In the days before adequate treatment controlled the blood level of uric acid, chronic gout presented with multiple joint involvement and chronic poly-arthritis. Today this is rare and only found in patients who refuse medication, have poor compliance or unable to take suitable medication.

Here the acute gout attack will become more frequent. Then other joints become involved. The crystals deposited in and around the joints are needle shaped and I suspect this is why acute gout is so painful.

I had an elderly patient who had heart failure and was on large doses of diuretics and ace inhibitors. She developed acute gout. Her medication was looked at and altered. Unfortunately her uric acid level remained very high. She was started on allopurinol.

She developed an allergic rash to allopurinol. In fact everything the consultant prescribed gave her problems. In the end she had no medication and refused any attempt to try anything for her gout because she was worried about side effects.

She was put on a specific diet. Eventually she developed poly-arthritis. Her fingers had big nobbles for joints and she had problems walking around her ground floor flat. Tophi developed first on the ear then elsewhere.

A joint badly damaged by chronic gout will on x-ray show erosions, secondary calcium deposits and soft tissue swelling.

Allopurinol is the drug of choice in chronic gout. By maintaining the blood level of uric acid within the normal range, separation of urate crystals into joints and kidneys are prevented.

Dr. Phil Hariram.

Arthritis Guide.