Treatment Of Gout

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Treatment Of Gout

Gout treatment involves several steps as is summarized in this table and explained in the text in more detail.

1.Treating the pain: The most important step is to treat the acute gout pain with anti-inflammatory medications, to minimize the soft tissue damage in the body and to help the patient overcome the severe pain.

This is achieved by colchicine, which usually controls the joint pains within 12 to 48 hours. Side-effects of colchicine therapy are diarrhea, which can lead to electrolyte disturbances, and bone marrow suppression. In patients with compromised kidney function the physician must carefully monitor for toxicity as in severe cases of kidney malfunction respiratory depression and cardiotoxic effects could lead to death.

Therapeutic steps in treating gout
Therapeutic step:	Comments:
pain control	colchicine and NSAIDs
lowering uric acid level	allopurinol, probenecid or sulfinpyrazone
dietary changes	increase fluid intake, reduce purine rich foods (liver etc.) and avoid alcohol
treat concomitant medical illness	control diabetes, treat hypertension etc.
kidney stones	treat with allopurinol maintenance program
resistant kidney stones	treat with extracorporal shock wave lithotripsy
large tophi	plastic surgery to remove tophi

On the other hand colchicine in the appropriate patient can be very effective and impressively takes the pain away through the specific suppression of the inflammatory response to the uric acid crystals. Colchicine is taken up in leukocytes and the inflammatory infiltration of leukocytes, which would have lead to kinin release and pain, is inhibited. Colchicine can also be taken for prevention of an attack or again when another gout attack flares up. However, colchicine has limits. It does not lower uric acid levels and does not prevent progression to chronic gout.

2. Lowering the uric acid level: This is achieved most reliably with allopurinol (brand name: Zyloprim, Lopurin) which inhibits the synthesis of uric acid and also inhibits the formation of purin in the body. All of this leads to lower serum uric acid levels and the dosage can be titrated by repeat blood tests that your physician will order. The level should be kept at around 4.5 mg/dL (or 0.26 mmol/L) or lower.

Another approach to lower uric acid levels is to increase uric acid elimination via the urine, this is called "uricosuric therapy". Two medicines can be used for this purpose: probenecid (brand names: Benemid and Benuryl) and sulfinpyrazone (brand name: Anturan). Salicylates such as ASA or non-steroidal antiinflammatory drugs (NSAIDs) counteract this uricosuric effect and should be avoided when this medication is given. Your doctor would know best what medication to use in your case and could also explain the allopurinol side effects and side effects of the other drugs.

3. Control inflammation: In the first few days or weeks the joint inflammation and inflammation of the affected connective tissue is causing a great deal of pain and discomfort. It is here where some anti-inflammatories such as NSAIDs may have a place.

However, as NSAIDs are eliminated through the kidneys and can on the longterm cause a nephropathy (kidney damage) themselves, this needs to be discussed with the treating physician. Kidney function can be assessed by measuring creatinine and BUN levels as well as electrolytes. If there are doubts based on these tests, a 24-hour urine collection can be done to determine the creatinine clearance, which would give a snapshot in time of how well the kidneys are functioning. Every couple of years the creatinine clearance test can be done again to follow the kidney function. Indomethacin (brand name: Indocid) is particularly effective in the acute gouty arthritis, but naproxen (brand names: Naprosyn or Rhodiaprox) is also useful. The COX-2 inhibitory drug (brand name: Celebrex) is also useful. Keep an eye on side-effects of the COX-2 inhibitory medications as one of these drugs (VIOXX) was pulled from the market in October of 2004. The VIOXX link explains this story in detail.

4. Increased fluid intake: As uric acid is not very soluble, it is advisable to take in fluids of more than 3 L per day, particularly patients who also pass kidney stones (uric acid stones or calcium oxalate stones). Alkalinization of the urine also helps and the physician may want to advise the patient to take 500 mg of acetazolamide at bedtime to make the nighttime urine alkaline, which increases solubility for uric acid in the urine and prevents kidney stones.

5. Other measures: To help with large tophi such as in the elbow region, a surgeon may be able to remove these surgically, if lowering of uric acid in the blood is not successful in melting this away. Also patients with large kidney stones in the center of the kidney (called the "renal pelvis") can be trated with extracorporal shock wave lithotripsy, where special ultrasond shock waves cause a resonance and the large kidney stone is broken into sand-like particles that are easily passed with the urine.

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References:

1. The Merck Manual, 7^th edition, by M. H. Beers et al., Whitehouse Station, N.J., 1999. Chapter 55.

2. ABC of rheumatology, second edition, edited by Michael L. Snaith , M.D., BMJ Books, 1999.

3. Goldman: Cecil Textbook of Medicine, 21st ed.(©2000)W.B.Saunders

4. Ferri: Ferri's Clinical Advisor: Instant Diagnosis and Treatment, 2004 ed., Copyright © 2004 Mosby, Inc.

5. Rakel: Conn's Current Therapy 2004, 56th ed., Copyright © 2004 Elsevier