Gout

Gout is a crystal-induced arthritis. A condition that resulted from deposition of monosodium urate (MSU) crystals in various tissues (eg joints, connective tissue, kidney) due to elevated serum urate level. 

Gout is always associated with the symptoms of sudden, severe attacks of pain, swelling, redness and tenderness in one or more joints. In patients with acute gout attack, joints of the lower limbs are more affected than upper limbs. It will usually last for few days to 3 weeks with a gradual complete resolution of the inflammation.
The normal uric acid level for adult male is 2.5-7.0 mg/dL. whereas for adult female is 1.5-6.0 mg/dL.

RISK FACTOR

1) Diet

Diet with purine-rich food will cause body to produce too much uric acids which form MSU crystal and gout.
Example of purine rich food: red meat, shellfish, drinking beverages sweetened with fruit sugar (fructose), alcohol consumption, especially of beer.

2) Weight

It is likely that higher BMI increases the risk of gout by increasing the serum uric acid level. Hyperuricemia has been associated with obesity via both increased production and decreased renal excretion of urate.

3) Medical Conditions

Some underlying medical conditions can increase the risk of developing gout, including:
– High blood pressure
– Diabetes
– Kidney disease
– High levels of cholesterol in blood

4) Certain Medications

Certain medications can increase your uric acid levels and your risk of developing gout. These include:
– Diuretics: used to treat high blood pressure or an abnormal build-up of fluid in your body
– Certain medicines used to treat high blood pressure: Beta-blockers and ACE inhibitors
– Low-dose aspirin: used to reduce the risk of blood clots

5) Family History

Gout is caused by a combination of genetic and environmental factors. Patients with family history of gout will have an increase risk of developing gout too.

SIGN AND SYMPTOMS

Gout is always associated with the symptoms of sudden, severe attacks of pain, swelling, redness and tenderness in one or more joints. In patients with acute gout attack, joints of the lower limbs are more affected than upper limbs. It will usually last for few days to 3 weeks with a gradual complete resolution of the inflammation. For acute gout attack, it is usually monoarticular. However, gout will progress into chronic gout when the patients does not have a good control on their diet or uric acid level. For chronic gout, it is usually polyarticular arthritis and the formation of tophi.

STAGES OF GOUT

1) Acute Gout

Acute gout commonly present as an acute, self-limiting, mono-articular inflammatory arthritis. Joint at the lower limbs are more affected than the upper limbs. The affected joints will have erythema (redness of the skin), warmth and swelling over the joint. Fever may be present.
Attack of acute gout last for a few days to 2-3 weeks, with a gradual complete resolution of all inflammatory sign

2) Chronic Gout

Chronic gout present with polyarticular arthritis and the formation of tophi. Tophi are chalky deposits of MSU crystal. They are subcutaneous and painless. They will appear as a firm, nodular or fusiform swellings. Tophaceous disease more likely occur in patients where serum urate level more than 9mg/dl.
Sites of tophi includes digit of the hands and feet (most common), pinna of the ear, bursa around elbows and knees, achilles tendon (tendon that connect calf muscle to heel).

DIAGNOSIS OF GOUT

Clinical diagnosis of gout is based on whether the patients experience two or more of the following criteria:

1. Presence of clear history of at least two attacks of painful joint swelling with complete resolution within 2 weeks.
2. A clear history or observation of podagral
3. Presence of tophus
4. Rapid response to colchicine within 48 hours of starting treatment. 

TREATMENT

A) Medications

– NSAIDs
Non-steroidal anti-inflammatory drugs (NSAIDs) are usually recommended as the first treatment for gout. They work by reducing pain and inflammation during an attack.
Example: Indomethacin, Naproxen, Diclofenac, Celecoxib

– Colchicine
If NSAIDs are ineffective, a medicine called colchicine can be used instead.
Colchicine reduces some of the swelling and pain associated with a gout attack. When taken in high doses, side effects of colchicine include feeling sick, abdominal pain and diarrhea.

– Corticosteroids
Corticosteroids are sometimes used to treat severe cases of gout if other treatments don’t work or unable to take an NSAIDs or colchicine.
A short course of steroid tablets often provides relief, but they can’t be used long-term in high doses as they cause side effects, including weight gain, osteoporosis, muscle weakness.

– Allopurinol
Allopurinol helps reduce the production of uric acid. It can help prevent gout attacks, although it won’t help relieve symptoms during an attack.

B) Alternative treatment

– Urinary Alkalinizer
Sodium citrate is metabolized to bicarbonates which increases urinary pH by increasing the excretion of free bicarbonate ions without producing systemic alkalosis when administered in recommended doses. (Ural: 1-2 sachet dissolved in water for four times a day)
 A rise in urinary pH increases the solubility of cystine in the urine and the ionization of uric acid to more soluble urate ion. By maintaining an alkaline urine, the actual dissolution of uric acid stones may be accomplished.

– Cherry Juice
According to studies, tart cherry reduce uric acid because of the ingredients anthocyanins. Anthocyanin have its anti-inflammatory effect which makes cherry juice a natural anti-inflammatory. Hence, this will help to resolve gout swelling in patient.

– Celery Extract
Studied shown that celery extract have significantly reduced the serum uric acid, lipid peroxidation, and increase activity of antioxidant enzyme levels in gouty rats. This may be due to the inhibition of xanthine oxidase activity.

– Juniper Berry
Juniper is traditionally known as a diuretic, it was valued as a urinary and kidney remedy in Europe and the Mediterranean. The American ethnic physicians used Juniper berry to treat arthritic gout because of the inhibition of xanthine oxidase. Juniper berry is noted to exert powerful antioxidant activity. It also has anti-inflammatory, analgesic, and hepatoprotective effects.

LIFESTYLE ADVICES

Certain lifestyle changes can also help reduce your risk of experiencing further attacks of gout, including:

– Avoiding foods containing high levels of purine such as red meat, offal, oily fish, seafood and foods containing yeast extract.

– Avoid alcohol intake.
Alcohol disrupts the removal of uric acid from the body. Normally, purines would break down into uric acid and get flushed out of the body through urine. However, this process is interrupted when uric acid levels get too high. Crystals form around the joints, and gout develops.
To prevent gout attack, avoid alcohol during attack and avoid beer.

– Avoid sugary drinks and snacks – these are associated with an increased risk of gout.

– Maintain a healthy weight – follow a balanced diet with high-protein, low-carbohydrate diets.

– Drink plenty of water – keep yourself well-hydrated will reduce the risk of crystals forming in your joints.

– Take regular exercise – try activities that do not put too much strain on your joints, such as swimming.