GOUT

Mauro Keiserman, MD. Rheumatology Specialist by the Brazilian Society of Rheumatology. Head Professor of Rheumatology at the Catholic University School of Medicine (PUC-RS).

Gout is a disease characterized by the elevation of uric acid in the bloodstream and outbreaks of acute arthritis secondary to the deposition of monosodium urate crystals.

The normal concentration of uric acid in the blood is as high as 7.0 mg/100 ml. Depending on the studied country, it can affect 18% of the population with uric acid above 7mg%. However, only 20% of hyperuricemic patients will develop gout. That is, having a high uric acid level is not tantamount to having gout.

It’s important to detect who has elevated uric acid, as often these individuals present high pressure, are diabetic and have lipid increase in the bloodstream with atherosclerosis, and the finding of hyperuricemia indirectly leads to the diagnosis of serious preexistent problems.

Another risk for hyperuricemia is the development of uric acid renal calculi, or, rarely, renal disease. It’s an adult men’s disease. Women will start suffering from gout crisis after menopause. Gout may be diagnosed in young women and men, but certainly these are rare situations.

How does it develop?

The most common disease-generating mechanism is the congenital absence of an enzymatic mechanism that excretes uric acid by the kidneys. Without adequate elimination, its blood concentration rises.

Another enzymatic defect, by far less common, overproduces uric acid. The kidneys, even being normal, can’t eliminate the excessive amount of uric acid, so it accumulates in the blood.

When there’s overproduction, there’s renal overexcretion of uric acid. It can be detected by measuring uric acid in the 24-h urine. overexcretion being confirmed, we must look for other less common overexcretion causes as polycythemia vera (excess of red blood cells) and psoriasis. The physician must advise tests for this purpose.

Some medications reduce the renal excretion of uric acid. Frequent examples are diuretics and low-dose acetylsalicylic acid. If these medications cannot be discontinued, it’s preferable to maintain them and treat gout. When the cause for hyperuricemia is not enzymatic, it is referred to as secondary gout.

Clinic

Gout patients can remain 20 to 30 years with elevated uric acid prior to the first crisis. In some cases, a urinary calculus crisis has already occurred.

Arthritis crisis is quite typical: the individual goes to bed feeling well and wakes up in the middle of the night experiencing an intolerable pain that compromises the big toe in over 50% of cases.

There are situations in which the pain is so strong that the patients can’t tolerate even sheets touching the affected region. Low-grade fever and chills may take place. The initial crisis lasts 3-10 days and disappears altogether. The patient returns to a normal life. They go on untreated because either they receive no orientation or decide against complying with what was prescribed.

A new crisis can come back in months or years. Either the same joint or another one may be affected. Any joint can be affected. Joints of the lower limbs are preferred but there are gout patients with severe deformities in the hands. Without treatment the intervals between crises decrease and their intensity increases. The outbreaks become longer and later tend to involve more than one joint. There are cases in which some joints don’t get rid of the symptoms anymore.

Gout patients that had a late diagnosis and untreated ones have monosodium urate crystals deposited on the joints, tendons, bursae and cartilage (tophi). They can become highly enlarged and severely deform the joints.

Very characteristic are sizeable tophi located in the elbows. Despite not being common, when appearing at the ear cartilage they’re useful for gout diagnosis.

Diagnosis

In the first crisis, the definite diagnosis of gout is made only if uric acid crystals are found in the fluid aspirated from the joint.

In the absence of joint fluid, even taking place in the big toe the first crisis shouldn’t be labeled before a follow-up period, as there are other causes of inflammation at this site. Remember that only 20% of hyperuricemic patients will develop gout. If tests and the disease progress fail to define other disease, the patient must be monitored as a gout sufferer.

It can be very easy when there’s a classic history of very painful acute monoarthritis due to repetitive motions and elevated uric acid. This can be normal during a crisis. When the suspicion is high, repeat the dosage two weeks later. Radiological changes can be typical.

For patients with chronic disease already having deformities and change to the x-ray, difficulties will not be posed at the diagnosis but at the treatment, probably. Patients in such state have gout of difficult management or remain untreated.

Treatment

There’s no cure for gout! But there’s treatment, for sure!

We’ve seen that uric acid rises due to defects in renal elimination or in its production. In either situation, defects are genetic, that is, definitive. Should the patient not comply with a diet and, most often, with the medication treatment, uric acid will rise again, and sooner or later a new gout crisis will loom. Curiously, a great number of gout patients don’t understand the treatment or quit it. The consequence is not only a very painful new acute arthritis crisis, but also the risk of developing joint deformities that can be quite uncomfortable. Nowadays, it isn’t justifiable for a gout patient to have new crises, much less established deformities.

Acute crisis

Never start allopurinol at a crisis! If you’re already taking it, keep it at the same dose.

0.5 or 1 mg colchicine every hour until the crisis alleviates was the ideal treatment until new potent non-steroid anti-inflammatory drugs emerged with fewer paraeffects, most notably when used for a short term.

The colchicine regimen was dropped due to the intense diarrhea it causes, so it must be used only by quite rare patients that have absolute contraindication to any non-steroid anti-inflammatory drug (NSAID), even recent ones that are very safe. The best drug combination is oral colchicine 3-4 times a day and intramuscular or intravenous NSAIDs. When pain decreases, start taking them orally. The association of potent analgesics is useful if pain still persists.

Emptying out an inflammatory fluid-laden joint by needle suction generates great relief.

Intra-articular injection of corticoid is indicated when there’s contraindication to classic regimens. Colchicine inhibits the arrival of leukocytes where the crystals are. It doesn’t reduce uric acid. This is achieved with diet and allopurinol (Zyloric).

Only get started with allopurinol after the inflammation resolves. The introduction mode must be slow. Use 100 mg a day 10-20 days, and then 200 mg a day. In 4-6 weeks, measure the uric acid level again. If it’s above 6 mg%, you’d better change to 300 mg of allopurinol.

Maintenance

diet

One must prescribe a diet low in purines, recommend strict consumption of alcoholic beverage and avoid long fasting. Every gout patient knows their own problems.

The ideal management of the diet must be conducted by a nutritionist. Some patients are able to control their uric acid only when on a diet. Undoubtedly, the enzymatic defect is less significant.

The great secret to a diet is to quit forbidden foods and not consume excessively, in a short period of time, controlled foods and alcoholic beverage.

medications

Most individuals will need varying doses of allopurinol, which can be as high as 600 mg/d. The daily use of 1 colchicine tablet can prevent crises. Thus, the combination of both drugs have been suggested. Patients with uric acid below 5 mg% aren’t likely to need colchicine if they maintain their diet and continue with allopurinol, which has shown to be safe and convenient, also helping prevent kidney stones.

Questions you can ask your doctor:

Does this disease have a cure?

What’s the treatment purpose?

Is the treatment restricted to this prescription only or should it be repeated?

Does it interfere with other medications I’m taking?

What are the side effects? Must I subject to management tests?

Are there problems with obesity and diet?

What’s the importance of exercises and rest?

What measures should I take with my daily-life, professional and spare-time habits?

 

 

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