Gout

Description

Alternative Names

Treatment

Acute attacks of gout and long-term treatment of gout and its associated hyperuricemia require different approaches. All phases are treated mainly with drugs. There are also specific treatment regimes for conditions associated with gout, including uric acid nephropathy and uric acid nephrolithiasis.

Lifestyle Measures

Many patients do not require medications. During the period between gout attacks, patients are advised to avoid foods high in purines and to maintain a healthy weight. Patients should also avoid alcohol and reduce any stress.

Treatments for Asymptomatic Hyperuricemia

Experts do not recommend treatment for hyperuricemia that causes no symptoms. For one, asymptomatic hyperuricemia usually does not lead to gout or other health problems. In addition, the drugs used to treat it are expensive and carry certain risks. In unusual circumstances treatment may be justified, for example in patients with very high uric acid levels that threaten the kidney or those with a personal or strong family history of gout, kidney stones, or kidney damage.

Treatment of an Acute Attack of Gout

Drug treatments for acute attacks of gout are aimed at relieving pain and reducing inflammation. They should be started as early as possible.

• NSAIDs. Powerful forms of nonsteroidal anti-inflammatory drugs (NSAIDs) are the drugs of choice for an acute attack in younger, healthy patients with no serious health problems, particularly problems that affect the kidneys, liver, or heart. Usually indomethacin is prescribed for two to seven days.
• Colchicine. Colchicine may be given within 48 hours of an attack to healthy adults. It is typically administered hourly to a maximum of six doses. It should not be used in patients with kidney or liver problems or in pregnant women.
• Corticosteroids. Corticosteroids may be used in patients who cannot tolerate NSAIDs and they may be particularly beneficial for elderly patients. Injections into an affected joint provide effective relief for many patients, but this is not useful for patients who have multiple joints that are effected. Oral steroids may be used for patients who cannot take NSAIDs or colchicine and who have gout in more than one joint.

Rest and protecting the affected joint with a splint can also promote recovery. A 2002 study reported that applying ice packs for 30 minutes four times daily significantly reduced pain. Interestingly, one 2001 study recommended applying warm water continuously and moving the joint. The theory behind this advice was that the pain in a gout attack is due to grinding from the crystals and that warmth would help dissolve the crystals and relieve pain.

After the first attack, some physicians advise their patients to keep a supply of medications on hand so that self-medication can begin at the first sign of symptoms of a second acute attack.

Treatments to Prevent Attacks During Intercritical Gout

After an acute attack some patients remain at high risk for another for several weeks during the intercritical period. (Such patients include those with kidney insufficiency or with congestive heart failure who are on diuretics.)In such cases, low doses of either of the following agents may be used to during this period for prevention.

• Colchicine.
• NSAIDs.

These agents should be taken in low doses for one to two months after an attack or longer in patients who have experienced frequent attacks. These are simply anti-inflammatory drugs, however, and have no effect on hyperuricemia.

Drugs Used to Reduce Uric Acid Levels in Chronic Gout

In some cases, patients will use agents (antihyperuricemic drugs) to reduce uric acid levels. The goals of antihyperuricemic therapy are to reduce the frequency of attacks and to dissolve monosodium urate (MSU) crystals and tophi. In fact, a 2001 study suggested that patients with chronic gout must maintain uric acid levels at or below 6 mg/dL in order to prevent further attacks.

Candidates. Long-term treatment of hyperuricemia may be recommended for the following situations:

• There is a risk for tophaceous gout.
• The patient has suffered more than two or three acute attacks of gout.
• Attacks are unusually severe or affect more than one joint.
• X-rays show joint damage from gout.
• Hyperuricemia is caused by an identifiable inborn metabolic deficiency.

Normal kidney function is essential for taking these drugs. This therapy, then, may not be as beneficial in many elderly patients, who often have some kidney insufficiency.

Agents Used to Reduce Uric Acid. A number of effective antihyperuricemic agents are available. In general, their effects differ depending on whether a patient's high uric acid is due to overproduction or a failure to eliminate enough in the urine. They including the following:

• Allopurinol. Allopurinol inhibits uric acid production and is useful for those who overproduce uric acid, who have kidney disorders, or who have kidney stones.
• Uricosurics. (Most often probenecid and sulfinpyrazone.) They are appropriate when gout is caused by under-excretion of uric acid, which occurs in about 80% of cases. They are not used for patients with reduced kidney function or those with tophaceous gout.

Certain steps must be made in undertaking hyperuricemic therapy:

• Some experts recommend a 24-hour collection sample in patients with frequent gout attacks to determine whether they are over-producers or under-excretors of uric acid.
• Before starting one of these drugs, any previous acute attack should be completely controlled and the joints should not be inflamed. Some physicians prefer to wait about a month after an attack.
• Low doses of NSAIDs or colchicine are used during several months after introducing anti-hyperuricemic therapies to prevent gout attacks that can occur. It should be noted that NSAIDs, particularly aspirin, as well as other salicylate drugs, interfere with uricosuric drugs and reduce effectiveness, so they should be avoided if possible by patients taking these agents.

The decision to use anti-hyperuricemic and if so, at what point, is not entirely clear, however. Some physicians do not prescribe them if hyperuricemia is mild or until a patient has had two attacks. Others prescribe them immediately after a single attack. Most of the time, antihyperuricemic therapy means taking a drug routinely throughout life, which many people find difficult to adhere to.

Surgery

Surgery is sometimes used to remove large tophi that are draining, infected, or interfering with the movement of joints. When infection is present, the procedure carries a high risk for complications. People most likely to have surgery are also tend to have other medical conditions that might worsen the outlook. In one study, experts suggested that better preventive measures, such as the use of allopurinol, could reduce the need for surgery.

Several other surgical procedures are available for relieving pain in and improving the function of affected joints. It is sometimes necessary to replace joints.