Gout and Increased Uric Acid Levels

Gout is a medical condition characterised by recurrent attacks  of inflammatory arthritis (a red, tender, swollen joint). Its called as PODAGRA when it involves the big toe.

PATHOPHYSIOLOGY:

• Its a disorder of Purine metabolism
• The triggering factors are cool temperatures,rapid changes in the uric acid levels, acidosis, extracellular matrix proteins such as proteoglycans, collagens and chondroitin sulphate.

Gout usually affects

Joints.

• Big toe is commonly affected-the metatarsophalangeal joint
• Also affect small joints (finger) and large joints, (knee and hip.)

Bursae.

These are thin, slippery sacs with just a slight amount of fluid in them act as cushions between bones and soft tissues. for example:

• The bony tip of the elbow (olecranon bursa) and the front of the kneecap (prepatellar bursa).

Tendon sheaths.

• The tendons in the hand and feet passes through these tunnels which provide them protection and nutrition.

Kidneys.

• It causes kidney stones finally resulting in kidney scarring /urate nephropathy
• After the first gout attack it may be months or years before another one occurs.
• If no preventive treatment is taken, next attack usually happens within 2 years,.
• Later attacks can become more severe and affect more than one joint at a time.
• As time goes on, gout attacks may also become more frequent.

If uric acid levels remain high over a long period of time, deposits can develop around joints and tendons. This leads to tophi (toothpaste like deposits) that later can cause permanent deformity and pain

CAUSES:

Hyperuricemia is the underlying cause of gout; may be overproduction or underexcretion of uric acid. The risk factors are:

• LIFESTYLE – consumption of alcohol, maet, sea food, fructose sweetened foods. also physical trauma, surgery.
• GENDER AND AGE-men>women. age between 30-45.
• GENETICS-3 genes are commonly associated with gout. SLC2A9, SLC22A12, ABCG2. Rare genetic disorders including familial juvenile hyperuricemic nephropathy, medullary cystic kidney associated with gout.
• MEDICAL CONDITION – Metabolic syndrome (abdominal obesity, hypertension, insulin resistance, abnormal lipid levels), polycythemia, psoriasis, lead poisoning associated with gout.
• MEDICATIONS – Diuretics, niacin, aspirin, immunosuppressive drugs (tacrolimus, ciclosporin) associated with gout.

SYMPTOMS

• It may wake you up at night with intense pain in your big toe
• The joint that is affected is typically red, swollen and hot.

DIAGNOSIS

• Blood Test-high uric acid level (hyperuricemia)
• Plasma urate levels more than 7.0mg/dl in males and 6.0mg/dl in females are diagnostic of gout

2.Synovial Fluid Analysis

• More accurate test for gout. Identification of monosodium urate crystals in synovial fluid.
• Under polarised  light microscopy, Spiked rods of uric acid crystals from synovial fluid.
• The fluid must also be examined relatively quicker after aspiration, as temperature and pH affect the solubility.

3. X-RAY- joint destruction

4.WBC may be > 40,000/mm3, ESR may be elevated.

TREATMENT:

ACUTE PAIN MANAGEMENT

Home remedies.

• Ice- Application of ice to the affected area by wrapping in a cloth for about 20 minute
• Elevate the limb above the level of heart.
• Complete rest to the part when the symptoms are present.
• If it’s a mild attack,  Nonsteroidal anti inflammatory drugs can be given.

Usually used medications:

• NON- STEROIDAL ANTI INFLAMMATORY –agents  such as indomethacin or ibuprofen.Usually improvement is seen within 4 hrs. Its not recommended if there is GI bleeding, renal failure or heart failure.
• COLCHICINE- is also given to reduce inflammation during an acute gout attack. Used as alternative to NSAIDS.
• STEROIDS-corticosteroids for acute gout attacks. It could be injected into the joint. Joint infection should be excluded before injection.

PROPHYLAXIS:

Lifestyle changes. Life style modification to prevent acute attack and future attacks are:

• Daily exercises to maintain body weight at an optimum level.
• Take plenty of water to increase the excretion of uric acid.
• Reduce calorie intake; avoid excess sugar and fat and take complex carbohydrates, increase the intake of vitamin C. (1500mg/day)

Medications. People with high blood uric acid will benefit from medications.

These medicines will keep the uric acid level less than 6 mg/dl. Long term therapy usually is given to those having more than 3 attacks /year, tophi, disabling disease, kidney stones,renal excretion of uric acid crystals

Medicines:

• XANTHINE OXIDASE INHIBITORS: allopurinol and febuxostat block uric acid production. Long term therapy is safe and well tolerated. Can be used in people with renal problems.
• COLCHICINE – used both for prophylaxis and control of acute attack,. It prevents WBC from attacking the gout crystals.
• URICOSURIC AGENTS – Probenecid and sulfinpyrazone are preferred if reduced secretion of uric acid as indicated by 24 hr urine collection shows uric acid level <800 mg. It helps in the excretion of uric acid. Not used if kidney stones present.

Surgical management:

People with destroyed joints due to chronic gout may benefit from surgery,.

Removal of tophi. the uric acid nodules around finger or toe joints, tendons, or bursae  are removed if they are painful or else they may get broken and infected.

Joint fusion: if there is chronic gout and destruction of joint, joint fusion done. It reduces pain and increases mobility.

Joint replacement. Commonly done for knee joint. It will relieve pain and helps in mobility

DIFFERENTIAL  DIAGNOSIS:

• Septic arthritis:considered when signs of infection present such as fever, high WBC count. To confirm gram stain and culture will be done.
• Pseudogout.
• Rheumatoid arthritis.

PROGNOSIS:

Without treatment, an acute attack of gout usually resolves in 5-7 days. 60% will have 2nd attack within one year. Without treatment episodes of acute attack develop into chronic gout with destruction of joint surfaces, joint deformity and painless tophi.

Tophi occur in those who are untreated for 5 yrs often in the helix of the ear, over the olecranon process, or in the achilles tendon. with aggressive treatment they resolve.