Gouty Arthritis

GOUTY ARTHRITIS

Gout is a disorder characterized by a sudden, recurring attacks of very painful arthritis caused by deposits of monosodium urate crystals (needle-like crystals), which accumulate in the joints because of an abnormally high uric acid level in the blood (hyperuricemia).

Monosodium urate or uric acid are deposited on the articular cartilage of joints, tendons, and surrounding tissues.
Gout is one of the most painful rheumatic diseases.

Joint inflammation can become chronic and deforming after repeated attacks. Almost 20% of the people who have gout develop kidney stones.


Reasons For Having The Disease:

Normally, some uric acid, a by-product of cell breakdown, is present in the blood because the body is continually breaking down cells and forming new ones and because familiar foods contain precursors of uric acid. The uric acid level becomes abnormally high when the kidneys can’t eliminate enough in the urine. The body may also produce very large amounts of uric acid because of a hereditary enzyme (inborn errors of purine-pyrimidine metabolism) abnormality or a disease such as blood cancer, in which cells multiply and are rapidly destroyed. Some types of kidney disease and certain drugs impair the kidney’s ability to eliminate uric acid.


Symptoms and Signs:

Attacks of gout (acute gouty arthritis) occur without warning. They may be triggered by a minor injury, surgery, consumption of large quantities of alcohol or protein-rich food, fatigue, emotional stress, or illness. Typically, severe pain occurs suddenly in one or more joints, often at night; the pain becomes progressively worse and often is excruciating. The pain is so intense that the sufferer may not be able to stand even the lightest sheet draped over the affected area. The joint swells, and the skin over the joint appears red or purplish, tight, and shiny. And it feels warm. Touching the skin over the joint can be extremely painful.

The disorder most often affects the joint at the base of the big toe, causing a condition called podagra, but it also commonly affects the instep, ankle, knee, wrist, and elbow. Crystals may form in these peripherally located joints because they are cooler than the central part of the body and urate tends to crystallize at cooler temperatures. Crystals also form in the ears and other relatively cool tissues. In contrast, gout rarely affects the spine, hips, or shoulders.

Other symptoms of acute gouty arthritis can include fever, chills, a generally sick feeling, and a rapid heartbeat. Gout can be more severe in people who develop symptoms before age 30. Usually gout develops during middle age in men and after menopause in women.

The first few attacks usually affect only one joint, and last for a few days. The symptoms gradually disappear, the joint’s function returns, and no symptoms appear until the next attack. Some people never have another attack between six months and two years after the first. After the second attack, more and more joints may be involved, and there may be constant pain due to damage to the joint from chronic inflammation. However, if the disorder progresses, untreated attacks last longer, occur more frequently, and affect several joints, Affected joints maybe permanently damaged.


Complications:
tophic formation
kidney stones (stones are composed of 80% calcium, the remainder, of various subs., including uric acid, cystine, struvite)
kidney failure (crystals, protein, or other substances in the kidney causes kidney failure


Foods that are high in purine and protein:
animal liver or other organ meats
sardines
wine
heavy alcohol consumption
poultry

Severe, chronic gout that causes a deformity may develop. Urate crystals continually deposited in the joints and tendons cause damage that increasingly restricts joint motion. Hard lumps of urate crystals (tophi) are deposited under the skin around joints. Tophi also can develop in the kidney and other organs, skin on the ears, or around the elbow. If untreated, tophi on the hands and feet can erupt and discharge chalky masses of crystals.

Diagnostic Procedures:
Because patients with gout typically have hypertension and impaired renal function, examination of the renal and cardiovascular systems is essential. Baseline laboratory tests should include a complete cell count, urinalysis, and serum creatinine, blood urea nitrogen (BUN) and serum uric acid measurements.

Gout is often diagnosed on the basis of its distinctive symptoms and an examination of the joint. A high uric acid level in the blood supports the diagnosis; however, this level is often normal during an acute attack. The diagnosis is confirmed when needle-shaped urate crystals (intracellular monosodium urate crystals) and polymorphonuclear leukocytes are identified in a sample of joint fluid (synovial fluid) removed by suction (aspirated)with a needle and viewed under a special type of microscope that uses polarized light.

Examination of aspirated joint fluid can also rule out other disorders that mimic gout, such as septic arthritis (infection in the synovial fluid caused by bacteria) and pseudogout a disorder characterized by intermittent attacks of painful arthritis caused by deposits of calcium pyrophosphate crystals). Occasionally, patients with gout may present without uric acid crystals in the synovial fluid aspirate. However, aspiration repeated five hours to one day later shows crystals in the synovial fluid.


Treatment:

The first step is to relieve pain by controlling the inflammation. Colchicine is a traditional treatment. Usually, joint pains begin to subside after 12 to 24 hours of treatment with colchicine and are gone within 48 to 72 hours. Colchicine can be given orally but can be given intravenously if it upsets the digestive tract. This drug often causes diarrhea and can cause more serious side effects, including damage to the bone marrow.

Currently, nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and indomethacin are used more often than colchicine and effectively relieve pain and swelling in the joint.

Sometimes corticosteroids such as prednisone are prescribed for the same purpose. If only one or two joints are affected, a corticosteroid crystal suspension can be injected to the affected joint. This treatment effectively terminates the inflammation caused by urate crystals. The inflamed joint may be immobilized to reduce pain.

For some people, especially those who have repeated, severe attacks – long-term drug treatment is started when symptoms of the attack have disappeared and is continued between attacks. Low doses of colchicine maybe taken daily and can prevent attacks or at least reduce their frequency. Routinely taking NSAIDs also can prevent attacks. Sometimes, both colchicine and NSAIDs are needed. However, this combination doesn’t prevent or heal progressive joint damage caused by crystal deposits, and it does pose some risks for people who have kidney or liver disease.

Drugs such as probenecid or sulfinpyrazone lower the uric acid level in the blood by increasing the excretion of uric acid in the urine. Aspirin blocks the effect of probenecid and sulfinpyrazone and should not be used at the same time. If pain medication is needed acethaminophen or ibuprofen can be safely used instead. Drinking plenty of fluids - at least 3 quarts a day – may help reduce the risk of damage to the joints and kidneys when the excretion of uric acid is increased.

Allopurinol, a drug that blocks production of uric acid in the body, is especially helpful to people who have high uric acid level and kidney stones or kidney damage. However, allopurinol can upset the stomach, cause a skin rash, decrease the number of WBC, and cause liver damage.

Most tophi on the ears, hands, or feet shrink slowly when the uric acid level in the blood is decreased, but extremely large tophi may have to be removed surgically.

People who have a high uric acid level in the blood but no symptoms of gout are sometimes treated with drugs to lower this level. However, because of the risk of adverse effects from these drugs, their used is probably not justified unless the amount of uric acid in the urine is very large. For such people, treatment is continued for life to prevent the possible development of hypertension and kidney disease.


Things a sufferer should do:
Consult a doctor if you suspect gout.
Drink plenty of fluids to lessen the risk of contracting kidney stones.
Take simple pain killers.
Apply a cold pack (ice cubes wrapped in a towel) on acutely inflamed joint.


Ibuprofen - A NSAIDs used in OTC preparations to relieve pain and fever and in prescription strength esp. to relieve the symptoms of rheumatoid arthritis and degenerative arthritis. Generally believed to be gentler on the stomach than aspirin. It can cause indigestion, nausea, diarrhea, heartburn, stomach pain, and ulcers.

Indomethacin – an NSAIDs with analgesic and antipyretic properties used esp. to treat painful inflammatory conditions. Most affects the brain, it sometimes causes confusion or dizziness.

Colchicine – A poisonous alkaloid that inhibits mitosis, is extracted from the corms or seeds of the autumn crocus, and is used in the treatment of gout and acute attacks of gouty arthritis. It can cause diarrhea and can cause damage to the bone marrow with prolonged use.

Allopurinol – a drug used to promote excretion of uric acid esp. in the treatment of gout. It can upset the stomach, cause a skin rash, decrease the number of WBC, and cause liver damage.

Prednisone – a glucocorticoid that is used as an anti-inflammatory, and as an immunosuppressant. It lower the uric acid in the blood by increasing the excretion of uric acid in the urine.

Sulfinpyrazone – a uricosuric drug used in the treatment of chronic gout.

Acetaminophen – a crystalline compound used in medicine instead of aspirin to relieve pain and fever.