gout in-depth report

8/9/2019 Gout in-Depth Report

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Gout In-Depth Report

Background

Gout is a painful and common type of arthritis. About 1 in 100 people develop gout.

The rate of gout has increased in recent decades, not only in America but also in other

developed countries. The increase is possibly due to dietary and lifestyle changes,

greater use of medications that cause hyperuricemia, and aging populations. Gout is

very uncommon in less-developed countries.

The condition is usually associated with a long-lasting, abnormally high amount of

uric acid in the blood, called chronic hyperuricemia.

HOW GOUT AND HYPERURICEMIA OCCUR

Metabolism of Purines. The process leading to hyperuricemia and gout begins with

the metabolism of purines, nitrogen-containing compounds that are important for

energy. Purines can be divided into two types

• Endogenous purines are manufactured within human cells.

• Exogenous purines are obtained from foods.

All mammals except humans have an en!yme called uricase that brea"s down purinesso they can be easily removed from the body. #n humans, however, purine brea"s

down into uric acid , which is not as easily removed and can build up in body tissues.

Uric Acid and Hyperuricemia. Purines in the liver produce uric acid. The uric acid

enters the bloodstream, and most of it eventually goes through the "idneys and is

e$creted in the urine. The remaining uric acid travels through the intestines, where

bacteria help brea" it down.

%ormally these actions "eep the level of uric acid in the blood plasma &the li'uid part

of the blood( at a healthy level, which is below ).* mg+d. ut under certaincircumstances, the body produces too much uric acid or removes too little. #n either

case, concentrations of uric acid increase in the blood. This condition is "nown

as hyperuricemia.


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#f concentrations of uric acid reach mg+d and above, needleli"e crystals of a salt

called monosodium urate &/( form. As / crystals build up in the 2oints, they

trigger inflammation and pain, the characteristic symptoms of gout.

GOUT AND OTHER CONDITIONS ASSOCIATED WITH HYPERURICEMIA

3igh levels of uric acid are also associated with several other conditions. uch

conditions, described below, may occur alone or when gout goes untreated.

Acute Gouty Arthritis. Acute gouty arthritis is the stage at which the first symptoms of

gout appear. #t most often occurs in men.

Chronic Tophaceous Gout and Tophi. After several years, persistent gout can develop

into a condition called chronic tophaceous gout. This long-term condition often

produces tophi, which are solid deposits of / crystals that form in the 2oints,

cartilage, bones, and elsewhere in the body. #n some cases, tophi brea" through thes"in and appear as white or yellowish-white, chal"y nodules that have been described

as loo"ing li"e crab eyes.

4ithout treatment, tophi develop about 10 years after the initial onset of gout,

although that can range from 5 to 67 years. Tophi are more li"ely to appear early in

the course of the disease in older people. #n the elderly population, women appear to

be at higher ris" for tophi than men. 8ertain people, such as those who are receiving

cyclosporine after a transplant, have a high ris" of developing tophi.

Uric Acid ephrolithiasis !"idney #tones$. Persons who have "idney stones thatformed from uric acid are more li"ely to have higher levels of uric acid in their blood

than in their urine. This suggests that gout is responsible for this type of "idney stones.

ric acid and other "idney stones are present in 10 - 79: of patients with primary

gout, a rate of more than 1,000 times that of the general population. #n gout caused by

other conditions &called secondary gout(, the reported rate reaches 67:.

%ot all of the "idney stones in patients with gout are made of uric acid. ome are

made from calcium o$alate, calcium phosphate, or substances combined with uric

acid. ric acid stones can also form when you do not have gout or hyperuricemia

Chronic Uric Acid %nterstitial ephropathy. 8hronic uric acid interstitial nephropathy

occurs when crystals slowly form in the structures and tubes that carry fluid from the

"idney. #t is reversible and not li"ely to in2ure the "idneys.


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"idney &ailure. udden overproduction of uric acid can occasionally bloc" the

"idneys and cause them to fail. This occurrence is very uncommon but can develop

after any of the following

• 8hemotherapy for leu"emia or lymphoma

• evere heat stress from vigorous e$ercise

• ;pileptic sei!ures

• 8orticosteroid therapy for severe allergic reactions

Sympom!

Gout typically stri"es the 2oint of the big toe, but may affect other 2oints, such as the

an"le or "nee. 8ommon symptoms of gout include

• #nflammation

• Pain

•


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• #ntercritical gout

• 8hronic tophaceous gout

ASYMPTOMATIC HYPERURICEMIA

Asymptomatic means there are no symptoms. Asymptomatic hyperuricemia is

considered the first stage of gout. / slowly builds up. #t lasts for an average of 50

years.

%ote 3yperuricemia does not inevitably lead to gout. #n fact, less than 70: of cases

develop the full-blown arthritic disease.

SYMPTOMS O" ACUTE GOUTY ARTHRITIS

Acute gouty arthritis occurs when the first symptoms of gout appear. ometimes thefirst signs of gout are brief twinges of pain &petit attac"s( in an affected 2oint, which

can precede the actual full-blown condition by several years. / crystals form at

normal body temperature when concentrations in the blood reach mg+d. At lower

temperatures, crystals form at lower concentrations. ince blood temperature falls the

further blood gets from the heart, gout stri"es the toes and fingers first.

ymptoms of acute gouty arthritis include

• evere pain at and around the 2oint

o /ay feel li"e =crushing= or a dislocated bone

o 4al"ing and the weight of bed sheets may be unbearable

o sually ta"es * - 17 hours to develop

o >ccurs late at night or early in the morning and may wa"e you up

• welling that may go beyond the 2oint may e$tend beyond the 2oint

•


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Monoarticular Gout. Gout that occurs in one 2oint is called monoarticular gout.

Appro$imately )0: of all first-time monoarticular gout attac"s in middle-aged adults

occur in the big toe. This occurrence is "nown as podagra. ymptoms can also occur

in other locations.

Polyarticular Gout. #f more than one 2oint is affected, it is "nown as polyarticular gout . /ultiple 2oints are affected in only 10 - 70: of first attac"s. >lder people are

more li"ely to have polyarticular gout. The most fre'uently affected 2oints are the

foot, an"le, "nee, wrist, elbow, and hand. The pain usually occurs in 2oints on one side

of the body and it is usually, although not always, in the lower legs and feet. People

with polyarticular gout are more li"ely to have a slower onset of pain and a longer

delay between attac"s. People with polyarticular gout are also more li"ely to

e$perience low-grade fever, loss of appetite, and a general feeling of poor health.

An untreated attac" will typically pea" 76 - 6* hours after the first appearance of

symptoms, and go away after 9 - days. 3owever, some attac"s last only hours, whileothers persist as long as several wee"s.

INTERCRITICA# GOUT

#ntercritical gout is the term used to describe the periods between attac"s. The first

attac" is usually followed by a complete remission of symptoms, but left untreated,

gout nearly always recurs in the future. >ne study reported that )7: of sub2ects had at

least one further attac" within a year. At the end of 7 years, *: of patients had a

recurrence. After 10 years, ?5: of the patients reported repeat attac"s.

SYMPTOMS O" CHRONIC TOPHACEOUS GOUT

'e(elopment of Chronic Pain. 4hen gout remains untreated, the intercritical periods

typically become shorter and shorter, and the attac"s, although sometimes less intense,

can last longer. >ver the long term &about 10 - 70 years( gout becomes a chronic

disorder characteri!ed by constant low-grade pain and mild or acute inflammation.

Gout may eventually affect several 2oints, including those that may have been free of

symptoms at the first appearance of the disorder. #n rare cases, the shoulders, hips, or

spine are affected.

#ymptoms of Tophi. Tophi, the "nobby / crystal deposits that form during chronic

gout, generally form in the following locations

• 8urved ridge along the edge of the outer ear

• @orearms


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• ;lbow or "nee

• 3ands or feet -- older patients, particularly women, are more li"ely to have

gout in the small 2oints of the fingers.

• Around the heart and spine &rare(

Tophi are generally painless. 3owever, they can cause pain and stiffness in the

affected 2oint. ;ventually, they can also erode cartilage and bone, ultimately

destroying the 2oint. arge tophi under the s"in of the hands and feet can give rise to

e$treme deformities.

Cau!$! and R%!k "acor!

Gout is classified as either primary or secondary, depending on what causes the high

levels of uric acid in the blood &hyperuricemia(.

/ore than ??: of primary gout cases are referred to as idiopathic, meaning that the

cause of the hyperuricemia cannot be determined. Primary gout is most li"ely the

result of a combination of hormonal, genetic, and dietary factors. econdary gout is

caused by drug therapy or by medical conditions other than an inborn metabolic

disorder.

The following factors increase your ris" for gout

• Advancing age

• /ale gender

• @amily history of the condition

• >besity

• se of certain drugs, including diuretics, aspirin, cyclosporine, or levodopa

• ;ating a lot of purine-rich foods

• rin"ing a large amount of alcohol, particularly beer

• ;$posure to lead


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• >rgan transplants

• Thyroid problems

• >ther, serious illness

;ach ris" factor is discussed in more detail below.

AGE

Middle)Aged Adults. Gout usually occurs in middle-aged men, pea"ing in the mid-

60s. #t is most often associated in this age group with obesity, high blood pressure,

unhealthy cholesterol levels, and heavy alcohol use.

Elderly. Gout can also first develop in older people, when it occurs e'ually in men

and women. #n this group, gout is most often associated with "idney problems and theuse of diuretics. #t is less often associated with alcohol use.

Children. ;$cept for rare inherited genetic disorders that cause hyperuricemia, gout in

children is rare.

GENDER

Men. /en are significantly at higher ris" for gout. #n males, uric acid levels rise

substantially at puberty. #n about 9 - *: of American men, levels e$ceed mg+d

&considered to indicate hyperuricemia(. Gout typically stri"es only after 70 - 60 yearsof persistent hyperuricemia, however, so men who develop it usually e$perience their

first attac" between the ages of 50 and 90.

*omen. efore menopause, women have a significantly lower ris" for gout than men,

possibly because of the actions of estrogen. This female hormone appears to facilitate

uric acid e$cretion by the "idneys. &>nly about 19: of female gout cases occur before

menopause.( After menopause the ris" increases in women. At age )0 the incidence is

e'ual in men and women, and after *0, gout occurs more often in women.

"AMI#Y HISTORY

According to the %ational #nstitute of Arthritis and /usculos"eletal and "in

iseases, up to 1*: of people with gout have a family history of the condition. ome

people with a family history of gout have a defective protein &en!yme( that interferes

with the way the body brea"s down purines.

OBESITY


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• y intensifying the bodyEs production of uric acid

• y interfering with the "idneysE ability to e$crete uric acid

Alcohol use is highly associated with gout in younger adults. inge drin"ing

particularly increases uric acid levels. Alcohol appears to play less of role among

elderly patients, especially among women with gout.

#EAD E&POSURE

8hronic occupational e$posure to lead is associated with build-up of uric acid and a

high incidence of gout. A 7007 study suggested that persistent low-level e$posure to

lead may also increase the ris" for gout.

ORGAN TRANSP#ANTS

Fidney transplantation poses a high ris" for renal insufficiency and gout. #n addition,

other transplantation procedures, such as heart and liver, increase the ris". The

procedure itself poses a ris" of gout, as does the medication &cyclosporine( used to

prevent re2ection of the implant. #t also interacts with indomethacin, a common gout

treatment.

The kidneys are responsible for removing waste from the body, regulating electrolyte balance andblood pressure, and stimulating red blood cell production.

THYROID PROB#EMS


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ome studies have reported a higher occurrence of gout in people with

hypothyroidism &underactive thyroid gland(. 3ypothyroidism may even trigger gout.

There is also some evidence to suggest that an overactive thyroid gland

&hyperthyroidism( can increase uric acid levels, although not to the degree that low

thyroid hormones levels do.

Although the thyroid gland releases the hormones which govern growth and metabolism, the brain(the pituitary and the hypothalamus) manages the release and the balance of the amount of

hormones circulated.

OTHER I##NESSES

everal other conditions can cause gout. They include

• eu"emia

• ymphoma

• Psoriasis

Tr%gg$r!

Triggers are events or conditions that can set off a gout attac". 8ertain ris" factors,

including a purine-rich diet, are also considered a trigger. Triggers include

• Boint in2ury


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• >verindulging in alcohol or purine-rich foods

• >ver strenuous e$ercise

• evere illness or infection

• tress

• udden weight loss

• urgery

• sing certain drugs

3ot and humid weather may also be strongly associated with recurrent gout attac"s,according to research present at the 700) American 8ollege of


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ynovial fluid e$amination is the most accurate method for diagnosing gout. The

synovial fluid is the lubricating li'uid that fills the syno(ium &the membrane that

surrounds a 2oint and creates a protective sac(. The fluid cushions 2oints and supplies

nutrients and o$ygen to cartilage, the slippery tissue that coats the ends of bones. This

e$am also helps detect gout during intercritical periods.

The health care provider uses a needle attached to a syringe to draw out fluid from the

affected 2oint. This is called aspiration. ocal anesthesia is not used because it can

reduce the effectiveness of the procedure. 3owever, the procedure is usually only

mildly uncomfortable. Afterwards, there can be some minor discomfort in the area

where the needle was inserted, but it usually goes away 'uic"ly.

The fluid sample is sent to a laboratory for analysis. Testing can reveal the presence of

monosodium urate &/( crystals, which will nearly always confirm a diagnosis of

gout. The laboratory can also test the sample for infection.

The procedure itself can cause infection, though this occurs in less than 0.1: of

patients. Aspiration sometimes eases a patientEs symptoms by reducing swelling and

pressure on the tissue surrounding the 2oint.

Synovial fluid analysis is a method to look at the fluid that cushions a joint. t is done to helpdiagnose and treat joint!related problems such as gout.

B#OOD TEST "OR URIC ACID #E'E#S

A blood test is usually given for measuring uric acid and detecting hyperuricemia. A

low level of uric acid in the blood ma"es a diagnosis of gout much less probable, and


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a very high level increases the li"elihood of gout. ome e$perts argue, however, that

such measurements are not very useful, given that uric acid levels in the blood during

an attac" of gout can lie within or below the normal range, and the presence of

hyperuricemia doesnHHt necessarily mean someone has gout. 3owever, new research

suggests that closer monitoring of blood uric acid levels in those with gout may help

reduce gout flares as well as health care costs.

URINE TESTS

#t is sometimes helpful to gauge the amount of uric acid found in a patientHHs urine,

particularly if the patient is young and has pronounced hyperuricemia that might be

related to a metabolic disorder. #f uric acid in the urine e$ceeds a particular value,

further tests for an en!yme defect or other identifiable cause of gout should be

performed. Greater-than-normal amounts of uric acid in the urine also mean that the

patient is more li"ely to develop uric acid "idney stones.

Typically, a 76-hour urine test is performed. The patient discards the first urination

sample on the day of the test. Afterward all urine passed over the ne$t 76 hours is

collected into a special container, including the first urination on the morning of day

two. The container is delivered to the patientEs health care provider or sent directly to

the laboratory.

The urine is collected during an intercritical period, after the patient has been placed

on a purine-reduced diet. The patient is also as"ed to temporarily stop using alcohol

and any medications that can interfere with the test. The patient should not change any

of his or her usual eating or drin"ing patterns when performing this test.

IMAGING TESTS

+),ays. @or the most part, $-rays do not reveal any problems during the early stages

of gout. Their usefulness lies in assessing the progress of the disorder in its chronic

phase and identifying other health problems with symptoms similar to gout. Tophi can

be seen on $-rays before they become apparent on physical e$amination.

Ad(anced %maging Techni-ues. Advanced imaging techni'ues being investigated for

identifying tophi include computed tomography &8T(, magnetic resonance imaging&/


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occurs in one 2oint from other arthritic conditions. The two disorders that may confuse

this diagnosis are pseudogout and septic arthritis. 8hronic gout can often resemble

rheumatoid arthritis. everal other conditions may at some point in their course

resemble gout. Pseudogout is a condition most li"ely to be confused with gout. ee

bo$ = Pseudogout !Calcic Gout$.=

PSEUDOGOUT (CA#CIC GOUT)

"seudogout (also called calcic gout and calcium pyrophosphate dihydrate depositiondisease) is a common inflammatory arthritis among older adults. t is very similar togout, but is caused by deposits of calcium pyrophosphate dihydrate crystals in andaround the joints.

Although symptoms of pseudogout resemble gout in some ways, there are differences#

• The first attack typically strikes the knee. $ther joints commonly affected are

the shoulders, wrists, and ankles. At least two!thirds of cases affect more thanone joint during a first attack. t may involve any joint, although the small jointsin the fingers or toes are not commonly affected.

• The symptoms of pseudogout also appear more slowly than those of gout,

taking days rather than hours to develop.

• "seudogout is more likely to first develop in elderly people, particularly those

with osteoarthritis. (t affects %& ! %' of people over '.)

"seudogout is more likely to occur in the autumn while gout attacks are most common

in the spring.*ho +ets "seudogout

-onditions that are associated with a higher risk for pseudogout in elderly patientsinclude underlying acute medical conditions, trauma, or surgery. edical conditionsassociated with pseudogout include hypothyroidism, diabetes, gout, and osteoarthritis./iver transplantation also may increase the risk.

0ow s "seudogout Treated

There is no cure for pseudogout. t is a progressive disorder that can eventuallydestroy joints. Treatments for pseudogout are similar to those for gout and are aimedat relieving the pain and inflammation and reducing the fre1uency of attacks.

• 2SA3s are effective for treating inflammation and pain from pseudogout.

• 4or acute attacks in large joints, fluid aspiration alone or with corticosteroids

may help.

• -olchicine may be used for acute attacks.


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• agnesium carbonate may help dissolve crystals but e5isting hard deposits

may remain.

• Surgery may be re1uired for joint replacement.

,heumatoid Arthritis. n the other hand, 2oint infection not

associated with surgery might indicate sepsis, which is a widespread and potentially

life-threatening bacterial infection that can cause inflamed 2oints, chills, and a spi"ing

fever. The severity of the fever and a high white blood cell count in the 2oint fluid

helps diagnose a septic infection, while urate crystals in the 2oint are a good indicator

of gout.

Charcot &oot. etween 1 - 7.9: of people with diabetes have 8harcot foot or 8harcot

2oint &medically referred to as neuropathic arthropathy(. This condition is caused by

problems in the nerves in the feet. ;arly changes may resemble gout, with the foot

becoming swollen, red, and warm.


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SOME DISEASES WITH SYMPTOMS SIMI#AR TO GOUT

D%!$a!$ Sp$c%*%c Su+yp$!

$steoarthritis

nfectious Arthritis /yme disease, septic arthritis, bacterial endocarditis, mycobacterialand fungal arthritis, viral arthritis, osteomyelitis

"ostinfectious or6eactive Arthritis

6eiters syndrome (a disorder characteri7ed by arthritis andinflammation in the eye and urinary tract), rheumatic fever,inflammatory bowel disease

"seudogout

6heumatic

Autoimmune3iseases

6heumatoid arthritis, systemic vasculitis, systemic lupus

erythematosus, scleroderma, Still88s disease (also called juvenilerheumatoid arthritis)

4ibromyalgia

$ther 3iseases -hronic fatigue syndrome, hepatitis -, familial editerranean fever,cancers, A3S, leukemia, bunions, *hipple88s disease,dermatomyositis, 9ehcet88s disease, 0enoch!Schonlein purpura,:awasaki88s disease, erythema nodosum, erythema multiforme,pyoderma gangrenosum, pustular psoriasis

Tr$am$n, M$d%ca%on!

/any patients do not re'uire medications. uring the period between gout attac"s,

patients are advised to avoid foods high in purines and to maintain a healthy weight.

Patients should also avoid alcohol and reduce any stress.

;$perts do not recommend treatment for hyperuricemia that causes no symptoms.

Asymptomatic hyperuricemia usually does not lead to gout or other health problems.

#n addition, the drugs used to treat it are e$pensive and carry certain ris"s.

#n unusual circumstances treatment may be 2ustified, for e$ample in patients with veryhigh uric acid levels that threaten the "idney or those with a personal or strong family

history of gout, "idney stones, or "idney damage.

Acute attac"s of gout and long-term treatment of gout and hyperuricemia re'uire

different approaches. Treatment usually involves medication. After the first attac",

some health care providers advise their patients to "eep a supply of medications on


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hand so that self-medication can begin at the first sign of symptoms of a second acute

attac". There are also specific treatments for conditions associated with gout,

including uric acid nephropathy and uric acid nephrolithiasis.

TREATING AN ACUTE GOUT ATTAC-

rug treatments for acute attac"s of gout are aimed at relieving pain and reducing

inflammation. They should be started as early as possible.

Treatment usually involves medication. There are also specific treatments for

conditions associated with gout, including uric acid nephropathy and uric acid

nephrolithiasis.

/edications include

• %A#s &nonsteroidal anti-inflammatory drugs(

• 8olchicine

• 8orticosteroids

NONSTEROIDA# ANTI.IN"#AMMATORY DRUGS (NSAIDS)

Powerful forms of nonsteroidal anti-inflammatory drugs &%A#s( are the drugs of

choice for an acute attac" in younger, healthy patients with no serious health

problems, particularly problems that affect the "idneys, liver, or heart. suallyindomethacin is prescribed for 7 - days.

There are do!ens of %A#s available. >ver-the-counter %A#s include

• Aspirin

• ow-dose #buprofen &/otrin #, Advil, %uprin(

• %apro$en &Aleve(

• Fetoprofen &Actron, >rudis FT(

Prescription %A#s include

• #buprofen &/otrin(


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• %apro$en &%aprosyn, Anapro$(

• @lurbiprofen &Ansaid(

• iclofenac &Ioltaren(

• Tolmetin &Tolectin(

• Fetoprofen &>rudis, >ruvail(

• e$ibuprofen &eractil(

• #ndomethacin ndocin(

#ndomethacin ndocin( is typically the first choice for patients who have no medicalconditions that would interfere with its use. sually 7 - days of high-dose

indomethacin is enough to treat a gout attac". The first dose of indomethacin usually

begins to act against the pain and inflammation within 76 hours and often much

sooner.

#buprofen, napro$en, sulindac, or others are good alternatives, particularly for elderly

patients who might e$perience confusion or bi!arre sensations with indomethacin.

&Aspirin is an %A#, but is associated with a higher ris" for gout and should be

avoided.(


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• 3eadache

• "in rash

• epression

• 8onfusion or bi!arre sensation &in some higher-potency %A#s, notably

indomethacin(

As with acetaminophen, high daily doses of aspirin have been associated with an

increased ris" of "idney failure, although the ris" remains low in those with healthy

"idney function. Fidney abnormalities have been reported in people ta"ing other

%A#s as well, which resolve when the drugs are withdrawn. Any sudden weight

gain or swelling should be reported to a physician. Anyone with "idney disease should

avoid these drugs.

Patients with diabetes who ta"e hypoglycemics by mouth may need to ad2ust the

dosage if they also need to ta"e %A#s because of possible harmful interactions

between the drugs.

ome studies have reported that ibuprofen &but not other %A#s( may reduce the

heart-protective effects of low-dose aspirin. Additional research is needed to confirm

these findings.

NSAID.INDUCED U#CERS AND GASTROINTESTINA# B#EEDING/ong!term use of nonsteroidal anti!inflammatory drugs (2SA3s) is a common causeof ulcers. 2SA3!related bleeding and stomach problems may be responsible for%&;,&&& hospital admissions and %,'&& deaths each year. 9ecause there are usuallyno gastrointestinal symptoms from 2SA3s until bleeding begins, health care providerscannot predict which patients taking these drugs will develop bleeding.

Those at high risk for 2SA3!related bleeding include the elderly, anyone with a historyof an ulcer or gastrointestinal bleeding, patients with serious heart conditions, thosewho drink too much alcohol, and persons on certain medications, such anticoagulants(blood thinners), corticosteroids, or bisphosphonates (drugs used for osteoporosis).

Preventing NSAID-Related Ulcers. Switching to alternative pain relievers is the firststep in preventing or healing ulcers caused by 2SA3s. f people cannot changedrugs, they should use the lowest 2SA3 dose possible. 4or e5ample, Arthrotec is acombination of an ulcer protective drug called misoprostol and the 2SA3 diclofenacthat may reduce the risk for gastrointestinal bleeding. $ne study found that patientstaking Arthrotec had ' !


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preventing ulcers in high!risk individuals. They have been shown to reduce 2SA3!ulcer rates by as much as verdose of colchicine can be dangerous, and there have even been

reports of death. The drug may also suppress blood cell production and cause nerveand muscular in2ury in certain people, sometimes even in those not ta"ing high doses.

CORTICOSTEROIDS

8orticosteroids may be used in patients who cannot tolerate %A#s and they may be

particularly beneficial for elderly patients. #n2ections into an affected 2oint provide


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effective relief for many patients, but this is not useful for patients who have multiple

2oints that are affected. teroids ta"en by mouth may be used for patients who cannot

ta"e %A#s or colchicine and who have gout in more than one 2oint. 8orticosteroids

include triamcinolone and prednisone. 8orticotropin &A8T3(, a drug that converts to

a steroid, is effective and safe, according to some evidence, but is not widely

available.

TREATMENTS TO PRE'ENT ATTAC-S DURING INTERCRITICA# GOUT

After an acute attac" some patients remain at high ris" for another for several wee"s

during the intercritical period. uch patients include those with "idney insufficiency

or with congestive heart failure who are on diuretics. ow doses of colchicine or

%A#s may be used to during this period for prevention. They should be ta"en in

low doses for 1 - 7 months after an attac" or longer in patients who have e$perienced

fre'uent attac"s.

ANTIHYPERURICEMIC MEDICINES "OR CHRONIC GOUT

A 7001 study suggested that patients with chronic gout must maintain uric acid levels

at or below ) mg+d in order to prevent further attac"s. There are numerous effective

antihyperuricemic medicines. #n general, their effects depend on whether a patientHHs

high uric acid is due to overproduction or a failure to eliminate enough in the urine.

ong-term treatment of hyperuricemia may be recommended for people who have

•

A ris" for tophaceous gout

• /ore than two or three acute attac"s of gout in the past

• nusually severe attac"s or attac"s that affect more than one 2oint

• Boint damage from gout, shown on $-rays

• 3yperuricemia caused by an identifiable inborn metabolic deficiency

People who ta"e these drugs should have normal "idney function. This therapy maynot be as beneficial in many elderly patients, who often have some "idney

insufficiency.

Uricosurics. These drugs prevent the "idney from reabsorbing uric acid and so

increase the amount e$creted in the urine. They are appropriate when gout is caused

by under-e$cretion of uric acid, which occurs in about *0: of cases. They are not


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used for patients with reduced "idney function or those with tophaceous gout. They

are usually the choice for preventing gout in the following patients

• Those under )0 years old

• Those with normal diets

• Those who have normal "idney function

• Those who have no ris" of "idney stones

ricosuric drug candidates should produce no more than 00 - *00 mg of uric acid in

urine over a 76-hour period.

Probenecid &enemid, Probalan( and sulfinpyra!one &Anturane( are the standard

uricosurics. A more potent uricosuric, ben!bromarone, may wor" for people with

severe tophaceous gout and "idney impairment when other drugs do not. #n some

studies, ben!bromarone was e'ual to or even more effective than allopurinol, another

type of antihyperuricemic drug. ecause ben!bromarone can cause liver failure in

some patients, it is available in the .. only with special authori!ation. A uricosuric

combined with allopurinol may be beneficial in cases.

Probenecid is ta"en two to three times a day, and sulfinpyra!one begins at twice a day

and increases to three or four times daily. The initial doses should be low and

gradually increased. Probenecid combined with colchicine is more effective than

probenecid alone, but everyone responds differently, so the dose needs to be carefully

individuali!ed.

The possible side effects of probenecid and sulfinpyra!one include s"in rashes,

gastrointestinal problems, anemia, and "idney stone formation. To help reduce acidity

and the ris" for "idney stones, patients should drin" plenty of fluids &ideally water, not

caffeinated beverages(. odium bicarbonate supplemented by aceta!olamide can also

reduce acidity and the ris" for stones.

%A#s, particularly aspirin, as well as other salicylate drugs, interfere with

uricosuric drugs and reduce effectiveness. Patients who re'uire minor pain relief

should instead ta"e acetaminophen &Tylenol and others(. ricosurics interact with

many other drugs, and a patient should be sure to inform their health care provider of

all medications they are ta"ing.


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Allopurinol &opurin, Jyloprim(. Allopurinol is a $anthine o$idase inhibitor that

bloc"s uric acid production. #t is the drug most often used in long-term treatment for

older patients and those who overproduce uric acid.

Allopurinol is ta"en by mouth once a day in doses of 100 - )00 mg, depending on the

patientHHs response to treatment. 4hen it is first used, allopurinol can trigger furtherattac"s of gout, and thus during the first months &or longer( of therapy the patient is

also given a %A# or colchicine to reduce that possibility.

Allopurinol has positive effects on CbadD cholesterol levels, so it may be better than

other drugs for patients with both gout and coronary artery disease.

ide effects, which can be severe, include

• iarrhea

• 3eadache

• @ever

• eu"openia &a reduction in the number of white blood cells(

• Thrombocytopenia &a reduction in the number of platelets(

• 8ataracts

#n rare cases, the rash can become severe and widespread enough to be life

threatening &called To$ic epidermal necrolysis, or T;%(. Allergic individuals who

e$perience only a mild rash may be able to build up their tolerance for the drug by

undergoing a desensiti!ation process.

Allopurinol interacts with certain other drugs, such as a!athioprine.

Puricase !PEG)Uricase$. This is an e$perimental drug that has been shown to rapidly

reduce e$cess uric acid. #f approved, it may help those who have failed other

treatments.

The decision to use an anti-hyperuricemic and at what point is not entirely clear. ome

health care providers do not prescribe them if hyperuricemia is mild or until a patient

has had two attac"s. >thers prescribe them immediately after a single attac". /ost of

the time, antihyperuricemic therapy means ta"ing a drug routinely throughout life,

which many people find difficult.


24/29

efore treatment, some e$perts recommend a 76-hour collection sample in patients

with fre'uent gout attac"s to determine whether they are over-producers or under-

e$creters of uric acid. Also, before starting one of these drugs, any previous acute

attac" should be completely controlled and the 2oints should not be inflamed. ome

health care providers prefer to wait about a month after an attac".

ow doses of %A#s or colchicine are used during several months after introducing

anti-hyperuricemic therapies to prevent gout attac"s. #t should be noted that %A#s,

particularly aspirin, as well as other salicylate drugs, reduce the effectiveness of

uricosurics, so they should be avoided if possible by patients ta"ing them.

WARNING NOTE ON DRUG TREATMENTS "OR GOUT

#t should be noted that many drugs used for gout can also precipitate acute gout

symptoms and so should not be used until symptoms have subsided. The patient

should then start with small doses that gradually increase.

Hypertensi(e Agents. People with gout have a higher ris" for high blood pressure.

ome of the agents used to treat hypertension, such as thia!ide diuretics, can increase

the ris" for gout attac"s. %ewer agents, such as losartan &an angiotensin ## receptor

antagonist(, and amlodipine &a calcium channel bloc"er(, may have beneficial effects

on both high blood pressure and gout.

&ebuxostat . @ebu$ostat is the first drug to emerge in many decades as a potential new

treatment for chronic gout. #t may prove to be an alternative for patients who are

allergic to allopurinol. The drug is awaiting approval from the .. @ood and rugAdministration &@A(.

O/$r Tr$am$n!

#urgery. arge tophi that are draining, infected, or interfering with the movement of

2oints may need to be surgically removed. 4hen infection is present, the procedure

carries a high ris" for complications. People most li"ely to have surgery also tend to

have other medical conditions that might worsen the outloo". #n one study, e$perts

suggested that better preventive measures, such as the use of allopurinol, could reduce

the need for surgery.

everal other surgical procedures are available for relieving pain in and improving the

function of affected 2oints. #t is sometimes necessary to replace 2oints.

Hot and Cold Therapy.


25/29


26/29

A supervised weight-loss program may be a very effective way to reduce uric acid

levels in overweight patients. 8rash dieting, on the other hand, is counterproductive

because it can increase uric acid levels and may cause an acute attac".

"#UIDS 1 A#COHO#

rin"ing plenty of water and other nonalcoholic beverages helps remove /

crystals from the body.

Alcohol should be avoided, since it promotes purine metabolism and uric acid

production. #t also may reduce e$cretion of uric acid. 3eavy drin"ing, especially

binge drin"ing of beer or distilled spirits, should be avoided.

A'OID 2OINT IN2URY

People with gout should also attempt to identify and avoid activities that cause

repetitive 2oint trauma, such as wearing tight shoes.

PRE'ENTING AN ATTAC- DURING TRA'E#

Travel is an e$ample of an activity that increases the ris" for gout. #t not only

increases stress, but eating and drin"ing patterns may change. efore traveling,

patients should discuss preventive measures with their health care providers. The

doctor may prescribe a prednisone tablet to be ta"en immediately at the first sign of a

gout attac". #n most cases, this stops the episode.

Comp0%ca%on!

Properly treated gout rarely poses a long-term health threat. #t can, however, be a

cause of short-term pain and incapacity for thousands of Americans.

PAIN AND DISABI#ITY

eft untreated, gout can develop into a painful and disabling chronic disorder.

Persistent gout can destroy cartilage and bone, causing irreversible 2oint deformities

and loss of motion. urvey results released in 700) show that two-thirds of persons

with gout consider the pain among the worst theyHHve ever e$perienced. An estimated9: of those surveyed said flare ups made wal"ing very difficult, and around 0:

reported trouble putting on shoes or playing sports.

Tophi are firm chal"y, gritty clumps of uric acid crystals that build up in tissue

surrounding a 2oint. #f gout is not treated, tophi can grow to the si!e of golf balls and

can destroy bone and cartilage in the 2oints, similar to the process in rheumatoid

arthritis. #f they lodge in the spine, tophi can cause serious damage including


27/29

compression, although this is very rare. #n e$treme cases, 2oint destruction results in

complete disability.

-IDNEY CONDITIONS

"idney #tones. Fidney stones occur in 10 - 60: of gout patients, and can occur at anytime after the development of hyperuricemia. Although the stones are usually

composed of uric acid, they may also be mi$ed with other materials. A 7005 study

showed that although a current diagnosis of gout doubles the ris" of "idney stones, a

history of gout does not increase "idney stone ris". Therefore, reducing gout ris"

factors with dietary and other lifestyle changes may reduce the li"elihood of stone

formation.

Fidney stones result when urine becomes too concentrated, and substances in the

urine crystali!e to form stones. ymptoms occur when the stones begin to move down

the ureter and cause intense pain. Fidney stones may form in the pelvis or calyces ofthe "idney or in the ureter.

"idney 'isease. About 79: of patients with chronic hyperuricemia develop

progressive "idney disease, which sometimes ends in "idney failure. #t should be

noted, however, that many e$perts believe that chronic hyperuricemia is unli"ely to be

a common cause of "idney disease. #n most cases, the "idney disease comes first and

causes high concentrations of uric acid.

GOUT AND HEART DISEASE

Gout is found in higher rates in people with high blood pressure, coronary artery

disease, and heart failure. 3yperuricemia, in fact, has been associated with a higher

ris" of death from heart conditions. >ne 7001 study reported that disease activity in

gout may even contribute to unhealthy cholesterol and lipid levels.

A newer study, published in the August 700) 2ournal Arthritis 1 ,heumatism, found

that gout increases the ris" of heart attac"s in men with no previous history of heart

problems.

OTHER MEDICA# CONDITIONS ASSOCIATED WITH GOUT

The following are some conditions that are associated with long-term gout

• 8ataracts

• ry eye syndrome


28/29

• 8omplications in the lungs &in rare cases, uric acid crystals occur in the lungs(

R$*$r$nc$!

3uang 3K, Appel B, 8hoi /B et al. The effects of vitamin 8 supplementation on

serum concentrations of uric acid results of a randomi!ed controlled trial. Arthritis ,heum. 7009 BunL97&)(1*65-.

8hen I8, 3o P, Kuen FK. Two probable cases of serious drug interaction between

clarithromycin and colchicine. #outh Med 2 . 7009 AugL?*&*(*11-5.

a$ena $idi!ed low-density lipoprotein autoantibodies in patients with primary

gout effect of urate-lowering therapy. Clin Chim Acta - 01-BA%-7006L 55?&1-7( 11-77.

ardin T. 8urrent management of gout in patients unresponsive or allergic to

allopurinol. 2oint /one #pine. 7006L 1&)(6*1-9.

A""asilpa . The efficacy of combined low dose of Allopurinol and ben!bromarone

compared to standard dose of Allopurinol in hyperuricemia. 2 Med Assoc Thai. 7006L

*&?( 10*-?1.


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Ganson %B, Felly B, carlett ;, undy B, 3ershfield /. 8ontrol of hyperuricemia

in sub2ects with refractory gout, and induction of antibody against poly&ethylene(

glycol &P;G(, in a phase # trial of subcutaneous P;Gylated urate o$idase. Arthritis

,es Ther . 7009 ec 7L*&1(thics and subscribes to the principles of the 0ealth on the 2et 4oundation (www.hon.ch).

A3D3A3M3 Copyr%g/The information provided herein should not be used during any medical emergency or for thediagnosis or treatment of any medical condition. A licensed medical professional should be consultedfor diagnosis and treatment of any and all medical conditions. -all ?%% for all medical emergencies./inks to other sites are provided for information only !! they do not constitute endorsements of thoseother sites. @ %??;! &&< A.3.A.., nc. Any duplication or distribution of the information containedherein is strictly prohibited.

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