When To Check Uric Acid After Gout Flare

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.

• References

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.

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 .

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.

How Can I Manage My Gout And Improve My Quality Of Life

Gout affects many aspects of daily living, including work and leisure activities. Fortunately, there are many low-cost self-management strategies that are proven to improve the quality of life of people with gout.

For gout in particular:

• Eat a healthy diet. Avoid foods that may trigger a gout flare, including foods high in purines , and limit alcohol intake .

CDCs Arthritis Program recommends five self-management strategies for managing arthritis and its symptoms. These can help with gout as well.

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How Is Pseudogout Treated

There is no cure for removing the calcium deposits that cause pseudogout. It is a progressive disorder that can eventually destroy joints. Treatments for acute attacks of pseudogout are similar to those for gout and are aimed at relieving the pain and inflammation and reducing the frequency of attacks.

• Nonsteroidal anti-inflammatory drugs are effective for treating inflammation and pain from pseudogout.
• For acute attacks in large joints, fluid aspiration alone or with corticosteroids may help.
• Colchicine may be used for acute attacks.
• Magnesium carbonate may help dissolve crystals, but existing hard deposits may remain.
• Surgery may be required for joint replacement.

How Hyperuricemia And Gout Develop

Metabolism of Purines

The process leading to hyperuricemia and gout begins with the metabolism, or breakdown, of purines. Purines are compounds that are important for energy. They are part of the nucleic acids that are present in all cells of the body. Purines can be divided into two types:

• Endogenous purines are produced within human cells.
• Exogenous purines are obtained from food.

The process of breaking down purines results in the formation of uric acid in the body. Most mammals, except humans, have an enzyme called uricase. Uricase breaks down uric acid so it can be easily removed from the body. Because humans lack uricase, uric acid is not easily removed and can build up in body tissues.

Uric Acid and Hyperuricemia

Purines in the liver are converted to uric acid. The uric acid enters the bloodstream. Most of the uric acid goes through the kidneys and is excreted in urine. The remaining uric acid travels through the intestines where bacteria help break it down.

The enzyme responsible for production of uric acid from purines is xanthine oxidase. This enzyme is the target of urate-lowering treatments such as allopurinol.

Normally these processes keep the level of uric acid in the blood below 6.8 mg/dL. But sometimes the body produces too much uric acid or removes too little. In either case, the level of uric acid increases in the blood. This condition is known as hyperuricemia.

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Treatment Of High And Low Levels

Certain foods contain purines, which create uric acid when the body breaks them down. Eating a diet that is too rich in purines can cause uric acid to build up in the blood.

It is not possible to avoid purines completely because small amounts are present in many foods. However, a person can follow a low purine diet and take other steps to help lower purine levels.

Foods that include moderate or high levels of purines include:

• alcohol

Avoid High Purine Foods

Todays standard diet makes it hard to avoid purines. To avoid uric acid buildup, you need to avoid foods that are high in purines such as seafood, organ meats, processed foods, and beer. In addition, you should also avoid alcohol and saturated fats since these inhibit your bodys ability to metabolize purines properly.

Beer is the worst alcohol to drink for gout because it both contains alcohol and yeast which is high in purines. If you have gout or hyperuricemia, you should completely avoid beer or just drink in moderation, preferably with just organic beer.

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Arthritis / Acute Gout Attack

Gout is a form of arthritis, hence it causes pain and discomfort in the joints. A typical gout attack is characterized by the sudden onset of severe pain, swelling, warmth, and redness of a joint. The clinical presentation of acute gouty arthritis is not subtle with very few mimics other than a bacterial infection.

The joint most commonly involved in gout is the first metatarsophalangeal joint , and is called podagra. Any joint may be involved in a gout attack with the most frequent sites being in the feet, ankles, knees, and elbows.

An acute gout attack will generally reach its peak 12-24 hours after onset, and then will slowly begin to resolve even without treatment. Full recovery from a gout attack takes approximately 7-14 days.

An accurate and colorful discription of a gout attack was elegantly written in 1683 by Dr. Thomas Sydenham who was himself a sufferer of gout:

What You Need To Know

• An acute attack of gout is likely to require treatment with a NSAID or colchicine

• In general, urate lowering therapy is targeted to patients with recurrent attacks, tophi, urate arthropathy, or renal damage and to symptomatic patients with very high serum uric acid levels. Allopurinal is the first line option

• All patients taking ULT require regular monitoring of renal function and serum uric acid level to ensure that the dose is appropriate. For many people, allopurinol 300mg daily will be insufficient to achieve target serum uric acid reductions.

• Despite limited evidence, patients should be encouraged to manage their weight, increase exercise, and reduce alcohol consumption

Gout is the most common inflammatory arthritis and its incidence in the UK has steadily increased from 1.5% in 1997 to 2.5% in 2012.12 It is characterised by deposition of monosodium urate crystals in joints and tissues and usually presents with intermittent painful attacks followed by long periods of remission.3 Here, we review the latest guidance on the management of gout and consider the role of long term urate lowering therapy.

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Are There Foods Or Medications That Might Increase The Risk Of Gout

Certain kinds of diet can increase the risk of gout. For example, high-fructose corn syrup is added to many foods and drinks. It causes uric acid to go up. It is typically found in sweetened soft drinks and juices certain cereals and pastries ice cream and candy and processed foods at fast food restaurants. Drinking a lot of alcohol, especially beer and hard liquor, also increases the risk of gout. Eating lots of red meat or shellfish will also increase the level of uric acid in the blood and make gout more likely.

Gout may occur after taking certain medicines, such as hydrochlorothiazide and other water pills, which may cause a higher level of uric acid in the blood. Cyclosporine or tacrolimus are medications used to suppress the immune system in people with organ transplants and can also increase blood level s of uric acid. Niacin is used to treat high triglycerides and can also increase the risk of gout.

How To Know If Your Gout Is Progressing

As you become more familiar with gout symptoms, you may be able to sense that a gout attack is coming on. Worsening of pain, swelling, redness, and warmth of the affected joint during the attack is the sign of progression of that attack, Dr. Meysami says.

In addition, the disease overall may progress with recurrent or more frequent gout attacks with longer duration, the involvement of more joints, and the presence of tophi, Dr. Meysami says.

If you have more than one gout flare a year, its really important to get on a regular gout medication, says Dr. Fields.

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What Types Of Questions Will My Provider Ask If I Am Concerned About Gout

The provider will ask about the following:

• Have you had an attack like this before?
• Have you been diagnosed with hyperuricemia ?
• Has anyone in your family had with gout or hyperuricemia?
• Do you have diabetes, kidney disease, hypertension or heart disease?
• Have you had a recent joint injury?
• What is your diet: high sugar or soda? How much alcohol? Red meat, high protein?
• If female, have you been through menopause?

Your provider will examine your joints, looking for swelling, redness, tenderness, deformity and look for tophi.

A blood test will be done to check serum uric acid levels. While a blood test doesnt provide a definitive diagnosis of gout, it helps the provider understand whether this is a potential diagnosis. Also, blood tests for diabetes and kidney function along with standard CBC and urinalysis.

A CT scan, ultrasound, MRI and/or joint fluid aspiration will be done to assess for crystals that are proof-positive of a gout diagnosis.

The Role Of Gout Tests

Gout testing can be used to diagnose the cause of a persons symptoms, help doctors plan treatment, and monitor the treatment of gout:

• Diagnosis: Testing for gout helps doctors to identify gout, distinguish it from other conditions, and investigate the cause of increased uric acid concentrations in the blood.
• Determining treatment: For many patients, urate-lowering therapy is the first approach to treating gout. Human leukocyte antigen testing is recommended for patients of certain ethnic backgrounds to determine their risk of severe side effects while taking urate-lowering medications.
• Treatment monitoring: Patients being treated for gout may have their uric acid concentration in their blood continuously monitored. Tracking the level of uric acid in the blood can help doctors ensure that the medication is working appropriately.

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Can Gout Be Cured

Cure is a very strong word, but we can certainly treat the gout and put it in remission by giving the treatment as mentioned, Dr. Meysami says.

Whether to use the word cure may be a matter of semantics: A patients gout tendency may never go away but can be well-controlled. Treatments for gout are extremely good, and the vast majority of gout patients can expect to be cured, Dr. Fields says. Cured is in quotes since it means that gout flares can completely disappear, but the person would need to stay on their medicine.

Gout progression, though, certainly isnt inevitable, which is close to the best news any gout patient can hear.

What Is Uric Acid

Uric acid is a natural waste product that your body produces when digesting foods containing purines. Purines are chemical compounds found in many foods including red meat, some seafood, and refined sugars.

Usually, your kidneys filter out uric acid and it passes out in your urine. But consistently high uric acid levels can build up in your blood and cause gout. Gout is a type of arthritis that leads to painful swelling due to crystals forming in your joints. Gout most commonly affects your hands, feet, wrists, elbows, and knees.

High uric acid levels are also associated with an increased risk of high blood pressure, kidney stones, kidney disease, and liver disease.

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Quick Answers For Clinicians

Hyperuricemia is a common condition and is classified by elevated serum urate concentrations. The most common complication of hyperuricemia is gout. However, many cases of hyperuricemia are asymptomatic. In patients with gout, serum urate concentrations are generally high, but can be normal at the time of an acute gout flare. The presence of hyperuricemia aids in the clinical diagnosis of gout, but it does not definitively confirm the diagnosis. Persistently low serum urate concentrations make the diagnosis of gout less likely. The Criteria for Diagnosis section has more detailed information about the definitive diagnosis of gout.

Imaging methods such as radiography and magnetic resonance imaging may be useful in monitoring the progression of joint erosion or tophus size in chronic gout. Ultrasound and dual-energy computed tomography are used to detect urate deposition in symptomatic joints. All of these imaging modalities are included in the American College of Rheumatology and the European League Against Rheumatism gout classification criteria. Imaging alone is insufficient to definitively diagnose gout and should be used in addition to laboratory testing methods.

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 Could I Take It I Have Severe Gout With Tophi

If you have many large tophi, your provider may prescribe pegloticase, also known as Krystexxa®, given by intravenous infusion every two weeks to more quickly dissolve gout crystals. Several gout specialists give infusions at their offices, where patients are monitored throughout the treatment, which takes two to four hours, including pre-infusion medication and post-infusion monitoring. This more aggressive treatment is used without other drug therapy and can reduce uric acid levels significantly and quickly and eliminate the tophi, often within eight to nine months.

Some side effects of pegloticase are muscle pain, nausea, vomiting and upset stomach which need to be addressed by a doctor if they persist or bothersome.

Proper treatment of acute attacks and lowering uric acid to a level less than 6 mg/dL allows people to live a normal life. However, the acute form of the disease may progress to chronic gout if the high uric acid is not treated adequately.

You may not be able to prevent gout, but you may be able to help by following the diet and life-style recommendations noted above. Taking medicines to lower uric acid can prevent progression of gout and over time your deposits of uric acid will disappear.

What are some possible complications of gout?

Who should treat my gout?

Usually your Primary Care Provider can treat early-stage gout. But, its important for your PCP to know what you expect in treating your gout.

Here are some questions to ask your PCP: