Category Archives: Gouty arthritis

What are the triggers for gout attacks?

I’m often asked, “What can bring on a gout attack?”  The following are the classic triggers for gout attacks:

gout_0Medical illnesses such as congestive heart failure, blood clots in the legs, and pneumonia. Patients who eat too much or, conversely, go on a fast are also at risk.  Alcohol consumption, particularly beer, is a common trigger.

Dehydration, which is common in the summer, can bring on an attack.

Trauma or surgery are two important triggers. This is often seen in a hospital setting.

The treatment of gout to lower serum uric acid can also trigger an attack. This is probably due to shifts of uric acid within body tissues during the process of uric acid elimination.

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Why does gout cause attacks?

Gout is a disease due to the abnormal metabolism of purines, a substance found in many foods. Purines are converted to uric acid.   When the concentration of uric acid in blood rises above 6.8mg/dl, there is deposition of monosodium urate crystals in the joint.

gout_0Sites where monosodium urate deposits occur are in areas where there is a relatively low core temperature.  This decreases the solubility of uric acid.  Examples of such sites are peripheral cooler joints like the feet, elbow bursa, and the helix of the ear.

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Gout medicines and heart medicines conflict

Patients who take medications for both heart conditions as well as gout may have a problem with drug conflicts.

gout_0For example, thiazide diuretics cause an increase in serum uric acid.

Losartan (Cozaar) and fenofibrate (Tricor), often prescribed for cardiac patients have a dual effect.  While they block the reabsorption of uric acid in the kidney which causes serum uric acid levels to decrease, they are also metabolized by the cytochrome P450 enzymes in the liver.  The issue here is that gout drugs are also metabolized through this enzyme system and therefore their effectiveness may be decreased.

What’s a mother to do?

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Cherries reduce risk of gout attacks

A study published in Arthritis and Rheumatism showed that cherry intake decreased the likelihood of gout attacks. cherries

Researchers from Boston University, the University of Sydney, and the Royal North Shore Hospital in New South Wales studied 633 patients with gouty arthritis. They found that cherry intake over a two day period was associated with a 35% lower risk of gout attacks compared with no intake.

When cherry intake was combined with allopurinol use, the risk of gout  attacks was 75% lower.

For a long time cherries have been touted as a natural treatment for gout.  Conventional medicine has affirmed it. Gouty arthritis is not a benign disease and is often associated with other medical conditions such as obesity, hypertension, hyperlipidemia, and diabetes. These new findings are encouraging.

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Gout… a deadly disease!

gout_0Gout is a disease due to the abnormal metabolism governing the conversion of purines to uric acid.  Essentially, uric acid excretion (getting rid of uric acid) can’t keep pace with production.

This condition is reaching epidemic proportions due to the  increasing incidence obese-manof obesity as well as the ever-rising consumption of high-fructose containing beverages.

Gout is not a benign disease because it is part of the “metabolic syndrome.”  This is a collection of medical conditions – called diabetes“co-morbidities”- that seem to cluster around gout.high-blood-pressure

They include diabetes, hypertension, obesity, elevated blood high-cholesterollipids, heart attack, stroke, heart failure, and strokeheart-attackkidney disease.

Treatment of gout is not an option.  It is mandatory!

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Gout Old scourge/ New scourge

An old disease is making a comeback…120px-the_gout_james_gillray

Gout is a common inflammatory form of arthritis that affects approximately four million Americans and this number is increasing dramatically.  The major reason for this is the parallel epidemic of obesity that is partially fueled by the increased consumption of high-fructose containing soft drinks.  In fact, many experts feel that high-fructose containing beverages are the number one cause of the gout epidemic.

When these soft drinks are metabolized through the liver, they generate an increased amount of uric acid.  Accumulation of uric acid leads to an elevated level of uric acid in the blood, internal organs such as the kidneys, and in the joints.uric-acid-crystals

Gout is not a benign disease.  It is associated with many other medical conditions such as high blood pressure, elevated blood lipids, diabetes, chronic kidney disease, and coronary artery disease.  Gout patients are at increased risk for both heart attack as well as congestive heart failure. Gout is also associated with the development of osteoarthritis.

While high fructose containing beverages increase the risk of gout, dairy products such as milk appear to reduce the risk of gout.  This is accomplished through two mechanisms: the first is an anti-inflammatory effect; the second is through the lowering of serum uric acid.

It is clear from epidemiologic data that while the incidence of gout is increasing, the proper treatment of gout can have an enormous positive effect.  Studies have demonstrated that lowering serum uric acid reduces the risk of both heart attack as well as stroke.

Newer therapies designed to decrease serum uric acid through various mechanisms are under study at the present time. It is predicted that the incidence of gout will continue to rise as a result of dietary indiscretion but that newer approaches to gout will help reduce the negative health impact of the disease.

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Arthritis Treatment: New approaches to treating gouty arthritis

Gout is a common cause of arthritis affecting more than 8 million Americans.  Although it affects men more than women, there appears to be an increasing incidence of the disease in post-menopausal women. The incidence overall appears to be increasing as a result of the epidemic of obesity, hypertension, diabetes, and elevated lipids, all of which are associated with gout.

Gout, in 90 per cent of cases, is caused by the inability of the kidneys to get rid of urate.  In the other 10 per cent, there is an overproduction of urate.

Animals other than humans don’t get gout because they have an enzyme called uricase which breaks urate down and allows the animal to excrete it. Human beings, on the other hand, lack this enzyme and therefore are unable to excrete urate (uric acid) appropriately.  This leads to accumulation of uric acid crystalsuric-acid-crystals in the joints and other organ systems.

Gout typically occurs in three stages.  The first stage is what is called “asymptomatic hyperuricemia.”  Asymptomatic hyperuricemia is characterized by elevate blood uric acid levels without attacks of gout.  The higher the blood uric acid level is, though, the greater likelihood of an eventual attack.

The second phase or stage is termed “acute intermittent gout”.  During this stage, patients have attacks of gout but after the attack is over, they are relatively symptom free.  The danger here is that chronic inflammation persists despite the absence of symptoms.gouty-arthritis

The third stage is called “chronic tophaceous gout.”  In this phase, patients have chronic pain due to repeated attacks of gout with an increasing burden of urate accumulation in the joints, kidneys, and other organs systems.  Patients develop tophus“ tophi” which are deposits of inflammatory cells, uric acid crystals and fibrin. Gradual destruction of the joints occurs with the development of crippling deformity. Tophi can cause lumps on finger joints in addition to other areas.

The treatment of gouty arthritis consists of a two-fold approach with relief of the acute attack accompanied by attempts to lower the urate burden.

Acute attacks can be treated with colchicine, non-steroidal anti-inflammatory drugs, and steroids.  The latter can be given either orally or directly into the affected joint.

Drugs that lower uric acid need to be used for the chronic treatment of gout.  These drugs, when initiated, need to be accompanied by gout prophylaxis in the form of daily doses of either colchicine or non-steroidal anti-inflammatory drugs, for at least six months.  The reason is this: as urate shifts as a result of the effect of uric acid lowering drugs, there is a predisposition to acute attacks.

Drugs used to lower uric acid consist of medicines that make patients urinate out their uric acid (probenecid), medicines that suppress uric acid production ( allopurinol, febuxostat [Uloric]), and uricolytic drugs.  An example of the latter is pegloticase (Krystexxa), which converts uric acid to allantoin, an inert ingredient that is then excreted.

Counseling a patient in regards to lifestyle and diet also plays a role in the comprehensive approach to gout.

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What is arthritis?

Arthritis is a word derived from the Greek, “arthron” meaning joint and “itis” meaning inflammation.  It is used to refer to more than one hundred different conditions that cause joint symptoms. Arthritis is a common condition affecting almost 70 million Americans.crowd

While arthritis is often considered to be a disease associated with aging, it can affect people of all ages, including infants and children.

Arthritis is the major cause of disability in people past the age of 55.  But what many people don’t realize is that it can also cause internal organ damage and early death.

It is the main cause of disability among people over fifty-five years of age in industrialized countries.

In order to understand what arthritis does to joints it’s helpful to understand basic joint anatomy.

A joint is where one bone interacts with another bone. The ends of the bones are covered by a thin layer of a gristle-like material called cartilage.  Cartilage serves as a gliding surface and also helps with shock absorption.

Multiple soft tissue structures such as ligaments, tendons and muscles hold the joint together.

A capsule encloses the joint. The space within the joint – the joint cavity – has a small amount of synovial fluid. Synovial fluid nourishes and lubricates the joint and the cartilage. Synovial fluid is produced by the synovium (synovial membrane) which lines the joint cavity.

Arthritis develops when abnormalities occur within the cartilage, synovium, or surrounding soft tissue structures. While there are more than 100 different types of arthritis, some are more common than others.

For example:

Osteoarthritis is the most common types of arthritis and is the one often associated with aging.  In this disease, the cartilage loses its elasticity and pliability. In addition, the synovium becomes inflamed and the underlying bone becomes hardened and develops spurs. The articulating cartilage begins to wear away as a result of degradation caused by destructive enzymes. The joint becomes mechanically unstable.  The end result is pain and loss of function.

rheumatoid-arthritisRheumatoid arthritis is a very different form of arthritis because it is an autoimmune condition where antibodies attack the joint lining as well as internal organs. The synovial membrane (synovium) becomes inflamed as a result of the autoimmune reaction.  The inflammation causes rapid destruction of cartilage, synovium, bone, and soft tissue structures.  Significant deformity is the end result.  And because it’s a systemic disease, rheumatoid arthritis also shortens life span.

Psoriatic arthritis is a common form of arthritis that occurs in patients with psoriasispsoriasis.  While it attacks the skin and joints, psoriatic arthritis also attacks the enthesis, the attachment of tendons into bone.  Like rheumatoid arthritis, psoriatic arthritis has systemic features and may also cause inflammation in the eyes and bowels.

Gouty arthritis is a type of arthritis due to the deposition of monosodium gouturate crystals (uric acid) in joints.  This causes an intensely painful form of inflammatory arthritis.  Early on it presents as discrete attacks of inflammatory arthritis.  Over time the attacks become more frequent. While more common in men than women, it can affect women quite commonly after the menopause.  Gout attacks usually start in the feet but may spread quickly to involve multiple joints.  It causes deposits of uric acid to form under the skin.  These deposits are called “tophi.” Gout also affects kidney function. It is associated with other medical conditions such as diabetes, obesity, elevated blood lipids, and hypertension.

Juvenile arthritis affects children of almost any age.  There are at least three variants of the condition but they all have an autoimmune component as well as a genetic component. This type of arthritis, if not diagnosed quickly and treated aggressively, can be devastating.  Juvenile arthritis has many patterns as far as joints involved.  Most types cause eye inflammation as well.juvenile-arthritis

Polymyalgia rheumatica is a common form of arthritis that affects people usually past the age of 50.  It is characterized by diffuse aching, pain, and stiffness in the morning.  The neck, shoulder, and hips are the areas most commonly involved.  Laboratory testing shows the erythrocyte sedimentation rate to be very elevated.  The major concern here is that about 15 per cent of patients with polymyalgia rheumatica also have another condition called giant cell arteritis.  This is an inflammatory condition that affects blood vessels and which can lead to blindness.

It is critical for a proper diagnosis to be made in order to render the appropriate arthritis treatment.

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