Gout: Difference between revisions

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[[Allopurinol]] can reduce frequency of attacks. However, when [[allopurinol]] is started:
[[Allopurinol]] can reduce frequency of attacks. However, when [[allopurinol]] is started:
* Allopurinol should be delayed for 1-2 weeks after a flare has resolved
* Allopurinol should be delayed for 1-2 weeks after a flare has resolved
* [[Colchicine]] 0.6 mg twice daily should also be used to prevent a flare. In a [[randomized controlled trial]], co-treatment with colchicine 0.6 mg twice daily while allopurinol was tapered up from 100 mg/day until 3 months after the serum urate concentration < 6.5 mg/dl, reduced flares of gout from 77% in the placebo broup to 33% with colchicine prophylaxis. Most of these patients had tophi.<ref name="pmid15570646">{{cite journal |author=Borstad GC, Bryant LR, Abel MP, Scroggie DA, Harris MD, Alloway JA |title=Colchicine for prophylaxis of acute flares when initiating allopurinol for chronic gouty arthritis |journal=J. Rheumatol. |volume=31 |issue=12 |pages=2429–32 |year=2004 |pmid=15570646 |doi=}}</ref>
* [[Colchicine]] 0.6 mg twice daily should also be used to prevent a flare. In a [[randomized controlled trial]], co-treatment with colchicine 0.6 mg twice daily while allopurinol was tapered up from 100 mg/day until 3 months after the serum urate concentration < 6.5 mg/dl, reduced flares of gout from 77% in the placebo broup to 33% with colchicine prophylaxis. Most of these patients had tophi.<ref name="pmid15570646">{{cite journal |author=Borstad GC, Bryant LR, Abel MP, Scroggie DA, Harris MD, Alloway JA |title=Colchicine for prophylaxis of acute flares when initiating allopurinol for chronic gouty arthritis |journal=J. Rheumatol. |volume=31 |issue=12 |pages=2429–32 |year=2004 |pmid=15570646 |doi=}}</ref> One third of the patients had diarrhea and many reduced the medication to once per day.


[[Allopurinol]] should be increased as possible to achieve a goal serum urate of <u><</u>6 mg/dl (360 micromoles/liter).<ref name="pmid17907217">{{cite journal |author=Perez-Ruiz F, Lioté F |title=Lowering serum uric acid levels: What is the optimal target for improving clinical outcomes in gout? |journal=Arthritis Rheum. |volume=57 |issue=7 |pages=1324–8 |year=2007 |pmid=17907217 |doi=10.1002/art.23007}}</ref>
[[Allopurinol]] should be increased as possible to achieve a goal serum urate of <u><</u>6 mg/dl (360 micromoles/liter).<ref name="pmid17907217">{{cite journal |author=Perez-Ruiz F, Lioté F |title=Lowering serum uric acid levels: What is the optimal target for improving clinical outcomes in gout? |journal=Arthritis Rheum. |volume=57 |issue=7 |pages=1324–8 |year=2007 |pmid=17907217 |doi=10.1002/art.23007}}</ref>

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In medicine, gout is a "hereditary metabolic disorder characterized by recurrent acute arthritis, hyperuricemia and deposition of sodium urate in and around the joints, sometimes with formation of uric acid calculi."[1]

Treatment

Clinical practice guidelines address treatment.[2] However, trials comparing glucocorticoids and non-steroidal anti-inflammatory agents (NSAIDs) were not published till after the guidelines.

Ice packs, applied for 30 minutes 4 times per day, can help according to a randomized controlled trial without allocation concealment.[3] In this trial, ice reduced the visual pain analog score by an additional 33 mm beyond the reduction provided by a combination of glucocorticoids and colchicine.

Regarding medications, if there are no mitigating factors in choosing a drug, steroids, non-steroidal anti-inflammatory agents (NSAIDs), and colchicine all work; however, colchicine consistently causes drug toxicity. While combining steroids with NSAIDs increased the risk for gastrointestinal drug toxicity[4], colchicine can be combined with steroids and possibly with NSAIDs that are not metabolized by the CYP3A4 isoenzyme of cytochrome P-450.

Non-steroidal anti-inflammatory agents

Non-steroidal anti-inflammatory agents (NSAIDs) are better than placebo according to a randomized controlled trial.[5] According to a summary of this trial, "the knee was affected in 14 cases and the great toe in only two cases. After 24 h, 67% of tenoxicam group had ≥50% reduction in pain compared with 26% of placebo group (P<0.05). However, at the end of the treatment (4 days), there was no significant difference between the groups."[6]

Glucocorticoids

Comparison of NSAID and steroids for acute gout
  Patients Interventions Results
Steroid NSAID
Janssens et al 2008[7] 120 total patients with uric acid crystals on arthrocentesis Prednisolone 35 mg once daily for 5 days Naproxen 500 mg twice daily for 5 days NSAID trended better (88% versus 80% response; p=0.3)
No differences in rates of drug toxicity.
Man et al 2007[8] 90 total patients with clinical diagnosis of gout† Initially prednisolone 30 mg
Followed by prednisolone 30 mg daily for 5 days and as needed acetaminophen 		Initially diclofenac 75 mg with indomethacin 50 mg
Followed by indomethacin 50 mg every 8 hrs for 2 days then 25 mg every 8 hrs for 3 days and as needed acetaminophen. 		Steroids faster reduction in pain.
Steroids used more acetaminophen.
More adverse effects from indomethacin.

Indomethacin trended to more relapses at 2 weeks (11% vs 17%).

Notes:

† Clinical diagnosis of gout was "pain and warmth in a joint, and presented within 3 days of the onset of pain and also had 1 or more of the following: metatarsal-phalangeal joint involvement; knee or ankle joint involvement and aspirate containing crystals; or typical gouty arthritis, with either gouty tophi present or previous joint aspiration confirming the diagnosis of gout." Seven patients allowed arthrocentesis and all were positive for gout.

Randomized controlled trials find similar benefit from non-steroidal anti-inflammatory agents and oral glucocorticoids. In the first trial the reduction in visual analog scale after 5 days was 44.7 with prednisolone and 46.0 with naproxen.[8] Less adverse drug reactions occurred in the glucocorticoids group; however, the NSAID group received a high dose (50 mg every 8 hours for 2 days, followed by 25 mg every 8 hours for 3 days)[9].

In the second randomized controlled trial statistically equal effect resulted from prednisolone 35 mg orally per day or naproxen 500 mg orally twice per day; however there was an insignificant 8% improvement in the NSAID group.[7] There were no significant differences in drug toxicity.

Colchicine

Colchicine is better than placebo according to a systematic review by the Cochrane Collaboration[10] that found a single randomized controlled trial[11]. In this study, colchicine 1 mg orally, followed by 0.5 mg every two hours led to a 50% reduction in pain in about 70% of patients compared to about 35% of patients who received placebo. However, all patients had drug toxicity from colchicine and in 90% of the patients toxicity occurred before 50% reduction in pain.

To avoid drug toxicity, lower doses of colchicine (0.6 per day) have been used in combination with glucocorticoids.[3] The UK National Library for Health recommends 0.5 mg two to four times a day.[12]

Prognosis

Acute flares

Without treatment, one third of flares improve within 2 days.[11]

Prevention

Diet

Avoiding products with high fructose such as sugary soft drinks (sweetened with high fructose corn syrup), and other high-fructose products, such as fruit juice, apples, and oranges may help.[13]

Medications

Xanthine oxidase inhibitors

Allopurinol can reduce frequency of attacks. However, when allopurinol is started:

  • Allopurinol should be delayed for 1-2 weeks after a flare has resolved
  • Colchicine 0.6 mg twice daily should also be used to prevent a flare. In a randomized controlled trial, co-treatment with colchicine 0.6 mg twice daily while allopurinol was tapered up from 100 mg/day until 3 months after the serum urate concentration < 6.5 mg/dl, reduced flares of gout from 77% in the placebo broup to 33% with colchicine prophylaxis. Most of these patients had tophi.[14] One third of the patients had diarrhea and many reduced the medication to once per day.

Allopurinol should be increased as possible to achieve a goal serum urate of <6 mg/dl (360 micromoles/liter).[15]

Febuxostat, a non-purine inhibitor, is equally effective as allopurinol when compared in a randomized controlled trial.[16]

Uricosuric agents

Famous persons with gout

Holy Roman Emperor Charles V had gout[17]and Theodore Roosevelt may have had gout[18].

References

  1. ↑ Anonymous (2024), Gout (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. ↑ Zhang W, Doherty M, Bardin T, et al (October 2006). "EULAR evidence based recommendations for gout. Part II: Management. Report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT)". Ann. Rheum. Dis. 65 (10): 1312–24. DOI:10.1136/ard.2006.055269. PMID 16707532. Research Blogging.
  3. ↑ 3.0 3.1 Schlesinger N, Detry MA, Holland BK, et al (2002). "Local ice therapy during bouts of acute gouty arthritis". J. Rheumatol. 29 (2): 331–4. PMID 11838852. [e] Cite error: Invalid <ref> tag; name "pmid11838852" defined multiple times with different content
  4. ↑ Fries JF, Williams CA, Bloch DA, Michel BA (September 1991). "Nonsteroidal anti-inflammatory drug-associated gastropathy: incidence and risk factor models". Am. J. Med. 91 (3): 213–22. PMID 1892140. [e]
  5. ↑ García de la Torre, Ignacio. (1987) Estudio doble-ciego paralelo, comparativo con tenoxicam vs placebo en artritis gotosa aguda (A comparative, double-blind, parallel study with tenoxicam vs placebo in acute gouty arthritis). Invet Med Int '14:'92–7 [Abstract in Spanish]
  6. ↑ Sutaria S, Katbamna R, Underwood M (November 2006). "Effectiveness of interventions for the treatment of acute and prevention of recurrent gout--a systematic review". Rheumatology (Oxford) 45 (11): 1422–31. DOI:10.1093/rheumatology/kel071. PMID 16632483. Research Blogging.
  7. ↑ 7.0 7.1 Janssens HJ, Janssen M, van de Lisdonk EH, van Riel PL, van Weel C (May 2008). "Use of oral prednisolone or naproxen for the treatment of gout arthritis: a double-blind, randomised equivalence trial". Lancet 371 (9627): 1854–60. DOI:10.1016/S0140-6736(08)60799-0. PMID 18514729. Research Blogging.
  8. ↑ 8.0 8.1 Man CY, Cheung IT, Cameron PA, Rainer TH (2007). "Comparison of oral prednisolone/paracetamol and oral indomethacin/paracetamol combination therapy in the treatment of acute goutlike arthritis: a double-blind, randomized, controlled trial". Annals of emergency medicine 49 (5): 670–7. DOI:10.1016/j.annemergmed.2006.11.014. PMID 17276548. Research Blogging.
  9. ↑ Henry D, Lim LL, Garcia Rodriguez LA, et al (June 1996). "Variability in risk of gastrointestinal complications with individual non-steroidal anti-inflammatory drugs: results of a collaborative meta-analysis". BMJ 312 (7046): 1563–6. PMID 8664664. PMC 2351326. [e]
  10. ↑ Schlesinger N, Schumacher R, Catton M, Maxwell L (2006). "Colchicine for acute gout". Cochrane Database Syst Rev (4): CD006190. DOI:10.1002/14651858.CD006190. PMID 17054279. Research Blogging.
  11. ↑ 11.0 11.1 Ahern MJ, Reid C, Gordon TP, McCredie M, Brooks PM, Jones M (June 1987). "Does colchicine work? The results of the first controlled study in acute gout". Aust N Z J Med 17 (3): 301–4. DOI:10.1111/j.1445-5994.1987.tb01232.x. PMID 3314832. Research Blogging. Summary at Bandolier Cite error: Invalid <ref> tag; name "pmid3314832" defined multiple times with different content
  12. ↑ CKS (2007) Gout - Mangement (Topic Review). Clinical Knowledge Summaries. http://cks.library.nhs.uk/gout/management [Accessed: Date]
  13. ↑ Hyon K Choi and Gary Curhan, “Soft drinks, fructose consumption, and the risk of gout in men: prospective cohort study,” BMJ (January 31, 2008): bmj.39449.819271.BE.
  14. ↑ Borstad GC, Bryant LR, Abel MP, Scroggie DA, Harris MD, Alloway JA (2004). "Colchicine for prophylaxis of acute flares when initiating allopurinol for chronic gouty arthritis". J. Rheumatol. 31 (12): 2429–32. PMID 15570646. [e]
  15. ↑ Perez-Ruiz F, Lioté F (2007). "Lowering serum uric acid levels: What is the optimal target for improving clinical outcomes in gout?". Arthritis Rheum. 57 (7): 1324–8. DOI:10.1002/art.23007. PMID 17907217. Research Blogging.
  16. ↑ Becker MA, Schumacher HR Jr, Wortmann RL, MacDonald PA, Eustace D, Palo WA, Streit J, Joseph-Ridge N.Febuxostat compared with allopurinol in patients with hyperuricemia and gout.N Engl J Med. 2005 Dec 8;353(23):2450-61. PMID 16339094
  17. ↑ Ordi J, Alonso PL, de Zulueta J, et al (August 2006). "The severe gout of Holy Roman Emperor Charles V". N. Engl. J. Med. 355 (5): 516–20. DOI:10.1056/NEJMon060780. PMID 16885558. Research Blogging.
  18. ↑ Pinals RS (February 2008). "Theodore Roosevelt's inflammatory rheumatism". J Clin Rheumatol 14 (1): 41–4. DOI:10.1097/RHU.0b013e3181639ad0. PMID 18431099. Research Blogging.
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