Gout, Podagra 4.29/5 (28)

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gout

Gout / podagra


Definition

Gout (gout) is an joint disease / arthritis due to uric acid crystals falling out of the blood and creating a powerful rheumatic inflammation, for example gout in the big toe. Some also get kidney stones (nephrolithiasis). Acute Arthritis in gout is due to high levels of uric acid in the blood and tissues. Gout is separated from high levels of uric acid in blood without arthritis (asymptomatic hyperuricaemia).

Disease Cause

The reason is most often that the uric acid level in the blood has exceeded a limit. This can happen if the production of uric acid is abnormally high (genetic,or by diseases where cells are destructed) kidney failure or with lifestyle problems with Metabolic syndrome.

  • When the blood uric acid level exceeds 420-450 micromol / L, the risk of precipitation of urinary crystals increases, most often in the big toe of predisposed people.
  • Gene analyzes have shown that some are hereditary predisposed to gout, while others tolerate a high level of uric acid in the blood without having arthritis (asymptomatic hyperuricaemia) (reference: Kawamura Y, 2019)

Occurrence

Among people over 75 years of age, gout occurs in 7% of men and 4% of women in the UK (reference: Cold CF, 2015)

Symptoms

Elevated uric acid in the blood does not cause ailments until uric acid crystals are formed, most often in joints.

Acute gout attacks

Acute inflammation with severe pain, redness and swelling

  • Quick start, often at night or in the morning
  • Maximum symptoms are experienced after 12-24 hours. Decline within days - few weeks
  • The vast majority (80%) have attacks in a single paragraph
    • Most often, it is the big toe's main joint (MTPXNUMX) (gout) or a knee
  • In case of repeated uric acid attacks, other joints are also attacked as ankle, wrists, fingers or mucous membranes (bursa) at elbows

Chronic gout

Painless deposition with crystals (tophi) under the skin of tendons or bursa for example on elbows

  • One often feels hard knots that often have yellow-white color
  • Tofi can sit on ears, fingers, forearms and elbows
  • Repeated episodes of acute gout or tophi can lead to permanent joint injury

Gout; Uric acid tofi before and after treatment over 10 months with febuxostat. Illustration from: Tausche AK, Wunderlich C, Aringer M - Case Rep Med (2011). CC BY 3.0

Diagnosis

Typical medical history and high uric acid levels measured in blood tests lead to suspicion of gout

  • Some people also get acute uric acid attacks with normal levels of uric acid in the blood sample
  • During an acute uric acid attack, inflammatory tests such as CRP and eventually the sedimentation rate (ESR)
  • Diagnosis is ensured by recognizing uric acid crystals from synovial fluid or uric acid to microscopy
  • In case of joint injury, X-ray or MRI images may show typical cyste-like abnormalities in the bone substance
  • Dual Energy Computer Tomography (DECT) can show uric acid crystals very clearly

EULAR / ACR 2015 classification criteria and calculator for classification here (University of Auckland)

Incorrect diagnosis? (Similar diseases / differential diagnoses)

Prevention

Information on the disease is important to prevent uric acid attacks and joint injuries

  • Diet change should be considered
  • Weight reduction is considered
  • Investigations for mapping if disposing diseases are present
    • These include heart, blood vessels, high blood pressure, diabetes and renal disease
    • Obesity, high cholesterol and smoking should be corrected
  • The use of some types of blood pressure medicine (including thiazides, ACE inhibitors) increases the risk of uric acid
  • Acetylsalicylic Acid (ASA) (Albyl-E) increases uric acid levels and risk of gout attacks
    • Combination with urin acid lowering treatment may be considered

Treatment

Acute gout

  • NSAID are tablets against rheumatic inflammation (NSAIDs = non-steroidal anti-inflammatory drugs)
    • For example, naproxen, dilofenac or COX-II inhibit Arcoxia
    • The treatment lasts until 2-3 days after symptoms have resumed (typically within a few weeks)
    • Combination with gastric ulcer medication (eg Somac) is recommended
    • Caution in high age and in diseases of the gastrointestinal, heart and / or kidneys
  • Colchicine low dose tablets (1mg followed 1 hour later with 0,5mg) are an alternative to NSAIDs, but are rarely used
    • Colchicine should not be used in renal failure or with concomitant use of ciclosporin (Sandimun Neoral) or certain antibiotics
  • Prednisone is an option when NSAIDs can not be used
    • Prednisolone tablets 30-35 mg / day for up to 5 days
  • Joint puncture and injection of cortisone (for example LederSpan, Triamcinolonheksacetonid)
  • Combination therapy (for example, Kolkisin + NSAIDs or Prednisolone)
  • Anakinra (Kineret) or canakinumab (Ilaris) injections are used in special cases. The latter, however, is extremely expensive.

Chronic gout

For all medications, the need must be considered against the risk of side effects. Renal, heart and gastrointestinal disorders or the use of ciclosporin (Sandimmun Neoral) may complicate the treatment.

  • Allopurinol (for example, Zyloric) tablets reduce the production of uric acid and hence uric acid levels and risk of gout
    • Should not be started before an attack has passed
    • Preventing new uric acid attacks, provided regular daily intake
    • Low dose and caution in case of renal impairment
    • Start with low dose (for example, 100 mg / day)
  • Febuxostat (Adenuric)
    • Use when Allopurinol is not applicable
    • Caution by heart disease
  • Probecid increases the secretion of uric acid
  • Colchicine in low dose (0,5-1mg / day), lower if impaired renal function
  • Low dose NSAIDs may be considered as an alternative to Kolkisin.
    • Caution in the risk of ulcers and impaired renal function
  • Lesinurad lowers uric acid levels and is approved by European Health Authorities (2016)

Elevated blood uric acid without symptoms (asymptomatic hyperuricaemia)

Medical examination should exclude special underlying disease

  • About 2 / 3 does not develop gout or other related symptoms
  • Dietand lifestyle changes may be appropriate measures
    • In case of overweight, weight reduction should be done
    • Reduce alcohol intake
    • Increase food intake of low fat and plant products
    • Reduce intake of red meat and fish
    • If persistently high values, benefit and risk are considered when using drugs in each case

Gout and diet

Some foods increase the uric acid level and thus the risk of gout attacks. This is especially true of meat, seafood and alcohol (especially beer, wine is less problematic). Also fructose in fruit juices, apples and oranges can increase the uric acid level. Diet with lots of vegetables and fruity fruit is good. Coffee reduces the risk of uric acid attack. Obesity is unfavorable and weight reduction is recommended. There are several effective drugs that reduce the risk of gout attacks (please see above).

Literature



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