Gout: The Health Implications Of Its Complications, Diagnosis, Treatment Plan And Its Form As Pseudogout
Gout Manifestations On The Elbows
A General Overview
The complications of Gout manifest on the kidneys and cardiovascular system in almost all cases.
Renal damage: This may occur in two forms. Acute hyperuricemic nephropathy is due to obstruction of renal tubules by urate crystals or uric acid calculi. Chronic hyperuricemic nephropathy is due to urate deposition in the renal parenchyma and its presents as chronic renal failure. Renal failure is the major cause of death in gout.
Cardiovascular damage: There is higher incidence of hypertension and ischemic heart disease in gouty subjects.
Diagnosis: Gout should be considered in all cases of obscure mono- or polyarticular disease. Presence of positive family history, tophi, and radiological findings strengthen the diagnosis. Serum uric acid levels above 7 mg/dl are diagnostic. Sometimes, serum uric acid may be normal in acute gout. Urate crystals can be demonstrated in synovial fluid by their birefringence under polarized light.
Radiological changes: In well developed chronic gout, periarticular bone shows small punched out erosions due to urate deposits, with super-added osteoarthritic changes.
Omit Purine Rich Diets
Emergency management of the acute attack: The affected part is immobilized in a splint. Phenylbutazone, 200 mg thrice daily or indomethacin 25 mg twice daily initially and then reduced to a maintenance dose is very effective in relieving pain and arthritis. Colchicine in a dose of 1 mg inititally followed by 0.5 mg/2 hours is specific in relieving the acute attack but sometimes, the response may be delayed. The mechanism of action of this drug is not clear. This drug is not freely available in most developing countries. In resistant monoarticular involvement, intra-articular hydrocortisone is highly useful. All precipitating factors should be meticulously avoided.
- Diet: Acute attacks can be avoided by omitting purine-rich diets like red meat, liver, pancreas, testes, peas and alcohol. Obese individuals should lose weight gradually.
- Uric acid lowering agents: When the attacks are frequent, or serum uric acid level is high and in the presence of tophi, drugs are indicated to lower serum uric acid. Allopurinol inhibits xanthine oxidase which is required for the conversion of xanthine and hypoxanthine to uric acid and is a very effective drug to lower serum uric acid. In addition, allopurinol also helps in elimination of urates. The advantages of this drug are its low toxicity and sustained therapeutic effect even in the presence of renal disease or diuretic therapy. The starting dose is 100 mg thrice daily, to be increased up to 500 mg/day if required to achieve the effect. Later, the dose is reduced to a maintenance level. Diarrhea, dyspepsia and skin rashes are untoward side effects.
Uricosuric agents such as probenecid, 0.5 to 1g twice daily and sulphinpyrazone ,100 mg thrice daily; help in eliminating uric acid in urine and lead to reduction of attacks and disappearance of tophi. They are indicated in conditions where production of uric aid is normal but elimination is impaired. They are contraindicated in conditions with overproduction of uric acid, renal failure and urate calculi.
Asymptomatic hyperuricemia: This warrants treatment if there is (1) previous history of gout, (2) presence of tophi, (3) family history of gout, (4) presence of uric acid stones, (5) presence of renal damage, and (6) serum uric acid greater than 9%.
This term denotes the condition of acute intermittent arthritis caused by the deposition of calcium pyrophosphate dehydrate (CPPD) in the synovium. The crystals can be demonstrated in the synovial fluid during the acute attacks. Radiological examination may show calcification of articular cartilage and fibrocartilages and hence the name- chrondrocalcinosis.
Acute attacks can be controlled by indomethacin or phenylbutazone. Aspiration and intra-articular steroid instillation may be required if the response is not satisfactory.
© 2014 Funom Theophilus Makama