspepsia, renal dysfunction, liver enzyme elevation, dizziness। |
| Major interactions | Warfarin → PT/INR increase; ACEi/ARB/diuretic effect reduce & renal risk; cyclosporine/tacrolimus nephrotoxicity; lithium increase। |
| Avoid/caution | Ischemic heart disease, stroke/TIA, PAD, CHF NYHA II–IV, uncontrolled HTN, active GI bleed/PUD, CrCl <30 ml/min, pregnancy/lactation। |
| Bangladesh available brand name | Aroxia 60/90/120 mg, Algirex 60/90/120 mg, Artorix 60/90/120 mg, Cox-E 60/90/120 mg, Coxia 60/90/120 mg, Coxitor 30/60/90/120 mg, Setorib 60/90/120 mg, SB-Eto 60/120 mg, Starcox 60/90 mg, Temcox 60/90/120 mg। MedEx therapeutic class: NSAIDs। |
4) Indomethacin
| Point | Details |
| Generic name | Indomethacin |
| Therapeutic category | Analgesic, anti-inflammatory |
| Pharmacological class | NSAID; indole-acetic acid derivative |
| Purpose — কেন used হয় | Acute gout flare-এ potent anti-inflammatory effect-এর জন্য historically widely used। |
| Adult dose | MedEx acute gout dose: 150–200 mg/day in divided doses; SR capsule হলে 75 mg BD used হয়। |
| Duration | Usually 2–5 days high-dose, তারপর response অনুযায়ী taper/stop। |
| Side effects | GI irritation/bleeding, headache, vertigo, dizziness, renal dysfunction, BP rise। MedEx headache, vertigo, GI effect উল্লেখ করেছে। |
| Major interactions | Anticoagulant, lithium, diuretic/antihypertensive, sulfonylurea; ulcer/gastritis/active UC-তে avoid। |
| Bangladesh available brand name | I-Cin 25 mg, Imet 25 mg, Imet SR 75 mg, Indocap 25 mg, Indomet 25 mg, Indomet SR 75 mg, Indomin 25 mg, Indorex 25 mg, Indoseem 25 mg, Indoxyl 25 mg, Inflacin 25 mg, Insaid 25 mg, Reumacap 25 mg, Reumacap SR 75 mg, Rheumet 25 mg। Rectal: Indo-A 100 mg suppository, Indomet 100 mg suppository। |
5) Diclofenac
| Point | Details |
| Generic name | Diclofenac sodium |
| Therapeutic category | Analgesic, anti-inflammatory |
| Pharmacological class | NSAID |
| Purpose — কেন used হয় | Acute painful inflammatory arthritis-এ pain/swelling control; gout indication হিসেবে MedEx diclofenac sodium তালিকাভুক্ত করেছে। |
| Common adult dose | 50 mg TDS after meal, অথবা SR 100 mg OD; IM 75 mg deep IM only selected severe pain cases, repeated routine use avoid। |
| Duration | Short course, usually 3–5 days। |
| Side effects | Dyspepsia, GI bleed, renal injury, edema/HTN, hepatotoxicity, cardiovascular risk। |
| Major interactions | Anticoagulant/antiplatelet/SSRI → bleeding; ACEi/ARB/diuretic → AKI; lithium/methotrexate toxicity; other NSAID avoid। |
| Bangladesh available brand name | A-Fenac 50 mg, A-Fenac SR 100 mg, Diclofen 25/50 mg, Diclofen SR 100 mg, Diclofen IM 75 mg/3 ml, Diclofix 50 mg, DicloGel 1%, Diclonac IM 75 mg/3 ml, Diclonac TR 100 mg, Intafenac 50 mg, Mobifen 50 mg, Mobifen SR 100 mg। |
6) Prednisolone
| Point | Details |
| Generic name | Prednisolone |
| Therapeutic category | Corticosteroid anti-inflammatory |
| Pharmacological class | Glucocorticoid |
| Purpose — কেন used হয় | NSAID/colchicine contraindicated হলে, CKD/ulcer/anticoagulant patient-এ acute gout flare control করতে। |
| Adult dose | 30–40 mg once daily for 5 days; alternative 0.5 mg/kg/day for 5–10 days। Short course হলে সাধারণত taper লাগে না। |
| Duration | 5 days common; prolonged course হলে taper consider। |
| Side effects | Hyperglycemia, BP rise, mood change, insomnia, dyspepsia, fluid retention, infection masking; long-term use-এ osteoporosis, myopathy, adrenal suppression। MedEx glucocorticoid adverse effects list-এ fluid retention, hypertension, hyperglycemia, peptic ulcer, infection masking উল্লেখ আছে। |
| Major interactions | NSAID → GI bleed risk; rifampicin/phenytoin/carbamazepine → steroid effect কমায়; diuretic/digoxin → hypokalemia-arrhythmia risk; live vaccine caution। |
| Bangladesh available brand name | Cortan 2/5/10/20 mg, Deltasone 5/10/20 mg, Pednisol 5/10/20 mg, Precodil 2/5/10/20 mg, Pred 5/10/20 mg, Predimax 5/10/20 mg, Solone 5/10/20 mg, Adam 33 5/20 mg, Cortisol 5/10/20 mg। MedEx therapeutic class: Glucocorticoids। |
7) PPI gastroprotection — NSAID/steroid দিলে
| Point | Details |
| Generic name | Omeprazole / Esomeprazole |
| Therapeutic category | Anti-ulcerant |
| Pharmacological class | Proton pump inhibitor |
| Purpose — কেন used হয় | NSAID বা steroid-related gastritis/ulcer/GI bleed risk কমাতে; gout-এর pain কমায় না। NICE NSAID/corticosteroid use করলে PPI consider করতে বলে। |
| Common dose | Omeprazole 20 mg OD before breakfast while NSAID/steroid; high GI risk হলে clinician অনুযায়ী। |
| Side effects | Headache, diarrhea/constipation, hypomagnesemia, B12 deficiency risk with long-term use। |
| Interactions | Omeprazole + clopidogrel interaction concern; warfarin/phenytoin monitoring; long-term unnecessary use avoid। |
| Bangladesh available brand name | Losectil V 20/40 mg, Omenix 20/40 mg, Omep 10/20/40 mg, Ometid 20/40 mg, PPI 20/40 mg, Procap 20/40 mg, Proceptin 20/40 mg। |
9) Long-term urate-lowering therapy — ULT
কখন ULT দেবেন?
NICE অনুযায়ী ULT offer করা উচিত যদি থাকে: frequent/troublesome flares, CKD stage 3–5, diuretic use, tophi, chronic gouty arthritis। ULT treat-to-target: serum urate <6 mg/dL / <360 µmol/L; severe gout/tophi/frequent flare হলে <5 mg/dL / <300 µmol/L consider।
1) Allopurinol
| Point | Details |
| Generic name | Allopurinol |
| Therapeutic category | Urate-lowering therapy; anti-gout |
| Pharmacological class | Xanthine oxidase inhibitor |
| Purpose — কেন used হয় | Uric acid production কমিয়ে recurrent flare, tophi, uric acid stone prevent করে। Acute pain কমানোর drug নয়। |
| Starting dose | 100 mg once daily; CKD/eGFR low হলে 50 mg/day বা lower start। ACR allopurinol low-dose start এবং CKD-তেও first-line support করে। |
| Titration | Every 2–5 weeks/monthly serum urate দেখে 100 mg করে বাড়ানো; target <6 mg/dL। |
| Usual dose | 100–300 mg/day common; severe case-এ higher dose specialist supervision। MedEx adult dose 100–900 mg/day range উল্লেখ করে। |
| Duration | Usually lifelong if definite gout with ULT indication। NICE ULT usually lifelong বলে। |
| Side effects | Rash, GI upset, headache, drowsiness, LFT abnormality, bone marrow suppression; rare but fatal allopurinol hypersensitivity syndrome/SJS/TEN। Rash হলে immediately stop। |
| Major interactions | Azathioprine/6-mercaptopurine dose ~25% করতে হয় or avoid; ampicillin/amoxicillin rash risk; theophylline/cyclosporine monitoring; warfarin monitoring। |
| Bangladesh available brand name | Aluric 100 mg, Alurol 100 mg, Duric 100 mg, Esloric 100/300 mg, Goutex 100/300 mg, Purinol 100/300 mg, Ucorex 100 mg। MedEx therapeutic class: Drugs used in Gout। |
2) Febuxostat
| Point | Details |
| Generic name | Febuxostat |
| Therapeutic category | Urate-lowering therapy; anti-gout |
| Pharmacological class | Non-purine selective xanthine oxidase inhibitor |
| Purpose — কেন used হয় | Allopurinol intolerance, target urate not achieved, or selected CKD patient-এ urate lowering। Acute pain control করে না। |
| Starting dose | 40 mg once daily। |
| Titration | 2–4 weeks/monthly urate দেখে 80 mg once daily; selected refractory case specialist supervision-এ 120 mg। MedEx 40→80→120 mg dose range উল্লেখ করে। |
| Duration | Long-term/lifelong if indicated। |
| Side effects | Gout flare at initiation, LFT abnormality, nausea, diarrhea, headache, rash, edema। |
| Major warning | Cardiovascular thromboembolic event concern; established major CVD থাকলে allopurinol preferred। NICE major cardiovascular disease-এ allopurinol first-line বলে। |
| Major interactions | Azathioprine, mercaptopurine, theophylline contraindicated/avoid। MedEx also says colchicine/indomethacin/HCTZ/warfarin-এর সাথে usually dose adjustment লাগে না, তবে clinical monitoring দরকার। |
| Bangladesh available brand name | Barif 40 mg, Eburic 40 mg, Febout 40/80 mg, Febox 40 mg, Febuget 40/80 mg, Feburen 40/80 mg, Febus 40/80 mg, Febustat 40/80 mg, Febutek 40/80 mg, Febux 40 mg, Febuxit 40/80 mg, Feluric 40/80 mg, Floxtat 40 mg, Fostat 40 mg, Goustat 40 mg, Goutacid 40 mg, Goutil 40/80 mg, Uristat 40/80 mg, Urostat 40 mg, Xanuric 40/120 mg। MedEx therapeutic class: Drugs used in Gout। |
ULT শুরু করলে flare prophylaxis
ULT শুরু করলে urate mobilization-এর কারণে flare বাড়তে পারে। তাই:
- Colchicine 0.5/0.6 mg OD–BD for 3–6 months preferred।
- Colchicine না হলে low-dose NSAID + PPI।
- NSAID/colchicine contraindicated হলে selected case-এ low-dose prednisolone short-term, specialist supervision।
ACR ULT শুরু করার সময় colchicine/NSAID/prednisone-prednisolone prophylaxis at least 3–6 months recommend করে।
10) Bangladesh doctors commonly prescribe — practical list
Acute flare prescription pattern
- Colchicine
- Used when early acute gout flare, especially NSAID avoid করতে চাইলে।
- Best within first 24–36 hours.
- Naproxen + PPI
- Used in young/low GI-renal-CV risk patient with severe pain/swelling।
- PPI added to reduce gastric risk.
- Etoricoxib
- Used when once-daily NSAID preferred or GI tolerability concern থাকে।
- CVD/uncontrolled HTN থাকলে avoid.
- Indomethacin
- Traditional potent NSAID for acute gout।
- CNS/GI side effect বেশি, elderly/CKD/ulcer patient-এ avoid.
- Diclofenac + PPI
- Common pain/inflammation control।
- CKD, CVD, GI bleed risk থাকলে avoid/caution.
- Prednisolone
- Used when NSAID/colchicine unsuitable: CKD, ulcer, anticoagulant, elderly, multiple comorbidity।
- Diabetic patient-এ glucose monitoring essential.
Chronic/recurrent gout prescription pattern
- Allopurinol + colchicine prophylaxis
- First-line ULT; recurrent flare/tophi/CKD/stone risk থাকলে।
- Febuxostat + colchicine prophylaxis
- Allopurinol intolerance বা target urate না হলে।
- Major cardiovascular disease থাকলে caution.
- PPI with NSAID/steroid
- Gastroprotection; gout treatment নয়।
11) Prevention — কীভাবে gout prevent করবেন?
- Serum urate target maintain: <6 mg/dL; severe/tophi হলে <5 mg/dL।
- ULT adherence: allopurinol/febuxostat নিজে নিজে বন্ধ করবেন না।
- Hydration: dehydration/fasting avoid।
- Weight reduction: obesity থাকলে gradual weight loss।
- Alcohol reduce: beer/spirits ও binge drinking avoid।
- Diet: organ meat, red meat, high-purine seafood কমানো।
- Sugary drink/fructose avoid।
- Low-fat dairy, vegetables, balanced diet encourage; NICE নির্দিষ্ট gout diet-এর শক্ত evidence কম বললেও healthy balanced diet, weight and alcohol control-এর গুরুত্ব দেয়।
- Comorbidity control: HTN, DM, CKD, dyslipidemia।
- Drug review: thiazide/loop diuretic, low-dose aspirin, cyclosporine ইত্যাদি gout worsen করতে পারে; indication ছাড়া stop নয়, physician review দরকার।
- Avoid self-medication: colchicine overdose, repeated NSAID, steroid misuse dangerous।
12) Red flags — urgent referral/admission consider
- First episode hot swollen joint with fever
- Septic arthritis suspicion
- Immunosuppressed/prosthetic joint
- Severe CKD, transplant patient
- Polyarticular severe flare
- Diagnostic uncertainty
- ULT failure despite adherence
- Severe rash after allopurinol/febuxostat
- GI bleeding, AKI, uncontrolled diabetes/BP
NICE rheumatology referral consider করতে বলে diagnosis uncertain, treatment contraindicated/not tolerated/ineffective, CKD stage 3b–5, organ transplant ইত্যাদিতে।
Overview / Summary
Gout হলো MSU crystal-induced inflammatory arthritis। Diagnosis clinically suspected হলেও confirmatory test হলো synovial fluid MSU crystal। Serum uric acid flare-এর সময় normal হতে পারে, তাই প্রয়োজন হলে flare settle হওয়ার ≥2 সপ্তাহ পরে repeat করতে হবে। Acute management: colchicine/NSAID/steroid। Long-term management: treat-to-target ULT, usually allopurinol first-line, target urate <6 mg/dL; severe gout/tophi হলে <5 mg/dL consider।
Actionable Plan / Steps
- Acute hot swollen joint হলে septic arthritis exclude করুন।
- Serum urate, CBC, ESR/CRP, creatinine/eGFR, LFT, glucose/HbA1c, lipid profile করুন।
- Diagnosis uncertain/first severe flare হলে joint aspiration: crystal + Gram stain/culture।
- Acute flare: patient profile অনুযায়ী colchicine OR NSAID OR prednisolone দিন।
- Recurrent flare/tophi/CKD/stone হলে ULT indication assess করুন।
- ULT শুরু করলে low dose start + titrate to target + colchicine prophylaxis 3–6 months।
- Lifestyle: hydration, weight loss, alcohol/fructose/purine moderation, comorbidity and medication review।
- Rash, renal deterioration, GI bleed, severe infection suspicion হলে urgent review।
Reference List — Textbook + Guideline + DOI
Textbooks
- Harrison’s Principles of Internal Medicine, 21st ed. Section: Rheumatology; Chapter: Gout and Other Crystal Arthropathies.
- Davidson’s Principles and Practice of Medicine, 24th ed. Section: Musculoskeletal disorders; Topic: Crystal arthropathies / gout.
- Kelley and Firestein’s Textbook of Rheumatology, 11th ed. Chapter: Gout and hyperuricemia.
- Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 14th ed. Chapters: NSAIDs, glucocorticoids, drugs for gout.
- Katzung & Trevor’s Basic & Clinical Pharmacology, 16th ed. Chapters: NSAIDs, anti-inflammatory drugs, gout pharmacotherapy.
Guidelines
- NICE Guideline NG219: Gout—diagnosis and management, 2022.
- American College of Rheumatology Guideline for the Management of Gout, 2020.
- EULAR evidence-based recommendations for the management of gout, 2016.
Peer-reviewed DOI
- FitzGerald JD, et al. 2020 American College of Rheumatology Guideline for the Management of Gout. Arthritis Care & Research. 2020;72(6):744–760. DOI: 10.1002/acr.24180.
- FitzGerald JD, et al. 2020 ACR Guideline for the Management of Gout. Arthritis & Rheumatology. 2020;72(6):879–895. DOI: 10.1002/art.41247.
- Richette P, et al. 2016 updated EULAR evidence-based recommendations for the management of gout. Annals of the Rheumatic Diseases. 2017;76:29–42. DOI: 10.1136/annrheumdis-2016-209707.
- Neogi T, et al. 2015 Gout Classification Criteria: ACR/EULAR collaborative initiative. Annals of the Rheumatic Diseases. 2015;74:1789–1798. DOI: 10.1136/annrheumdis-2015-208237.
Md.Rafiqul Islam Lipu,Date:-17-06-2026 Wednesday,Time:-09-49-12 Pm