16. Gout

OTHER NAMES
gout - chronic; gouty arthritis – chronic, metabolic arthritis
DEFINITION
Gout is a disease due to a congenital disorder of uric acid metabolism. In this condition, monosodium urate or uric acid crystals are deposited on the articular cartilage of joints, tendons and surrounding tissues due to elevated concentrations of uric acid in the blood stream. This provokes an inflammatory reaction of these tissues. These deposits often increase in size and burst through the skin to form sinuses discharging a chalky white material.
CAUSES, INCIDENCE, AND RISK FACTORS
Gout is caused by a defect in metabolism that results in an overproduction of uric acid, or a reduced ability of the kidney to eliminate uric acid. The exact cause of the metabolic defect is unknown. The condition may also develop in people with diabetes mellitus, obesity, sickle cell anemia, and kidney disease, or it may follow drug therapy that interferes with uric acid excretion.
Gout has four stages: asymptomatic, acute, intercritical, and chronic. In acute gouty arthritis, there is a sudden onset of symptoms that usually involves only one or a few joints. The pain frequently starts during the night and is often described as throbbing, cmshing, or excruciating. The joint appears infected with signs of warmth, redness, and tenderness. The attacks of painful joints may subside in several days, but may recur at irregular intervals. Subsequent attacks usually have a longer duration.
Several attacks of gout may occur each year resulting in chronic joint symptoms such as joint deformity and limitation of motion in the affected joints. Uric acid deposits called tophi develop in cartilage tissue, tendons, and soft tissues. Deposits also can occur within the kidneys, leading to chronic renal failure.
Risk factors include recurrences of acute attacks of gouty arthritis, lack of preventative measures in those with prior attacks, kidney disease, diabetes mellitus, sickle cell anemia, or obesity. Men and postmenopausal women are at higher risk than younger women.
PREVENTION
Drugs that lower the serum uric acid concentration may prevent the development of chronic gouty arthritis in susceptible people.
SYMPTOMS
- joint pain—persistent pain in many joints
- large crystal deposits (tophi) in joints, tendons, and soft tissue
SIGNS AND TESTS
There may be a current or previous medical history of acute arthritis in one joint. A physical examination ofjoints shows arthritis and tophi.
Tests that indicate gouty arthritis include:
- synovial fluid analysis that detects uric acid crystals
- uric acid level that is elevated
- joint X-rays that show damage consistent with gouty arthritis

Treatment Options

Treatment Strategy Gout is often completely controlled by proper treatment. _... Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain and inflammation _... Abstinence from alcohol _... Dietary restrictions (avoid fat, alcohol, sardines, anchovies, scallops, organ meats, sweetbreads, cocoa, spinach, asparagus, eggs, oatmeal, and mushrooms) _... Medication to reduce the amount of uric acid produced or to promote its excretion

Drug Therapies

 _... NSAIDs-such as ibuprofen and indomethacin; IM 50 mg every 8 hours until symptoms resolve (5 to 10 days); avoid if allergic or have active peptic ulcer disease or impaired renal function. _... Colchicine-0.5 to 0.6 mg orally every hour until pain is relieved or nausea or diarrhea appears, then stop drug; usual total dose, 4 to 8 mg; generally only effective for 24 to 48 hours; many side effects, but GI symptoms relieved by IV administration of initial dose of 1 to 2 mg in 10 to 20 ml saline solution; severe toxicity limits usefulness of IV colchicine. Can also be used to prevent future attacks. _... Corticosteroids-dramatic symptom relief in acute attack; best for patients who cannot take NSAIDs. For monarticular disease, give intra-articularly (e.g., triamcinolone, 10 to 40 mg depending on size of joint). For polyarticular disease, give IV (e.g., methylprednisolone, 40 mg daily tapered over seven days) or orally (e.g., prednisone 40 to 60 mg daily tapered over seven days). Do joint aspiration and Gram stain of synovial fluid before giving steroids. _... Analgesics-such as codeine or meperidine for severe pain. Avoid aspirin as salicylates may exacerbate the condition. _... Uricosuric agents-to reduce serum uric acid levels; probenecid (250 mg bid for one week, increased to 500 mg bid) or sulfinpyrazone (100 mg daily initially, gradually increased to 200 to 400 mg daily). Hypersensitivity is indicated by fever and rash (5% of cases) or GI complaints (10%). Maintain daily urine output of at least 2,000 ml and urine pH of at least 6.0; salicylates must be avoided. _... Allopurinol-to reduce serum uric acid levels; 100 mg daily for one week, increased as needed; normal levels often obtained with 200 to 300 mg daily. Use cautiously in renal insufficiency; do not use in asymptomatic hyperuricemia (may precipitate attack). May develop signs ranging from pruritic rash to toxic epidermal necrolysis (rare, yet potentially fatal).

Complementary and Alternative Therapies

 A combination of therapies can be very effective at decreasing both the length and frequency of attacks. Alternative therapies are often most useful in decreasing the frequency and severity of attacks, but may not necessarily offer the best pain relief. Alternative therapies avoid the sometimes toxic effects of some pharmaceutical agents used for gout. Some nutrients may actually exacerbate the condition.

Nutrition

 _... Avoid obesity. However, it is important to avoid crash dieting and rapid weight loss. _... Avoid alcohol, especially beer, which has a higher purine content than wine or spirits. _... Hydration-Drink plenty of water; dehydration may exacerbate gout. _... Restrict purines in diet-Purines increase lactate production which competes with uric acid for excretion. Foods with a high purine content are beef, goose, organ meats, sweetbreads, mussels, anchovies, herring, mackerel, and yeast. Foods with a moderate amount of purines include meats, poultry, fish, and shellfish not listed above. Spinach, asparagus, beans, lentils, mushrooms, and dried peas also contain moderate amounts of purines. _... Cherries-One half pound of cherries/day (fresh or frozen) for two weeks lowers uric acid and prevents attacks. Cherries and other dark red berries (hawthorn berries and blueberries) contain anthocyanidins that increase collagen integrity and decrease inflammation. 8 to 16 oz. of unadulterated cherry juice per day is also helpful. A lower maintenance dose can be continued for prevention. _... Vitamin C-8 g/day can lead to decreased serum uric acid levels. Note that there is a small subset of patients with gout who will actually get worse with this level of vitamin C. _... Folic acid-10 to 75 mg/day inhibits xanthine oxidase which is required for uric acid production. B12 levels need to be monitored to avoid masking a B12 deficiency. _... EPA (eicosapentaenoic acid) inhibits pro-inflammatory leukotrienes. Dose is 1,500 mg/day. _... Niacin-Avoid niacin in doses greater than 50 mg/day. Nicotinic acid may precipitate an attack of gout by competing with uric acid for excretion. _... Vitamin A-There is some concern that elevated retinol levels may play a role in some attacks of gouty arthritis.

EXPECTATIONS (PROGNOSIS)
Symptoms are gellerally worse iii people who develop the disease before 30 years old.
COMPLICATIONS
- kidney stones
- kidney failure
- joint deformities
- person becomes bedriddell, rarely 

Courtesy:

Compiled and Shared By: Habib Anwar 

habib.anwar@hotmail.com