GOUT

Overview

Gout is a metabolic disorder of purine metabolism, characterized by intermittent attacks of acute pain, swelling and inflammation. Most common site of initial attack metatarsophalangeal joint of the great toe. 

An attack of gout can occur suddenly, often waking you up in the middle of the night with the sensation that your big toe is on fire. The affected joint is hot, swollen and so tender that even the weight of the sheet on it may seem intolerable.

Pathophysiology

The deposition of uric acid crystals is usually secondary to relatively high levels in the blood. This can occur because of diet, genetic predisposition, or underexcretion of uric acid

Causes & Risk Factors

Diet and Lifestyle

• Diet rich in Meat and Seafood
• Dried Mushroom & Potatoes 
• Alcohol especially beer or fructose-sweetened drinks
• Obesity appears to be an independent risk factor as the body produces more uric acid.

Genetics and family history

• It is partly genetic & it has been associated with certain familial conditions/syndromes.

Age and sex

• It is more common in males; occurs in 30-50 years of age. 
• Women usually develop gout after menopause. 

Medical conditions

• Obesity (BMI greater than or equal to 35), increases the risk of gout three times in males.
• Metabolic syndrome
• Hemopoietic disorders 
• Renal failure,
• Psoriasis.

Medication

• Mainly diuretics(except hydrochlorothiazide) have been associated with attacks of gout. 
• Other commonly used medicines like Asprin, Antihypertensive, Immunosuppressive drugs also increase the risk of gout.

Symptoms

Acute gout

• Painful arthritic attack of sudden onset
• Inflammation & Redness
• Involves one or few joints
• Most common site of initial attack metatarsophalangeal joint of the great toe (known as podagra).
• Other sites ankle, heel, knee, wrist, elbow and fingers.

Chronic gout

• Frequency of Attacks Increases, continuous deposit leads to damage of joints & chronic pain
• Patients may develop large subcutaneous tophi (Stones) in the pinna of the external ear, eyelids, nose and around joints
• The ureate crystals in the kidney lead to renal disease.
• Articular cartilage may be destroyed result in joint deformities

When to see a doctor

• Sudden, intense pain in a joint
• Fever 
• Inflamed Joint

Diagnosis

Tests to help diagnose gout may include:

• Synovial Fluid Test

The doctor may use a needle to draw fluid from your affected joint. Urate crystals may be visible when the fluid is examined under a microscope.

• Blood Investigation

Doctors may recommend a blood test to measure the levels of uric acid and creatinine in your blood. 

Though hyperuricemia is a classical feature of gout, the diagnostic utility of measuring uric acid levels is actually limited because approximately 50% of the time gout may occur without hyperuricemia and not everybody with raised uric acid levels will develop gout.

• Radiology

X-Ray Findings: In chronic gout cases, X-Ray might show evidence of bony erosions. Also, it helps to rule out other causes of arthritis.

Ultrasound Findings: Musculoskeletal ultrasound can detect urate crystals in a joint or in a tophus.

Treatment

It is broadly divided into :

1. By Medications
2. Lifestyle Modification

By Medications:

     ACUTE GOUT:

• NSAIDs
• Corticosteroids
• Colchicine

    CHRONIC GOUT:

• Inhibit uric acid synthesis:- Allopurinol, febuxostat (Urostatic)
• Increase uric acid excretion:- Probenecid, Sulphinpyrazole (Urosuric)

Lifestyle Modification

• Instead of alcoholic beverages, drink plenty of nonalcoholic drinks, especially water. Coffee also helps in reducing uric acid levels.
• Avoid consuming red meat, organ meats and seafood as they are rich in Purines.
• Vitamin C supplements may reduce the levels of Uric Acid in the Blood
• Regularly exercising & maintaining body weight, reduces the risk of gout