Medications For Acute Gout
How Is Gout Diagnosed
In a clear-cut case, a primary care physician can make the diagnosis of gout with a high level of confidence. However, often there are two or more possible causes for an inflamed toe or other joint, which mimics some of the symptoms of gout, so tests to identify the presence of uric acid is performed.
Since the treatment for gout is lifelong, its very important to make a definitive diagnosis. Ideally, the diagnosis is made by identifying uric acid crystals in joint fluid or in a mass of uric acid . These can be seen by putting a drop of fluid on a slide and examining it using a polarizing microscope, which takes advantage of the way uric acid crystals bend light. A non-rheumatologist, when possible, can remove fluid from the joint by aspirating it with a small needle and send it to a lab for analysis. A rheumatologist is likely to have a polarizing attachment on their microscope at their office. Gout crystals have a needle-like shape, and are either yellow or blue, depending on how they are arranged on the slide .
Figure 11: Uric Acid Crystals Under Polarizing Light Microscopy
There are many circumstances where, however ideal it would be, no fluid or other specimen is available to examine, but a diagnosis of gout needs to be made. A set of criteria has been established to help make the diagnosis of gout in this setting .2
Table 1: Diagnosing gout when no crystal identification is possible
Ideally, 6 of 10 features will be present of the following:
How Does Allopurinol Work
Allopurinol helps reduce urate levels in your blood and reduces gout attacks. Uric acid is a normal product of your metabolism and in the blood, uric acid becomes urate. When urate levels are high, crystals can form around joints causing inflammation, pain and damage. This is known as gout.To reduce gout attacks, it is important to keep your serum urate level below 0.36 mmol/L. When the serum urate is below 0.36mmol/L no new crystals form and crystals that are in your joints or skin can dissolve. Read more about gout.
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Treatment Of Acute Gout
In a patient with no contraindications, first-line treatment comprises a non-steroidal anti-inflammatory drug , such as naproxen 750mg initially and thereafter, 250mg every eight hours until the episode has passed.
Diclofenac is effective, but the MHRA has issued warnings regarding its cardiovascular risk being similar to selective cox-2 inhibitors. Diclofenac is now contraindicated in patients with established IHD, peripheral arterial disease, cerebrovascular disease and heart failure.3
Indometacin, the historical choice for gout, is no longer recommended due to gastrointestinal and renal toxicity.4
Before prescribing NSAIDs, assess the risk of GI side-effects in the patient and consider adding a PPI. The selective cox-2 inhibitor etoricoxib 120mg daily is another alternative in patients at risk of GI toxicity.
Colchicine is an alternative first line therapy where NSAIDs are contraindicated or cannot be tolerated. A low-dose regimen, 0.5mg two to four times daily, is advised. This is as effective as traditional larger doses, but results in lower rates of GI side-effects.
Before prescribing colchicine in patients on multiple medications it is important to check your prescribing formulary for potential drug interactions. For example, there is increased risk of colchicine toxicity with macrolide antibiotics, and verapamil and diltiazem.5 The BNF also advises caution when co-prescribing with a statin due to possible higher risk of myopathy.
Allopurinol And Renal Impairment
One of the only ways allopurinol will be forbidden from therapy in gout is related to renal impairment. Patients with kidney damage can have life-threatening complications when they start using allopurinol, either in the acute or the chronic phase. Renal injury is a risk factor to develop a condition called allopurinol hypersensitivity syndrome.
Allopurinol hypersensitivity syndrome is a severe systemic reaction to allopurinol. It includes symptoms such as fever, skin manifestations, eosinophilia , and multiorgan dysfunction. There is a 25% mortality in patients who develop this syndrome, which is quite high and alarming. Thus, even though there are guidelines to prevent this from happening, doctors might prefer to use other urate-lowering alternatives in this group of patients.
In a nutshell, the main goal of allopurinol is to lower uric acid levels in chronic gout patients. There is current debate on the matter, but the majority of doctors agree that initiating allopurinol in patients recently diagnosed with acute gout is not recommended and does not have any benefit. It is only maintained in patients with chronic gout under treatment with allopurinol, and the only side effect doctors will try to avoid is allopurinol hypersensitivity syndrome, which is more common in patients with renal impairment.
Drug and Therapeutics Bulletin Editorial Office. . Latest guidance on the management of gout. BMJ, 362, k2893.
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Which Joints Are Involved In Gouty Arthritis And Why Is It Most Common In The Foot
As with all other known types of arthritis, Gout has particular joints it tends to attack, and the foot is its most common location. Gout especially favors the bunion joint, known as the first metatarsophalangeal joint , but the ankle, midfoot and knee are also common locations, as is the bursa that overlies the elbow.
The bunion joint is the first joint involved in 75% of patients and is ultimately involved in over 90% of those with this condition. . It is thought that this joint is especially involved in gout because it is the joint that receives the highest pounds per square inch of pressure when walking or running.
Late in gout, if untreated, multiple joints can be involved, including the fingers and wrists. The shoulder joint is very rarely involved by gout and the same is true of the hip.
Figure 5: Location of Gout Attacks
Managing Symptoms And The Underlying Triggers
Gout is a form of arthritis caused by the buildup and crystallization of uric acid in a joint. Depending on the severity of an attack, treatment may involve over-the-counter anti-inflammatory drugs to alleviate pain, as well as behavioral modifications to reduce the frequency of attacks. Chronic attacks may require prescription medications to help reduce uric acid levels in the blood.
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The Role Of Diet In Gout Prevention
Dietary control may be sufficient in a patient with mildly elevated uric acid, for example, 7.0 mg/dL
For those with a higher level, for example, 10.0 mg/dL, diet alone will not usually prevent gout. For the latter, even a very strict diet only reduces the blood uric acid by about 1 mg/dL- not enough, in general, to keep uric acid from precipitating in the joints. The cutoff where patients with gout seem to dramatically reduce their number of attacks is when their uric acid level is taken below 6.0 mg/dL.4
Clinical Features And Pathogenesis
Gout is characterised by the acute onset of excruciating joint pain, with associated swelling, erythema and tenderness. The first metatarsophalangeal joint is most commonly affected in the first attack .
Always consider bacterial infection in the differential diagnosis. Other causes of an acute monoarthritis include other crystal arthropathies, such as pseudogout, osteoarthritis, trauma, and rheumatoid and seronegative arthritis.
Gout can be diagnosed on the basis of good history-taking and examination, but when in doubt, the affected joint should be aspirated.
The underlying risk factor for gout is an elevated serum uric acid level, but not all patients with hyperuricaemia will develop the disease. Hence, the clinician should be wary of checking a uric acid level in a well person with no history of gout. The diagram below summarises the pathogenesis of gout which is important to appreciate, in order to understand the aim of therapeutic treatment.
The Link Between Allopurinol And Gout Flares
As allopurinol reduces the amount of uric acid in the bloodstream, urate crystals in the joints begin to dissolve.7 But as the uric acid crystals begin to dissolve, a gout flare can occur.7 Fortunately, when used as directed, anti-inflammatory medicines such as colchicine can help prevent gout flares in adults who are starting allopurinol or another ULT.7
The Irony Of Allopurinol
Allopurinol is an acclaimed very effective medication in the reduction of uric acid. Coming along with this is febuxostat, these two are the most common of all the medications that help in lowering the uric acid.
In spite of being recommended as a medication for gout, the allopurinol may worsen the gout attacks. The pain may become more severe and more intense. This has something to do with the mechanism of the allopurinol.
The allopurinol, as we know, is a xanthine oxidase inhibitor. Meaning, it prevents the xanthine oxidase enzyme from responding with purine. If the purine doesnt react with the xanthine oxidase, it isnt broken down into uric acid.
Simply speaking, the allopurinol ensures the binding with the xanthine oxidase rather than having purine bind with the enzyme. It just distracts the xanthine oxidase.
Now, to answer the question why does allopurinol worsen acute gout? we need to understand the mechanism of gout attacks first.
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Effects On Other Treatments
Some drugs interact with allopurinol, so you should discuss any new medication with your doctor before starting it. You should also tell anyone else treating you that youre taking allopurinol.
Do not use complementary treatments, such as herbal remedies, without discussing this first with your doctor or pharmacist. Some of them could react with allopurinol.
You should avoid taking aspirin while youre being treated for gout. If youre in pain, you can take paracetamol and NSAIDs. But remember you should only take one NSAID at a time so do not take another if you have already been prescribed one to reduce the effects of gout attacks.
Allopurinol can also react with drugs that are often prescribed for high blood pressure, such as bendroflumethiazide, indapamide, lisinopril, ramipril.
It can also reduce the breakdown of the leukaemia drug mercaptopurine, so the dose of mercaptopurine will need to be reduced if you take this drug.
Allopurinol may also increase the risk of developing a rash if you take them with the antibiotics ampicillin or amoxicillin.
When Is Surgery Considered For Gout
The question of surgery for gout most commonly comes up when a patient has a large clump of urate crystals , which is causing problems. This may be if the tophus is on the bottom of the foot, and the person has difficulty walking on it, or on the side of the foot making it hard to wear shoes. An especially difficult problem is when the urate crystals inside the tophus break out to the skin surface. This then can allow bacteria a point of entry, which can lead to infection, which could even track back to the bone. Whenever possible, however, we try to avoid surgery to remove tophi. The problem is that the crystals are often extensive, and track back to the bone, so there is not a good healing surface once the tophus is removed. In some rare cases, such as when a tophus is infected or when its location is causing major disability, surgical removal may be considered.
Since it is hard to heal the skin after a tophus is removed, a skin graft may be needed. For this reason, we often try hard to manage the tophus medically. If we give high doses of medication to lower the urate level, such as allopurinol, over time the tophus will gradually reabsorb. In severe cases, we may consider using the intravenous medication pegloticase , since it lowers the urate level the most dramatically, and can lead to the fastest shrinkage of the tophus.
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What Precautions Are Necessary
- You may need to have blood tests during the first few months of treatment depending on what other medicines you are taking and depending on your other health concerns. The uric acid level in your blood will be checked to make sure the medicine is working.
- It is important to see your general practitioner regularly as they have an important role in monitoring your condition.
Use with other medicines
Use with alcohol
- Alcohol can trigger an attack of gout. When taking allopurinol, keep your alcohol intake to a safe amount, 1 to 2 standard drinks, several times a week.
- In addition to alcohol, other things that may trigger an acute gout attack include dehydration, diuretics and stopping allopurinol treatment.
Use in pregnancy and when breastfeeding
- The effects of allopurinol during pregnancy have not been well studied, so it is not clear if it causes birth defects.
- Gout in women of child bearing age is uncommon.
- If you are pregnant or are considering having a child you should discuss this with your doctor before beginning this medication.
- Allopurinol may be taken when breast feeding.
Does Allopurinol Help With Gout
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Worries That It Might Prove Unfounded In Randomized Trial
Initiating allopurinol during an acute gout attack doesn’t adversely affect the resolution of the attack, according to results of a new placebo-controlled, double-blind study.
The acute gout attack resolved after an average of 13.4 days in patients who received placebo and 15.4 days in those taking allopurinol, but the difference was not statistically significant , Erica H. Hill, DO, San Antonio Military Medical Center, San Antonio, Texas, and colleagues reported in the Journal of Clinical Rheumatology.
- Allopurinol given during an acute gout attack does not adversely affect the resolution of the acute episode.
- Urate-lowering therapy during an acute gout attack should be accompanied by appropriate acute management.
Most patients in both groups had very low Physician Global Assessment scores, and patient-rated pain scores were relatively low for both groups even early into the study.
The results support the 2012 American College of Rheumatology guidelines recommending that urate-lowering therapy can be started during an acute attack, provided patients receive effective acute management.
The analysis included patients with gout who were randomized to receive either placebo or allopurinol for 28 days. The drug was initiated at 100 mg daily for the first 14 days and then increased to 200 mg daily for the next 14 days.
In addition to the study drug, all patients were given prophylactic colchicine, except one placebo patient who took meloxicam.
How To Take It
Swallow the allopurinol tablets with water, ideally after food. You’ll usually take it once a day, but if you’re on a high dose, your doctor may advise you to split the dose and take it twice a day.
If your doctor has recommended you take allopurinol with lots of fluid, try to drink 2 to 3 litres of fluids every day.
You can take allopurinol at any time of the day, however, try to take your doses at the same time of day each day.
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What This Means For You
Stamp encourages patients to take control. If your gout is managed well, you should have no gout attacks. If you are still having regular attacks or have tophi, talk to your doctor. It is important that your blood uric acid levels are checked and your urate-lowering medicines adjusted to reduce your uric acid and improve your symptoms.
Dr. Kay agrees. Reducing the total body urate burden will improve control of gouty arthritis, and perhaps improve hypertension and reduce cardiovascular morbidity as well, he says.Beth Axtell for the Arthritis Foundation
Natural Xanthine Oxidase Inhibitors
Several studies have indicated that certain flavonoids in fruits such as cherries may inhibit xanthine oxidase and help lower uric acid.
In addition, there are numerous herbs said to lower uric acid by inhibiting xanthine oxidase in the same way as allopurinol, with some being at least 87% as effective as allopurinol.
Some of the most potent are to be found in North America:
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Diagnosis Treatment And Prevention Of Gout
BARRY L. HAINER, MD ERIC MATHESON, MD and R. TRAVIS WILKES, MD, Medical University of South Carolina, Charleston, South Carolina
Am Fam Physician. 2014 Dec 15 90:831-836.
Gout is the most common inflammatory arthropathy, affecting more than 8 million Americans.1 Gout accounts for approximately 7 million ambulatory visits in the United States annually at a cost of nearly $1 billion.2 Risk factors include genetics, age, sex, and diet.2,3 These factors may contribute to a high serum uric acid level, which is currently defined as a value of at least 6.8 mg per dL .4,5
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Oral corticosteroids and nonsteroidal anti-inflammatory drugs are equally effective in the treatment of acute gout.
To prevent recurrent gout, patients should reduce their consumption of high-fructose corn syrupsweetened soft drinks, fruit juices, and fructose-rich vegetables and fruits . Reducing consumption of meat and seafood, and increasing consumption of dairy products help reduce the frequency of gouty symptoms. Consumption of low-fat or nonfat dairy products may help reduce the frequency of flares.
A = consistent, good-quality patient-oriented evidence B = inconsistent or limited-quality patient-oriented evidence C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to .