Gout is related to chronic hyperuricemia that should be treated to ensure the reduction or even the disappearance of acute attacks ("gout flares") and to reduce the size and number of tophi. Superiority of Low-Dose Benzbromarone to Low-Dose Febuxostat in a Prospective, Randomized Comparative Effectiveness Trial in Gout Patients With Renal Uric Acid Underexcretion. 2019 Aug 17. 2018 Feb. 77 (2):270-276. 2008 Jul. 2020 Jun. 2012 Jan. 71(1):157-8. Risk factors for gout and prevention: a systematic review of the literature. This search included meta-analyses, randomized controlled trials, and reviews. [QxMD MEDLINE Link]. Tophi are MSU crystal aggregates that most often develop in joint and cutaneous tissue. The .gov means it's official. [QxMD MEDLINE Link]. Joint inflammation is usually accompanied by warmth, swelling (due to intra-articular fluid, or effusion), and uncommonly read more , particularly older adults or those with other risk factors. [QxMD MEDLINE Link]. Available at http://www.medsafe.govt.nz/profs/puarticles/colchdose.htm. 2010. 2023 Jan. 48 (1):101437. Data Sources: A PubMed search was completed using the MeSH terms gout and gout suppressants. Meta-analysis of 28,141 individuals identifies common variants within five new loci that influence uric acid concentrations. Classic radiographic findings are chondrocalcinosis (yellow arrow), hooked osteophytes, and subchondral cysts (red arrow). INTRODUCTION. 2012 Oct. 64(10):1431-46. Fernandes EA, Lopes MG, Mitraud SA, Ferrari AJ, Fernandes AR. Quantitation of urinary uric acid excretion to differentiate between overproduction and underexcretion is no longer recommended; it does not predict a patient's response to allopurinol or febuxostat (both of which decrease uric acid production). Yokose C, McCormick N, Choi HK. 25(6):1593-617. Chronic corticosteroid use is not an ideal prophylactic therapy because of its adverse effect potential. An inflammatory crystal arthropathy that is caused by the precipitation and deposition of uric acid crystals in synovial fluid and tissues. 39(1):93-6. Consumption of skim milk and low-fat yogurt, vegetables, soybeans, vegetable sources of protein, and cherries is recommended.31, Local ice therapy reduces pain in acute gouty arthritis.32, Colchicine, nonsteroidal anti-inflammatory drugs, and corticosteroids relieve pain in adults with acute gout.33, Nonsteroidal anti-inflammatory drugs are first-line treatment unless use is contraindicated (e.g., cardiovascular disease, cerebrovascular disease, chronic kidney disease, history of gastric bypass, history of gastrointestinal bleeding, inflammatory bowel disease, peptic ulcer disease, pregnancy).8, Oral prednisolone (35 mg once daily) is equal to naproxen (500 mg twice daily) in the treatment of acute gout, with no significant difference in pain relief or adverse effects.34, In acute gout, low-dose colchicine (1.2 mg orally followed by 0.6 mg one hour later) was as effective as high-dose colchicine (1.2 mg followed by 0.6 mg every hour for six hours) and had fewer adverse effects. Clinical disease occurs as a. Gout is common in the elderly, affecting an estimated 4.7 million people aged > 60 years in the USA alone. [QxMD MEDLINE Link]. 2009 Sep. 36(9):1958-62. Efficacy and Safety of Pharmacologic Interventions in Patients Experiencing a Gout Flare: A Systematic Review and Network Meta-Analysis. Use of imaging for diagnosis requires particular expertise in the relevant imaging techniques and their interpretation, as . A diagnostic study of 40 patients with crystal-proven nontophaceous gout and 41 patients with other rheumatic diseases found that dual-energy CT was 90% sensitive and 83% specific.26,29. Figure 1 presents a suggested approach to the treatment of gout. Chatfield SM, Grebe K, Whitehead LW, Rogers KL, Nebl T, Murphy JM, et al. Flare frequency can also be decreased with daily low-dose NSAIDs if renal function allows. (Cleveland Clinic, 2019), Differential Diagnosis II : Septic Arthritis. Definition Gout is a syndrome characterised by: hyperuricaemia and deposition of urate crystals causing attacks of acute inflammatory arthritis; tophi around the joints and possible joint destruction; renal glomerular, tubular, and interstitial disease; and uric acid urolithiasis. 2023 Jan. 42 (1):203-214. 2018 Oct 1. [QxMD MEDLINE Link]. Rheumatology (Oxford). 336(7639):309-12. 1984 Jun. Ann Rheum Dis. It is given IV every 2 to 3 weeks for many months (typically at least 6 to 9 months) to totally deplete the excess urate deposits; it often lowers the serum urate level to < 1 mg/dL (< 0.1 mmol/L). KOSKOFF YD, MORRIS LE, LUBIC LG. Gout. Intake of low-fat dairy products should be encouraged. MCWILLIAMS JR. Ocular findings in gout; report of a case of conjunctival tophi. 1993 Sep. 36(9):1274-85. Bodofsky S, Merriman TR, Thomas TJ, Schlesinger N. Advances in our understanding of gout as an auto-inflammatory disease. 2014 Aug 27. [QxMD MEDLINE Link]. Dalbeth N, Merriman TR, Stamp LK. Fever, tachycardia, chills, and malaise sometimes occur. BMJ. [Full Text]. 2012 Feb. 64(2):256-61. Arch Intern Med. If you log out, you will be required to enter your username and password the next time you visit. Probenecid can be used as monotherapy if both allopurinol and febuxostat are contraindicated or not tolerated. Your doctor may recommend a blood test to measure the levels of uric acid in your blood. Nonsteroidal anti-inflammatory drugs and corticosteroids are equally effective for the treatment of acute gout, with no significant difference in pain relief or adverse effects. Semin Arth Rheum 46:594-600, 2017. doi: 10.1016/j.semarthrit.2016.10.009. Effect of urate-lowering therapies on renal disease progression in patients with hyperuricemia. Shogan CP, Folio CL. Available at http://www.medscape.com/viewarticle/871265. This content is owned by the AAFP. Kleiber Balderrama C, Rosenthal AK, Lans D, Singh JA, Bartels CM. Shoulder tendinitis. 2008;58:S878. 1 ). [QxMD MEDLINE Link]. Ann Rheum Dis. Clin Exp Rheumatol. 2009 Aug. 68(8):1290-5. Arthritis Rheum. Hu S, Sun M, Li M, Xue X, Terkeltaub R, Wang C, et al. Feig DI, Johnson RJ. Hematoxylin and eosin (H&E) stain, low power, showing abundant pale pink areas surrounded by histiocytes and multinucleated giant cells. Joint Bone Spine. 2020 Jan. 116(8):2073-5. 2012 Jun 7. Antidepressants, antiseizure drugs, and other central nervous system (CNS)active drugs may also be used for chronic or read more are effective in treating acute flares and are generally well-tolerated. Arch Orthop Trauma Surg. Febuxostat is begun at 40 mg orally once a day and increased to 80 to 120 mg orally once a day if urate does not decrease to < 6 mg/dL (< 0.35 mmol/L). Inflammation of the tendons that typically affects the shoulder (rotator cuff), hip, heel, and hamstring. FDA takes action to stop the marketing of unapproved injectable drugs containing colchicine. Ortiz-Bravo E, Sieck MS, Schumacher HR Jr. Changes in the proteins coating monosodium urate crystals during active and subsiding inflammation. [Full Text]. Am J Med. [QxMD MEDLINE Link]. Singh JA, Reddy SG, Kundukulam J. [QxMD MEDLINE Link]. 1952 Dec. 35(12):1778-83. Available at https://wayback.archive-it.org/7993/20170113075756/http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm116853.htm. Urate precipitates as needle-shaped monosodium urate (MSU) crystals, which are deposited extracellularly in avascular tissues (eg, cartilage) or in relatively avascular tissues (eg, tendons, tendon sheaths, ligaments, walls of bursae) and skin around cooler distal joints and tissues (eg, ears, finger pads). If ongoing urate-lowering therapy is not initiated, patients can develop chronic deforming arthritis from tophaceous gout due to ongoing urate deposition. Joint damage can be prevented and, if present, may be reversed with urate-lowering drugs. Treatment-failure gout: a moving target. 2010 Nov 24. All Rights Reserved. The genetics of hyperuricaemia and gout. 27(6):585-91. [QxMD MEDLINE Link]. Meyer MM, Marks LA, Aslam F. Clinical implications of synovial fluid specimen handling for crystal associated arthritides: A systematic review. [QxMD MEDLINE Link]. Treat acute flares of gout with oral colchicine, an NSAID, a corticosteroid, a combination of colchicine with an NSAID or a corticosteroid, or an interleukin-1 (IL-1) antagonist. Arthrocentesis should be performed when suspicion for an underlying septic joint is present; synovial fluid or tophus analysis should be performed if the diagnosis is uncertain. Zeng L, Qasim A, Neogi T, Fitzgerald JD, Dalbeth N, Mikuls TR, et al. Rheumatology (Oxford). Forien M, Combier A, Gardette A, Palazzo E, Dieud P, Ottaviani S. Comparison of ultrasonography and radiography of the wrist for diagnosis of calcium pyrophosphate deposition. 2008 Dec 6. Skeletal Radiol. [QxMD MEDLINE Link]. Schumacher HR, Berger MF, Li-Yu J, Perez-Ruiz F, Burgos-Vargas R, Li C. Efficacy and tolerability of celecoxib in the treatment of acute gouty arthritis: a randomized controlled trial. . The frequency of flares can be reduced by regular use of nonsteroidal anti-inflammatory drugs (NSAIDs). Arthritis Rheum. [QxMD MEDLINE Link]. Clin Rheumatol. [QxMD MEDLINE Link]. [Guideline] Khanna D, Fitzgerald JD, Khanna PP, Bae S, Singh MK, Neogi T, et al. Arthritis Res Ther. 2011 Mar 3. Contemporary epidemiology of gout in the UK general population. PLoS Genet. 304(20):2270-8. Uricase is an enzyme, absent in humans, that converts urate to allantoin, which is more soluble. Female gout. [QxMD MEDLINE Link]. 2013 Apr. 2004 Aug. 31(8):1575-81. Abbott RD, Brand FN, Kannel WB, et al. [Full Text]. [QxMD MEDLINE Link]. J Rheumatol. 2012 May. Acute gouty arthritis may be triggered by trauma, medical stress (eg, pneumonia or other infection), surgery, use of thiazide diuretics or drugs with hypouricemic effects (eg, allopurinol, febuxostat, probenecid, nitroglycerin), or indulgence in purine-rich food or alcohol. Choi HK, Atkinson K, Karlson EW, et al. Chehab MR, Goyal J, Schlesinger N. Tophaceous Pustule-like Rash in a Patient with Gout. Spine (Phila Pa 1976). [Full Text]. Gout and Excess Risk of Severe SARS-CoV-2 Infection Among Vaccinated Individuals: A General Population Study. Diagnosis of gout can be made using several validated clinical prediction rules. The Burden of Cardiac Arrhythmias in Gout: A National Representative Database Study. 1999 Feb. 24(1):125-7. Arthritis Rheum. 2006 Oct. 65(10):1312-24. 17(1):79-83. 2022 Jun. Terkeltaub RA, Furst DE, Digiacinto JL, Kook KA, Davis MW. Merriman TR. The effectiveness of the currently available preparation is limited by a high rate of development of drug neutralizing antibodies. 2017 Jan. 69 (1):22-34. Gout is caused by monosodium urate crystal deposition in joints and tissues. 82(3):421-6. 306(7):711-20. Renal insufficiency and drug interactions, especially with clarithromycin and some statins, may warrant reduction of dosage or use of other treatments. Macfarlane DG, Dieppe PA. Diuretic-induced gout in elderly women. 2014 Apr. 10(3):218-27. Increased concentration of serum urate (hyperuricaemia) is the most important risk factor for the development of gout. listening to your lungs as you breathe. Pseudogout (calcium pyrophosphate deposition disease) . Stamp LK, Frampton C, Morillon MB, et al: Association between serum urate and flares in people with gout and evidence for surrogate status: a secondary analysis of two randomised controlled trials. Kolz M, Johnson T, Sanna S, Teumer A, Vitart V, Perola M, et al. Absorption of allopurinol may decrease at doses higher than 300 mg, so split dosing (eg, twice daily dosing) should be considered. Nguyen C, Ea HK, Palazzo E, Liot F. Tophaceous gout: an unusual cause of multiple fractures. 2011 Jan 13. Desmarais J, Chu CQ. [Full Text]. What Factors Compound the Risk for Gout in Those Genetically Predisposed? [QxMD MEDLINE Link]. Reginato AM, Mount DB, Yang I, Choi HK. Public Health. June 2022. The impact of short-chain fatty acid-producing bacteria of the gut microbiota in hyperuricemia and gout diagnosis. Patient and clinical characteristics associated with gout flares in an integrated healthcare system. [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. 4 (11):e2135353. Ann Rheum Dis. However, the baseline serum urate level between flares reflects the size of the extracellular miscible urate pool. 2018 Nov. 47 (11):1499-1504. Impact of fenofibrate therapy on serum uric acid concentrations: a review and meta-analysis. Naredo E, Uson J, Jimnez-Palop M, Martnez A, Vicente E, Brito E, et al. . An elevated serum urate level supports the diagnosis of gout but is neither specific nor sensitive; at least 30% of patients have a normal serum urate level during an acute flare in part due to the uricosuric properties of the proinflammatory cytokine interleukin-6 (IL-6) or because a sudden lowering of the serum urate precipitated the flare. O'Dell JR, Brophy MT, Pillinger MH, et al: Comparative effectiveness of allopurinol and febuxostat in gout management. 2012 Oct. 64(10):1447-61. Blood test. Pegloticase is a pegylated form of recombinant uricase. The role of diet in hyperuricemia and gout. Mackenzie IS, Ford I, Nuki G, et al: Long-term cardiovascular safety of febuxostat compared with allopurinol in patients with gout (FAST): a multicentre, prospective, randomised, open-label, non-inferiority trial. N Engl J Med. Logistic regression identified GOUT-36 rule 2, a predictive index for inpatient gout flare, as the only factor associated with gout flare (OR 5.46, 95%CI 1.18 to 25.37). Dalbeth N, Schauer C, Macdonald P, Perez-Ruiz F, Schumacher HR, Hamburger S, et al. Pharmacokinetic and pharmacodynamic interaction between allopurinol and probenecid in patients with gout. [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. Arthritis Res Ther. Later flares may affect several joints simultaneously or sequentially and persist up to 3 weeks if untreated. Dalbeth N, Doyle AJ, Billington K, Gamble GD, Tan P, Latto K, et al. Tophi in and around joints may eventually cause deformities and secondary osteoarthritis. A critical review of the available evidence on the diagnosis and clinical features of CPPD: do we really need imaging?. Bruce M Rothschild, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Rheumatology, International Skeletal Society, New York Academy of Sciences, Sigma Xi, The Scientific Research Honor Society, Society of Skeletal RadiologyDisclosure: Nothing to disclose. There is no evidence from clinical trials to support the use of intra-articular corticosteroid injection in the treatment of acute gout.46 It could be considered in patients for whom nonsteroidal anti-inflammatory drugs or oral steroids are contraindicated. Yamanaka H, Tamaki S, Ide Y, Kim H, Inoue K, Sugimoto M, et al. J Rheumatol. Symptoms of ED include. 2008 Sep. 58(9):2587-90. [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. 2019 Sep 30. Uric acid stones or gravel may dissolve during allopurinol treatment. Lead poisoning and cyclosporine, usually in the higher doses given to transplant patients, alter renal tubular function leading to urate retention. Open-label randomised pragmatic trial (CONTACT) comparing naproxen and low-dose colchicine for the treatment of gout flares in primary care. Strongly negative birefringent, needle-shaped crystals diagnostic of gout obtained from acutely inflamed joint. 2009 Jun. Gout. Urate deposition over the articular cartilage (double-contour sign) and clinically inapparent tophi are characteristic changes. Arthritis Rheum. 2012 Nov. 51(11):2070-4. LiverTox: Clinical and Research Information on Drug-Induced Liver Injury. Gout. African American patients with gout: efficacy and safety of febuxostat vs allopurinol. Causes read more are at increased risk of gout. Radiograph of erosions with overhanging edges. Loffler C, Sattler H, Peters L, Loffler U, Uppenkamp M, Bergner R. Distinguishing gouty arthritis from calcium pyrophosphate disease and other arthritides. [QxMD MEDLINE Link]. The overlying skin may become tense, warm, shiny, and red or purplish. Pseudogout attack induced during etidronate disodium therapy. [QxMD MEDLINE Link]. Use for phrases Lancet. Shimizu T, Hori H. The prevalence of nephrolithiasis in patients with primary gout: a cross-sectional study using helical computed tomography. Inflammation can be flaring in some joints while subsiding in others. Figure 5. Management of Acute and Recurrent Gout: A Clinical Practice Guideline From the American College of Physicians. [QxMD MEDLINE Link]. Arthritis Rheum. Development of the American College of Rheumatology Electronic Clinical Quality Measures for Gout. Beer is associated with a larger increase in risk of gout compared with wine or hard liquor.14, Use of loop or thiazide diuretic or tacrolimus (Prograf) is associated with increased risk of gout.14, Consumption of two or more sugar-sweetened soft drinks per day, fruits high in fructose, or any fruit juices is associated with an increased risk of gout in men. [QxMD MEDLINE Link]. Such flares may herald the onset of RA, and rheumatoid factor tests can help in differentiation; they are positive in about 50% of patients (these tests are positive in 10% of gouty patients also). [QxMD MEDLINE Link]. The elderly have more comorbidities, and gout manifests differently, with more frequent involvement of knees, ankles, and wrists at disease onset, systemic upset, and tophi . Yagnik DR, Evans BJ, Florey O, et al. The dissolution of the urate deposits may take many months after initiating therapy. 46 (7):748-750. 2011 Mar. Anakinra has the advantage of not affecting glucose levels or renal function or causing fluid retention and can be used in a patient with an active infection that is being appropriately treated. [QxMD MEDLINE Link]. Kim KY, Ralph Schumacher H, Hunsche E, Wertheimer AI, Kong SX. Levy GD, Rashid N, Niu F, Cheetham TC. [Full Text]. 2012 Feb 9. [Full Text]. [Guideline] Wallace SL, Singer JZ, Duncan GJ, et al. Search dates: February 24, 2020; April 25, 2020; and September 13, 2020. Treatment usually begins with 50 to100 mg orally once a day and can be slowly dose escalated up to 800 mg orally once a day. 2011 Jan 17. [QxMD MEDLINE Link]. Rai SK, Fung TT, Lu N, Keller SF, Curhan GC, Choi HK. Swelling, warmth, redness, and exquisite tenderness may suggest infection. Clin Rheumatol. Use OR to account for alternate terms Effect of Urate-lowering Therapy on the Risk of Cardiovascular Disease and All-cause Mortality in Patients with Gout: A Case-matched Cohort Study. Chung MC, Hung PH, Hsiao PJ, Wu LY, Chang CH, Wu MJ, et al. A case of conjunctival tophi eventually cause deformities and secondary osteoarthritis of Low-Dose Benzbromarone to Low-Dose febuxostat gout! A cross-sectional Study using helical computed tomography approach to the treatment of gout in elderly women in gout management literature... The next time you visit, redness, and red or purplish T, Murphy,... 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