Tophi

General facts about Gout

Gout has been known to people since the days of Hippocrates and was historically known as “the disease of kings” as it’s prevalent among well-fed people. It is also known as the “King of all diseases” as it cause intolerable pain and suffering. This disease is caused by the body’s reaction to the crystallized form of uric acid. Uric acid crystallizes when blood gets saturated and this usually happens when serum uric acid rises beyond 07mg/dl.

These crystals may be deposited in joints, tendons, soft tissues and sometimes in various internal organs of the body such as in the kidney.

What is the cause of Gout? Is it genetic?

Gout is a hereditary disorder caused by an inborn instability of nucleic acid 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. It may remain latent, but under the influence of some outside factors such as infections, trauma, extreme cold exposure or high intake of proteins and alcohol, it manifests as local inflammatory tissue reactions to crystallized form of uric acid, in joints or elsewhere in the body. The condition may also develop in people with diabetes mellitus, obesity, sickle cell anaemia, and kidney disease, or it may follow drug therapy that interferes with uric acid excretion. Certain drugs can also cause gout. Certain diseases such as leukaemia and haemoglobin disorders lead to excessive production of uric acid in the body.

How common is this disease?

Gout afflicts an estimated 840 out of 100,000 people.

Is it associated with other disease conditions?

Gout is strongly associated with obesity, hypertension, hyperlipidemia and diabetes.

What are the symptoms of Gout?

Gout develops gradually or suddenly with severe symptoms. It usually involves only one or a few joints. The pain frequently starts during the night and is often described as throbbing, crushing, or excruciating involving usually the “Big Toe” called “Podagra”.

The affected joint appears warm, red, and tender. The pain at the joints may subside in several days, but may recur at irregular intervals. Subsequent attacks usually have a longer duration. In some people, it may progress to chronic gouty arthritis, while others may have no further attacks. Recurrent attacks can lead to large deposition of uric acid crystals around the joints called “Tophi”. Joints can be damaged and deformities may form if disease is not controlled in time. When deposited in kidneys, it can cause renal stones and kidney failure.

Who is at risk of getting Gout?

Men, postmenopausal women, people with kidney disease, diabetes mellitus, sickle cell anaemia, or obesity have higher chances of getting Gout.

Which specialist should I consult if I have Gout?

You should consult a Rheumatologist where available; otherwise consult a General Physician.

Is Gout curable?

It cannot be completely cured. But by administering medication, further damage can be prevented.

Who can get Gout?

If you eat a lot of food that is rich in purines, you may get Gout. Some of these foods are salmon, sardines, liver and herring. You may get Gout if you’re overweight, drink alcohol or have high cholesterol. Men have Gout more often than women do. Women are more likely to have Gout after menopause. Some medicines may cause Gout, such as certain diuretics (“water pills”), niacin (a B-complex vitamin), aspirin (taken in low doses), and some drugs used to treat cancer.

This is how is Gout diagnosed:

  • Physical examination of the joint shows swelling, redness and warmth.
  • Joint fluid analysis shows uric acid crystals.
  • Uric acid (in blood test) may be elevated above 7.5 mg/dl.
  • Joint X-rays may be normal or may show eroded bones near joints.

How to prevent Gout attacks?

Acute Gout attacks can be prevented by:

  1. Maintaining adequate fluid intake, it also decreases the risk of kidney stone formation in these patients
  2. Weight reduction can be helpful in lowering the risk of recurrent attacks of Gout. This is best accomplished by reducing dietary fat and calorie intake, combined with a regular aerobic exercise program.
  3. Avoiding alcohol consumption, as it is known to have diuretic effects that can contribute to dehydration and precipitate acute Gout attacks. Alcohol can also affect uric acid metabolism and cause hyperuricemia.
  4. Dietary changes can help reduce uric acid levels in the blood. Since purine chemicals are converted by the body into uric acid, purine rich foods should be avoided. Examples of foods rich in purine include shellfish and organ meats, such as liver, brains, kidneys, and sweetbreads.
  5. Milk consumption has also been shown to reduce the serum uric acid level.

How to treat Gout:

There are multiple aspects to the medication treatment of gout.

1.Anti-inflammatory agents such as nonsteroidal anti-inflammatory drugs (NSAIDS), colchicine, and corticosteroids are used to decrease joint inflammation.

2. Once acute episodes are controlled and if there are recurrent episodes of Gouty arthritis, or if there are renal stones, or if there is evidence of eroded bones, certain medications are used to reduce the raised serum uric acid level to less than 06 mg/ dl. These drugs are Allopurinol and Probenecid.

3. Dietary control: Avoid alcohol especially red wine as it increases uric acid accumulation. Reduce intake of roasted food and food without Vitamin E. Lack of Vitamin E has been linked with a rise in uric acid. Drink plenty of water. Eat raw fruits including red cherries, vegetables, grains, seeds and nuts. Avoid sprouted pulses and grains as these contain lot of uric acid forming nucleic acids. Last but not the least; drink skimmed milk as it has been found out to have uric acid lowering properties

Avoid eating meat especially organ meat as it is rich in uric acid forming components. It is to be remembered that maximum dietary control can reduce the level of uric acid level by only 01 mg/ dl. If more reduction is required, then it can be done by Uric acid lowering agents only.

Does everybody respond to these medications?

About 3 percent of the three million adults who suffer from Gout are not helped by conventional therapy. FDA, USA has recently approved a new drug, called  “Pegloticase” and it’s likely to enter the US market by the end of this year. This new drug offers an important new option for these refractory cases. The clinical data has demonstrated that many patients treated with Krystexxa 8 mg administered every two weeks can, within six months of treatment, experience significant positive clinical improvement reversing the course of this severe, crippling and debilitating disease

During an acute Gout attack what should I do and what drugs should I be taking ?

Change your diet plan. Avoid the intake of red meats, shellfish, beer, red wine and salt.  Anti-inflammatory agents such as nonsteroidal anti-inflammatory drugs (NSAIDS), colchicine, and corticosteroids can be used to decrease joint inflammation.

What are the side effects of NSAID group of drugs?

Common side effects of NSAIDS include irritation of the gastrointestinal system, ulceration of the stomach and intestines, and even intestinal bleeding. Patients who have a history of allergy to aspirin or nasal polyps should avoid NSAIDS because of the risk of an intense allergic (anaphylactic) reaction.

What are the precautions to be taken with NSAID group of drugs?

Always take the medication after food or with a glass of milk.

Glossary:

Arthritis – Inflammation of tissues in the joints.
Metabolism – A bio-chemical process through which energy consumption and energy production is carried out in cells.

Uric Acid – White crystals of water-soluble lithic acid found in urine.

Synovial Fluid – This is a clear fluid that fills the joint cavity and acts as a lubricant. The Synovial fluid is secreted by the synovium, the membrane that surrounds a joint and creates a protective sac. In addition to cushioning joints, this fluid supplies nutrients and oxygen to cartilage, the slippery tissue that coats the ends of bones.

Sickle Cell Anemia – A condition in which the red blood cells appear in a sickle or crescent shape preventing the normal functioning of red blood cells thus causing anaemia.

Let me know if you have any other questions about gout.

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