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Information for Patients

Sports-Medicine Kalyan-Dombivali
Questions and Answers about Gout
What is Gout?
Who Is Affected?
What Are The Causes?
What Are The Joints Affected?
How Will It Affect Me?
How Is Hyperuricemia Defined?
What Are Stages Of Gout?
What Are Signs & Symptoms of Gout?
How Is It Diagnosed?
How Is It Treated:  
Treatment of Acute Attack:
Is Medication Required To Prevent Repeat Attack?
What Can People With Gout Do To Stay Healthy?
Diet Sheet For Patients With Gout
Which Medicines Are To Be Avoided?
Tell Me More About Medicines Used In Gout:
What Are The Precautions To Be Taken With Colchicin Therapy?
What Research Is Being Conducted To Help People With Gout
Gout is one of the most painful rheumatic disease characterized by deposition of needle like crystals of uric acid in the connective tissue, joint spaces, or both. It accounts for about 5% of all case of arthritis. Pseudogout (chondrocalcinosis) is a similar disease that results from deposits of calcium pyrophosphate dihydrate crystals in the joints.

Who Is Affected?

It is more commonly found in males above 40 years of age & in postmenopausal females (after cessation of monthly menstrual bleeding)

What Are The Causes?

Exact etiology is not known. It is postulated that hereditary predisposition may play an important role. Any rapid change in uric acid can precipitate acute gouty attack. Certain predisposing factors include sustained alcohol consumption, sudden stoppage of alcohol consumption, diet rich in purine contents, hypertension, kidney disease, cancers & certain drugs.

What Are The Joints Affected?

Characteristically great toe is most commonly affected in foot. Other joints involved may be elbow, wrist, knee, ankle & other joints in the feet.

How Will It Affect Me?

Uric acid is a substance that results from the breakdown of purines or waste products in the body.Normally uric acid is dissolved in the blood & passes through the kidneys in to the urine, where it is eliminated. If body increases its production of uric acid or if the kidneys do not eliminate enough uric acid from the body, levels build up (a condition called hyperuricemia). Hyperuricemia may also result when a person eats many high purine foods such as liver, dried beans & peas, anchovies & gravies. Hyperuricemia is not a disease and by itself it is not dangerous. However, if excess uric acid crystals form as a result of hyperuricemia, gout can develop. The excess crystals build up in the joint spaces, causing inflammation. Deposits of uric acid, called tophi, can appear as lumps under the skin around the joints & at the rim of ear. In addition, uric acid crystals can also collect in the kidneys & cause kidney stones.

How Is Hyperuricemia Defined?

Hyperuricemia has been defined as a serum or plasma urate concentration greater than 7mg/dl in males & 6 mg/dl in females.

What Are Stages Of Gout?

The disease can progress through 4 stages:

  1. Asymptomatic Hyperuricemia: Here serum uric acid levels are raised but patient has no symptoms. The tendency to develop gout, however is present. A person in this stage does not usually require treatment.
  2. Acute Gout, Or Acute Gouty Arthrits: In this stages, due to hyperuricemia, uric acid crystals get deposited in joint spaces leading to acute attack of arthritis lasting for 3 to 10 days. Next attack may occur after a variable time interval.
  3. Interval or Intercritical Gout: This is symptom & disability free interval between acute attacks.
  4. Chronic Tophaceous Gout: This develops over a long period such as 10 years & is associated with permanent damage to joints & kidneys & severe disability.

What Are Signs & Symptoms of Gout?

·              Hyperuricemia

·              Presence of uric acid crystals in joint fluid

·              More than one attack of acute arthritis

·              Arthritis that develops in 1 day

·              Attack of arthritis in only one joint, usually the toe, ankle    or knee

·              A painful joint that is swollen, red and warm

How Is It Diagnosed?

To confirm a diagnosis of gout, doctors typically test the synovial fluid by drawing sample from the joint. The fluid is placed on a slide & under a special microscope urate crystals are looked for. Presence of does not rule out the diagnosis. Doctor may also check synovial fluid for presence of bacteria. Doctor may also tophi deposits for examination

How Is It Treated:

Goals:

  • Relieve the signs & symptoms of acute attack

  • Reduce uric acid levels

  • Reduce & if possible, eliminate the factors that produce gout

With proper treatment, most people with gout are able to control their symptoms & live normal lives.

Treatment of Acute Attack:

  1. Absolute rest
  2. Immobilisation of affected limb
  3. Local cold or heat therapy
  4. Adequate fluid intake, diet inclusive of glycine & rich in carbohydrate
  5. Alcohol must be avoided
  6. Drug Therapy:
    • Colchicine-oral or intravenous (IV)
    • NSAIDs ( Painkillers)
    • Intrearticular (inside joint) steroid injection

Is Medication Required To Prevent Repeat Attack?

Prophylactic therapy (medication to prevent repeat attack) is required in following cases:

  • Recurrent attacks
  • Tophaceous gout (lumps of crystals under the skin)
  • Presence of renal disease
  • Family history of renal or heart disease
  • Young patient with high uric acid levels (>=9 mg/dl)
  • The prophylactic therapy is aimed at reducing hyperuricemia most commonly used drug for the same are allopurinol & probenecid

What Can People With Gout Do To Stay Healthy?

  • To help prevent recurrent attacks medicines should be taken as prescribed & as advised. Acute gout is beat treated when symptoms first occur.
  • To tell your doctor all about medicines & vitamins you are taking. Some of these may increase risk of hyperuricemia
  • Plan follow up visits with your doctor to evaluate your progress
  • Maintain a healthy balanced diet; avoid foods that are high in purines; & drink plenty of fluids, especially water, fluids help remove uric acid from the body
  • Exercise regularly & maintain a healthy body weight. Lose weight if you are overweight

Diet Sheet For Patients With Gout

Rapid/ sudden fasting is not advisable as it can lead to hyperuricemia

  1. Foods with very high purine content completely forbidden: Meat exhats, yeast, alcohol, herring
  2. High Purine Content (Once in a week may be allowed): Beef, chicken soup, mutton leg, mutton chop, salmon, sausage, venison, lobster, crab.
  3. Moderate Purine Content (Restricted intake to 4 times a week): Asparagus, chicken, duck, cauliflower, beans, lentils, mushrooms, oysters, peas, pork, spinach, wholegrain cereals & bread
  4. Acceptable: These include beverages (tea/ coffee etc), soft drinks, fruit juices, sugar, sweets, vegetable soups, butter, cheese, eggs, fruit, milk, nuts. Bread & cereals (except wholegrain) are allowable.

Which Medicines Are To Be Avoided?

1.      Diuretics, which decrease the amount of uric acid passed in the urice. Many people take diuretics for hypertension, edema, or cardiovascular disease.

2.      Salicylates or medicines made from salicylate acid, such as aspirin.

3.      The vitamin niacin, also called nicotinic acid

4.      Cyclosporine, a medicine used to control the body's rejection of transplanted organs.

5.      Levadop, a drug used for treatment of partison's disease

Tell Me More About Medicines Used In Gout:

The most commonly used medicines in acute attack are high doses of NSAIDs & injection of corticosteroid drugs in to the affected joint. These drugs reduce the inflammation caused by crystals deposits in the joint. Most commonly used are indomethacin & naproxen, which are taken by mouth (orally) every day. Pateint usually responds within hours & the attack goes away completely within a few days.

When NSAIDs do not control symptoms, the doctor may use colchicine. This drug is most effective if used  within first 12 hours of attack. It may be taken by moutn or by injection directly into a vein (intraverously). Usually it is given every hourly in an acute until symptoms go away.

Prophylactic therapy if indicated comprise of either NSAIds or oral colchicines in small daily doses to prevent future attacks. If attacks continue & tophi develop, however, the doctor may prescribe medicine to treat hyperuricemia such as allopurinol & probenecid

What Are The Precautions To Be Taken With Colchicin Therapy?

The dose should be halved in the elderly & in patients with renal & hepatic dysfunctions. The drug is contraindicated in pregnancy & lactation. Drug like cimitidine or erythromycin have harmful drug interaction with colchicin & should not be combined with it.

What Research Is Being Conducted To Help People With Gout

There is research going on regarding the structure of the enzymes that breakdown purines in the body, in hopes of achieving better knowledge of enzyme defects that case gout, studies are also being conducted on various medications (e.g. fish oil supplements) that can be used to treat gout.