The Four Stages Of Gout
Gout is best understood by seeing it as having four phases or stages :
Stage 1: High uric acid
Elevated uric acid without gout or kidney stone, this stage has no symptoms and is generally not treated.
Stage 2: Acute flares
This stage is marked by acute gout attacks causing pain and inflammation in one or more joints.
Stage 3: Intercritical periods
These are periods of time between acute attacks, during which a person feels normal but is at risk for recurrence of acute attacks.
Stage 4: Advanced gout
This is a stage of chronic gouty arthritis, in which there are lumps of uric acid, or tophi , frequent attacks of acute gout, and often a degree of pain even between attacks .
Figure 1: Stages of Gout
Figure 2: Illustration of Toe Joint with Gouty Tophus. normal toe joint Urate crystals, shown in white, at the “bunion joint,” represent a gouty tophus.)
Figure 3: Progression of Gout
How Do We Prevent Gout Flare
Generally, we need to get your uric acid levels lower to prevent gout flare-ups. Firstly, you need to treat lifestyle factors. Examples include losing weight, reducing alcohol intake, and a healthy diet. Secondly, your doctor may prescribe medications to lower uric acid. The most common drug is allopurinol. It is important to wait until an acute attack has settled before starting this drug. Speak to your doctor about whether you should consider this drug. In general, preventative medication such as Alluprinol is useful if youre uric acid levels are high .
When you start taking Allopurinol, you should take another tablet such as colchicine for about 4 weeks to prevent another attack.
Typically, a change in lifestyle can reduce uric acid levels. Examples of foods that increase purine and should be avoided include organ meats, sardines, anchovies, prawns, board beans, and foods containing a high concentration of high fructose corn sugar. In addition, yeast and yeast-based foods such as frozen foods and canned food can be problematic. Also, sugar-sweetened beverages and alcoholic drinks increase acid levels. Generally, wine is better than hard liquor or beer.
On the contrary, foods that reduce uric acid include cherries, fruit and vegetables high in vitamin C, low-fat dairy products, and a vegetarian diet. Also, keeping well hydrated can prevent and treat an attack.
How And When To Take It
Follow your doctors instructions about how many tablets to take, and how many times a day.
Its important to stick to your prescribed dose. This is because there is only a small difference between a correct dose and an overdose.
Colchicine comes as 500 microgram tablets. The word microgram is sometimes written with the Greek symbol followed by the letter g . A microgram is 1,000 times smaller than a milligram .
If you have kidney or liver disease, your doctor may prescribe a lower dose. You will also have regular blood and urine tests.
Swallow your tablet whole, with a glass of water.
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Getting The Most From Your Treatment
- You will be given a Steroid Treatment Card which says that you are on steroids and contains some important advice for you. It is important that you read this card and carry it with you at all times. It also contains details about your dose, how long you have been taking prednisone for, and who prescribed it for you. Please make sure that this information is kept up-to-date. If you are having an operation or dental treatment or any treatment for an injury, tell the person carrying out the treatment that you are taking prednisone and show them your treatment card.
- Try to keep your regular appointments with your doctor. This is so your doctor can check on your progress. Your doctor will want you to have tests from time to time to make sure you remain free from some of the unwanted side-effects of treatment.
- Prednisone may suppress your immune system, so it is important if you become ill that you make an appointment to see your doctor straightaway. Also, if you come into contact with anyone who has measles, shingles or chickenpox , you should see your doctor as soon as possible.
- Some vaccines may not be suitable for you while you are being treated with prednisone. If you need any immunisations, make sure you mention that you are taking a steroid.
- If you need to buy any medicines, check with a pharmacist that they are suitable for you to take with your other medicines.
Prednisone And Gout Related Topics
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Prednisone and Gout References
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What To Do If Gout Gets Worse With Prednisone: What You Must Know
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How Can An Attack Of Gout Be Treated
The management of an acute attack of gout is very different from the prevention of subsequent attacks.
Treatments used for prevention, such as allopurinol can actually make things worse if given during an attack, and so need to be held back until the attack has resolved for several weeks.
There are a number of measures that can help resolve an attack of gout. See Table 2 for summary of treatment strategies for acute gout. One principle is that treatment for an attack of gout should be instituted quickly, since quick treatment can often be rewarded with a quick improvement.
If an attack of gout is allowed to last more than a day or so before treatment is started, the response to treatment may be much slower.
Table 2: Medications to treat acute attacks of gout
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Comorbidities Age Mean Fewer Options
NSAIDs increase the risk of gastrointestinal bleeding, especially in the first week of use. Cyclooxygenase-2 inhibitors, considered as effective as NSAIDs in treating acute gout pain, are also associated with GI bleeds. In addition, NSAIDs and COX-2 inhibitors increase cardiovascular risks, prompting the American Heart Association to recommend restricted use of both. NSAIDs effect on renal function, fluid retention, and interactions with anticoagulants are additional concerns, because gout patients are generally older and often have comorbid renal and cardiovascular diseases.,-
In the United States, nearly 70% of patients who develop acute gout seek treatment from primary care physicians. Family physicians need a safe alternative to NSAIDs to relieve the severe pain associated with this condition. Will oral corticosteroids fit the bill?
Prednisone Or Indomethacin For Gout
This is a very brief review of a study comparing prednisone with indomethacin for gout. Because the full report is widely available.
This study concludes:
Our results are in line with epidemiologic reports that acute gouty arthritis most commonly affects elderly patients and that the risk of serious gastrointestinal toxicity of NSAIDs is higher in this age group. According to the findings in our study, we recommend that moderate doses of oral prednisolone supplemented with oral acetaminophen be considered as first-line therapy in the treatment of acute gout.
However, the report also summarizes many common side-effects of long-term steroid use.
This is a very brief review of a study comparing prednisone with naproxen for gout. Because the full report is widely available.
This study concludes:
The present study confirmed the risk profile of patients with gout for NSAIDs . Although no patients were excluded because of the risks from a prednisolone treatment, a quarter of the eligible patients had to be excluded because of direct safety risks if they would have been treated with naproxen . For them, a 5-day treatment with prednisolone would have been no problem.
In conclusion, the present study provides a strong argument to consider prednisolone as a first treatment option in patients with gout.
So again, we see that the main consideration is the comparison of side-effects.
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What If I Forget To Take It
If you take allopurinol:
- once a day take the missed dose as soon as you remember. If you do not remember until the following day, skip the missed dose.
- twice or more a day – if you do not remember until your next dose is due, skip the missed dose and take the dose that is due.
Never take a double dose to make up for a missed dose.
If you often forget to take your medicines, it may help to set an alarm to remind you. You could also ask a pharmacist for advice on ways to help you remember to take your medicines.
Prednisone And Your Gout
Now you know that steroids are as effective as NSAIDs at controlling acute gout. Yet both these groups of gout pain medicine have serious issues with side-effects from long-term use. So you must make uric acid control the priority over gout pain control. Then you can remove the need for either of these groups of medicines for gout.
For steroids during uric acid treatment see .
Leave Prednisone and Gout to return to your .
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Avoid Changing Hypouricaemic Therapy
During the treatment of acute gout any sudden change in the concentration of serum uric acid will exacerbate the attack. Patients taking regular hypouricaemic therapy should therefore not stop their treatment. Likewise, hypouricaemic therapy should not commence until after the attack has settled. The use of concurrent low-dose colchicine during the introductory phase of hypouricaemic therapy reduces the frequency of attacks during that relatively high-risk period.
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:
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Eligibility Criteria Of Rcts
We then searched for all trials that examined the efficacy of prophylactic drugs during initiation of ULT by using the following search terms: gout, prophylaxis, prevention and randomized controlled trials . Studies were eligible for inclusion if they were original articles of a randomized controlled design that included adults with gout and evaluated the prophylaxis of GFs following initiation of ULT. Studies were excluded if they were published in a non-English language, examined diseases other than gout, evaluated the treatment of acute GFs or their prophylaxis without initiating ULT or were a post hoc analysis of previously published data from RCTs. Other articles cited in this review were retrieved separately, either by checking references of relevant studies or by hand searching.
Prophylactic Treatments: Current Recommendations
Adherence to treatment is a key issue in the management of chronic gout, because once prescribed, ULT should remain for life. Unfortunately, non-adherence among patients with gout who start ULT is common . This adherence may be compromised both by GFs triggered after ULT initiation and by the practice of delaying the introduction of ULT a few weeks after resolution of a flare. Indeed, the latter tends to promote the idea that no additional treatment is needed once an acute attack has resolved. In contrast to EULAR recommendations , ACR guidelines recommend that ULT be started during an attack, if anti-inflammatory treatment has been introduced beforehand . This strategy was supported by a recent RCT showing no difference in pain, recurrent flares or inflammatory markers with allopurinol initiated during an acute GF as compared with a 10-day delay in initiation .
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How Can A Gout Attack Be Prevented
Diet plays a key role diet in gout prevention: Since foods can directly set off gout attacks, patients with gout should receive counseling as to which foods are more likely to induce attacks. Losing weight is often also helpful. However, as important as diet is in gout, for most people with gout diet, and even weight loss, are not enough, and medications will be needed to get to their uric acid goal.
Prednisone As Gout Treatment
What is Prednisone?
Prednisone is a drug that is used to treat inflammation. It prevents the release of substances in the body the cause inflammation. This drug is also used to treat other diseases such as psoriasis, allergic disorders, breathing disorders, and skin allergies. It has also been used in the treatment of severe tuberculosis, thyroiditis, laryngitis, asthma, and migraine. Prednisone is also sometimes used to treat the symptoms of certain types of cancer. It works to treat other conditions by reducing swelling and redness and by changing the way the immune system works.
How should prednisone be used?
Prednisone should not be taken by someone who is allergic to it or if there are fungal infections in the body. Before taking this medicine, one has to consult a doctor about his condition. Intake of prednisone is also not recommended for those who are pregnant or lactating. Prednisone either comes as a tablet, a liquid solution, or a concentrated solution to be taken by mouth. It is usually taken with food one to four times a day or as the doctor prescribes. It is very important to follow the prescription label of the drug carefully and take the medicine exactly as directed.
What are the side effects of prednisone?
Prednisone may sometimes cause serious side effects such as:
- vision problems
- numbness of some parts of the body
- difficulty in breathing or swallowing
- vomiting
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What Does A Gout Attack Look And Feel Like What Would A Foot Or Toe With Gout Look Like
When gout occurs, the joint tends to be extremely painful and is warm, red and swollen . The inflammation that is part of a gout attack is systemic, so that fever and chills, fatigue and malaise are not uncommonly part of the picture of a gout attack.
Figure 6: Toe with Acute Attack of Gout
Gout attacks can occur in joints that look normal, or in joints that have easily visible deposits of uric acid. These deposits are called tophi and can be in numerous locations, but especially on the feet and elbows. In Figure 9, the little finger of the right hand is bandaged since fluid was just removed from it, which demonstrated innumerable uric acid crystals.
Figure 7a: Tophi on Foot
Figure 7b: Tophus Over Achilles’ Tendon
Figure 8: Tophus on Elbow
Figure 9: Tophi on Hands
Figure 10: Large Tophus of Finger
While some gout attacks will solve quickly by themselves, the majority will go on for a week, several weeks, or even longer if not treated. Since gout attacks are usually quite painful and often make walking difficult, most gout sufferers will request specific treatment for their painful condition.
Prednisone And Gout Overview
We need gout pain relief when we get diagnosed with gout after early gout attacks. So this is called acute gout control. Then long-term we need a plan to get uric acid safe. But we can still get gout attacks during the first six months of uric acid treatment. So good doctors will prescribe preventative gout pain control. Or you might agree to rely on acute gout control you are already familiar with.
In this article, I review two studies of prednisone for acute gout control.
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