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gout

Gout is one of the oldest diseases. In the old days it was widespread among people who exaggerate in food and drink and is therefore called `the disease of kings`. Gout is manifested as inflammation of the joints (arthritis) that occurs as a result of deposition of uric acid crystals in the joints. ... read more

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Gout is one of the oldest diseases. In the old days it was widespread among people who exaggerate in food and drink and is therefore called `the disease of kings`. Gout is manifested as inflammation of the joints (arthritis) that occurs as a result of deposition of uric acid crystals in the joints. It is a metabolic disorder. The disease usually begins with severe pain, redness and swelling of the toe. Redness and pain can spread to the ankle and lower leg and practically tie you to the bed.

Gout is more common in men than in women because they are protected by the action of estrogen which stimulates the discharge of uric acid from the kidneys. In men, it usually occurs in a period between 35 and 50 years of age, and in women it often occurs after menopause. In people who have been affected by gout before 30th birthday, the prognosis of the disease is worse.

Probable cause

In many cases the cause of this metabolic disorder is unknown. The crystals that accumulate are salts of uric acid, which is formed in the body as an end product of purine metabolism. Purines are found in food, and are produced naturally by the body through metabolism of nucleic acids in cells or by biological synthesis. The accumulation of uric acid salts occurs due to increased production or decreased excretion. In majority of patients the both causes of the metabolic disorder are present.

Clinical picture

Gout begins suddenly, usually at night, with a very severe pain in the joint, so severe that even the touch of the blanket evokes an extremely painful sensation. Usually only one joint is affected, the big toe joint, although in exceptional cases the disease can begin in two or more joints. The affected joint provides a clear picture of inflammatory arthritis, with pronounced swelling, and red, tight, shiny skin. Sometimes, because of the inflammation in the joint, fever and chills also occur. This inflammatory process lasts up to two weeks, after which it completely disappears. The culmination is reached during the first 24 hours. During the standstill phase, the patient does not have any joint problems, but hyperuricemia is present. The disease recurs within the first year of the first attack and usually affects the same joint as the previous time.

There are certain factors that accelerate or stimulate the recurrence of gout. These are, first of all, gourmet meal and alcohol consumption, especially food rich in purines (fish, intestines). In some cases a trigger can be a surgery, and taking certain medicines (salicylate and salidiuretic), sudden weight loss, injuries, etc. If gout is not treated properly, it eventually turns into a chronic form which is characterized by the appearance of subcutaneous and bone tophi and chronic urate arthropathy.

Tophi are the characteristic nodules on the skin, resulting from years of untreated disease, formed as a result of urate deposition in the cartilage, synovial joints, tendons, hands, fingers, knees, and even on the earlobes. Tophi are characteristic white lumps that can ulcerate and release the whitish urate formation. Approximately 20% of patients have present kidney stones. Urate nephropathy is usually manifested only after several years of illness and is initially accompanied by mild symptoms, but later progresses and leads to renal failure, which is the cause of death of about 25% of patients suffering from gout.

Diagnosis

The diagnosis is determined according to characteristic clinical picture and the finding of elevated levels of uric acid in the blood and urine.

Treatment

The therapeutic approach to the disease is moving in two directions - the treatment of arthritis and the treatment of hyperuricemia.

It is necessary to start the treatment of arthritis as early as possible, because of the inflammatory process in the joints. Nonsteroidal anti-inflammatory drugs are used in the maximal dose, usually indomethacin (Indocin) in the form of capsules of 200 mg per day divided in three or four doses, or naproxen (Nalgesin, Anaprox, Naprelan, Naprosyn), ketoprofen (Orudis, Ketonal), diclofenac (Voltaren XR, Cataflam, Arthrotec, Naklofen) and ibuprofen (Advil, Motrin, Brufen).

The use of colchicine (Colcrys) (specific product for the treatment of gouty arthritis) is also recommended. Colchicine is given in the form of tablets of 0.5 mg every 1-2 hours until alleviation of arthritis or the occurrence of gastrointestinal intolerance, but not more than 8 times a day.

The drugs for the treatment of the metabolic disorder (Uricosuric agents – probenecid and Xanthine oxidase inhibitors – allopurinol (Zyloprim, Aloprim) or febuxostat (Uloric, Adenuric)) are also used in severe forms of the disease. These agents should not be started during an attack of acute gouty arthritis without adequate control of the gouty inflammation. Because agents that lower uric acid can precipitate attacks of gout, low-dose colchicine is typically used as prophylaxis (usually for 6 months) when such therapy is initiated. Long-term use of these drugs may alleviate hyperuricemia, prevent the re-emergence of chronic arthritis and creation of chronic changes. If the tophi are present, they lead to their dissolution and disappearance.

All patients suffering from gout are recommended proper hygienic-dietary regimen, with an emphasis on reducing fat, foods rich in purine and alcohol. They are also advised to drink more fluids, to prevent the formation of kidney stones.

The treatment of gout lasts a lifetime.