ARTHRITIS-GOUT
DIAGNOSTIC CRTERIA
Definition : A clinical disorder with poly-arthritis caused by hyperuricaemia leading to deposition of Jnonosodium urate crystals in tissues.
- primary gout is due to over production or under-excretion (90%) of uric acid. Secondary gout is due to renal failure, myeloproliferative disorders and their therapy.
- Acute pain of sudden onset Imonoarticular/usually first metatarso phalangeal joint! Acute attack often precipitated by alcohol indulgence, intercurrent illness or surgery? Polyarticular episodes commoner in the elderly! Recurrent acute episodes usual.
- Asymptomatic between episodes! Later involvement of larger joints/usually asymmetric. Higher incidence of urolithisis.
- Hyperuricaemia in most patients./Urate crystals in joint aspirate and tophi is diagnostic. Acute attack occasionally occurs with normal levels of serum uric acid.
- Dramatic response to Colchicine! NSAIDs/ Corticosteroids.
- In chronic cases-Crystal deposits as ‘tophi’ in subcutaneous tissues, cartilage, bones.
Prognosis: Total control is possible with early treatment. If recurrent attacks occur, life long uricosurics or allopurinol prevents attacks. During the first 6-24 months of such therapy, attacks of gout might occur. Asymptomatic hyper-uricaemia does not need therapy. There is no significant correlation between gout and CAD. Renal involvement with urate deposition can occur but is of slow progression with no effect on life expectancy.
MANAGEMENT
General Principles:
- Treated as outpatient unless there is associated infection, or the response to therapy is poor.
- Asymptomatic hyperuricaemia is not treated routinely because of expense, potential drug toxicity and the low risk of adverse outcome on account of hyperuricaemia itself.
- The management comprises address of two components 1) Treating the acute attack, 2) treating the ynderlyi rig cause.
Chronic Gout with recurrent attacks
Control of Hyperuricaemia gets to be important here. Aim to serum keep Uric acid level below 6mg. Do not treat the hyperurcaemia if the patient is asymptomatic. Or If arthritic episodes are sporadic. Evidence of tophaceous gout, or renal disease merits therapy.
General Measures
- Ensure high liquid intake
- Restriction of high purine foods like meat extracts, kidney, liver, anchovies, sardines, sweetbreads would appear to play insignificant role.
- Cautious use of alcoholic beverages.
- Avoid use of Thiazides, Loop diuretics, Small dose aspirin, and nicotinic acid, as they block uric acid excretion leading hyperuricaemia.
Follow up
- If on uricosurics monitor, CBC, renal and hepatic function, and urine analysis at monthly intervals until desired levels of uric acid are obtained.
Prevention
High fluid intake / Cautious use of alcohol.
Colchicine Prophylaxis-for patients with mild hyperuricaemia, and recurrent attacks ( 0.5 mgs bid).
Use of Uricosurics, Allopurinol used as indicated above.
Colchicine may be used to prevent an attack precipitated by starting Uricosurics/AHopurinol.
