Arthritis-India

Gout	Chronic Grout

Gout manifests as sudden swelling and severe pain usually in a single joint. This is due to an inflammatory response within a joint following deposition of uric acid crystals. Uric acid is a normal constituent of our body formed during disintegration of senescent cells as also from degradation of certain food items containing high levels of purines. Gout is the most common form of inflammatory arthritis in men (5-27 per 1000 men). Gout rarely occurs in children and in women before menopause. Raised uric acid in children can be due to inborn errors of metabolism.

Gout is an ancient disease described by Hippocrates as well as in classical Ayurveda texts. It has affected many great personalities especially the wealthier ones such as kings and emperors. 3 Indian studies indicate that about 65% of patients are from middle socioeconomic class. Prevalence of gout appears to be increasing although public awareness about the condition is extremely poor. Gout has a familial predisposition in about one-sixth of cases and certain genetic factors are important risk for development of gout.

Causes
Most cases of gout do not have an identifiable cause (primary gout). High uric acid levels are found in patients with severe kidney disease due to insufficient excretion and in some cancers due to excessive formation. Uric acid can rise temporarily during strenuous exercise, starvation and dehydration. Meat, seafood, sugary drinks and alcohol (especially beer) are most important food items that increase levels of uric acid. Dietary excess of these items can trigger an attack of arthritis. Pulses and poultry contain moderate quantities of purines. Purine content of milk, eggs and vegetables is negligible.

Some drugs increasing uric acid levels:

Low dose aspirin
Diuretics (Drugs that increase urine output)
Drugs used in tuberculosis e.g. ethambutol, pyrizinamide
Few drugs used in cancer and AIDS

Raised uric acid levels can also be seen in severe psoriasis, hypothyroidism, lead intoxication (use of herbal compounds), sickle cell disease and certain forms of anemia. Vitamin C (citrus fruits) and coffee appear to prevent attacks of arthritis in patients with raised uric acid levels.

Features

Gout is a chronic disease that manifests in 4 stages.

Uric acid may be raised without any arthritis.
Acute attack - An acute attack of gout manifests as exquisite pain and warm pink shiny swelling usually at the base of a great toe (podagra). The pain usually starts early in the morning during cold weather following a high protein dinner alongwith alcohol. Unless treated, severity of pain increases rapidly over a couple of days and regresses over a week or so alongwith peeling of overlying skin. Acute gout usually occurs in a single joint although it may affect multiple joints simultaneously in about 15% cases. Other joints such as knees, ankles and wrists may also be involved.
Inter-critical gout - This is pain free period during two attacks of acute arthritis. A second attack can be expected within 1 year in 62% cases and additional 16% cases during second year. About 90% patients will have another attack in 5 years.
Chronic gout - Quality of life decreases with progressive gout. Urate crystals accumulate in joints and destroy them. Tophi (nodular masses of white chalky paste-like material containing urate crystals) around joints develop 10 or more years after the first attack. Tophi can be found in hands, feet, knees, elbows, pinna of ears and other sites. They can ulcerate and extrude pasty material.
Kidney disease - Kidneys can be damaged due to uric acid in many ways. The crystals can cause swelling of interstitium, occlude the excretory system in kidneys or form stones within the kidneys.

Investigations
Acute gout is a clinical diagnosis which should preferably be established by aspiration of joint fluid and demonstration of urate crystals. Joint aspiration is necessary to rule out other causes of swelling in a single joint such as septic arthritis. Aches and pains with raised uric acid is not gout. Uric acid levels in blood may not be raised in all cases of acute gout. Normal uric acid level in blood is upto 7 gm/dl in men and upto 6 mg/dl in premenopausal women. Measurement of urinary uric acid and kidney function is required in some cases. X-ray of involved joint shows swelling in acute stage and damage in later stages.
Obesity, hyperlipidemia (raised cholesterol and other lipids), diabetes, hypothyroidism and hypertension can accompany gout. These must be suitably investigated.

Treatment
An acute attack of gout responds well to painkillers that reduce swelling (anti-inflammatory drugs). Steroids can be used orally or injected in the joint in selected cases. Allopurinol should not be used in acute stage as it dissolves crystals within the joint and does not allow swelling to subside. Terminating an attack of gout is not the only therapy - prevention of further attacks as well as other risks is equally essential. Allopurinol should be used 2-3 weeks after the swelling subsides. The dose of allopurinol should be adjusted to maintain blood uric acid levels less than 6 mg/dl. Allopurinol dissolves crystals and excretes uric acid through urine. Allopurinol can cause digestive upsets, hair loss, skin rashes, headache and other adverse effects in a few cases. Febuxostat is another drug now available in India and many high-end drugs are in pipeline. Some drugs (such as losartan and atorvaststin) used for other diseases also reduce uric acid levels to some extent. Raised uric acid upto 8 mg/dl without joint disease does not require any treatment.
Diet in gout - Avoidance of meat, fish, alcohol and sugary drinks is necessary. Dairy products, pulses and vegetables should not be avoided as such restrictions do not reduce uric acid levels substantially and lead to protein malnutrition. Reducing weight by controlling fats and oils is desirable. Adequate water intake (upto 2 liters/day) is also essential.

Gout and Life Style
Gout is a lifestyle disease and a component of metabolic syndrome alongwith raised blood pressure, obesity, stress and diabetes. It carries a higher risk of heart disease if uric acid levels remain higher than 8 mg/dl. Control of weight and avoidance of stress are extremely important. Patients of gout are known to be non-compliant. Therapy must be continued throughout life with regular blood-checks for uric acid.