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Gout Treatment


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Title: Gout Treatment

Gout is a form of arthritis that causes the
sudden onset of painful inflammation and redness
in the affected joints because of crystal
deposits. At one time it was called "the disease
of kings" because it was thought to be associated
with eating too much wine and rich foods, but the
truth is, anyone can develop gout. The condition
often develops in the joint of the big toe, but
it occasionally affects other joints as well,
such as the elbows, wrists, ankles, knees, feet
and hands. Sometimes it affects tendons and soft
tissue. Gout typically only affects one joint at
a time, but is some cases it becomes chronic, and
over time affects multiple joints.
  • If you are diagnosed with gout, your treatment
    plan will first aim to relieve the symptoms of an
    attack. Further treatment aims toprevent attacks
    by lowering uric acid levels.
  • Non-steroidal anti-inflammatory drugs (NSAIDs)
    are a type of painkiller usually recommended as
    an initial treatment for gout. They work by
    reducing the levels of pain and inflammation.
  • NSAIDs often used to treat gout include
  • Naproxen

gout attack, it is important to rest, raise your
limb and avoid knocking or damaging the affected
joint. Keeping the affected joint cool should
also help. Remove surrounding clothing and apply
an ice pack to it, such as a bag of frozen peas
or some ice wrapped inside a towel. Apply the ice
pack to your joint for around 20 minutes. Do not
apply ice directly to your skin and do not apply
it for more than 20 minutes at a time because
this could damage the skin.
  • Colchicine
  • If you are unable to take NSAIDs or if NSAIDs are
    ineffective, colchicine can be used instead.
  • Colchicine is derived from the Autumn crocus
    plant. It is not a painkiller, but works by
    reducing the ability of the urate crystals to
    inflame the joint lining (synovium), which
    reduces some of the inflammation and pain
    associated with a gout attack.
  • It is best to keep them near you at all times so
    you can use them at the first sign of a gout
  • Colchicine can be an effective treatment for
    gout. However, it should be used at low doses as
    it can cause side effects, including
  • nausea
  • abdominal pain
  • diarrhoea
  • Colchicine can cause major gut problems if taken
    in too high a dose. It is important to follow the
    recommended dose. For most people, this means
    taking no more than two to four tablets a day.

  • Corticosteroids
  • Corticosteroids are a type of steroid sometimes
    used to treat severe cases of gout in people
  • do not respond to other treatment
  • are unable to take or cannot tolerate an NSAID or
  • A short course of steroid tablets often provides
    relief, but can't be used long-term in high doses
    as they cause side effects, including
  • weight gain
  • thinning of the bones (osteoporosis)
  • bruising
  • muscle weakness
  • thinning of the skin
  • increased vulnerability to infection
  • Corticosteroids can also exacerbate diabetes and
    glaucoma (an eye condition that can cause
    blindness if left untreated).
  • Corticosteroids may not be suitable for you if
    you have
  • impaired kidney function
  • impaired liver function
  • heart failure
  • Corticosteroids can also be given by injection,
    either into muscle or directly into the affected
    joint, which can provide rapid pain relief.

  • Two methods used to try to prevent further
    attacks of gout are
  • medication to reduce uric acid levels
  • making lifestyle changes to reduce uric acid
  • Drug treatment is recommended on a long-term
    basis for
  • frequent attacks of gout and signs of tophi under
    the skin (tophi are small white lumps that can
    form under the skin)
  • evidence of joint damage either in terms of
    associated symptoms or damage detected by X-ray
  • a history of kidney stones
  • reduced kidney function
  • Around 40 of people meet these criteria when
    gout is first diagnosed. More than 80 of people
    develop these symptoms within five years. Drug
    treatment is therefore considered and explained
    to most people before their gout becomes more
  • The main treatment for gout is known as
    urate-lowering therapy (ULT). The goal of ULT is
    to lower uric acid levels below the levels
    required for crystals to form (the saturation
  • This prevents any new crystals forming and also
    helps to dissolve existing crystals. This
    eventually leads to the removal of all the
    crystals in your body and prevents any further
    attacks or joint damage. But you normally need to
    continue with ULT on a daily basis for the rest
    of your life to maintain this "cure".
  • Many people with gout begin ULT as soon as they
    are diagnosed to reduce the frequency of future
    attacks and the risk of develop- ing joint
    damage. This has to be balanced against possible
    side effects that can occur with ULT, although
    these are rare.
  • Discuss the potential benefits and disadvantages
    of ULT with your GP or the doctor in charge of
    your care. If you agree to start ULT, allopurinol
    is usually the medication that is tried first.

Allopurinol Allopurinol helps to lower uric acid
levels by inhibiting the enzyme (xanthine
oxidase) responsible for converting purines into
uric acid, which reduces the production of uric
acid. However, allopuri- nol is not a painkiller
and will have no effect during an attack of
gout. Allopurinol is a tablet taken once a day.
The dose needs to be adjusted to ensure that the
target level of serum uric acid is achieved. The
aim is to maintain the level well below 360
umol/L or 6mg/dl. The dose is usually increased
every three to four weeks, depending on the
results of the blood tests for uric acid. Once
this target is achieved, it often takes up to a
year or two before all crystals have dissolved
and no further attacks occur. The medication will
then usually be taken for the rest of your life.
It can take a while to assess the most effective
dose for your circumstances. You may need to have
several blood tests to find the most effective
dose. When you first start taking allopurinol, it
can sometimes cause a gout attack, because the
rapid reduction of uric acid levels to below the
saturation point causes existing crystals in the
joint cartilage to partially dissolve and become
smaller. The smaller crystals can escape more
easily or "shed" from the cartilage into the
joint cavity, and then inflame the joint lining
(synovium). The risk of this happening is reduced
by slowly increasing the dose of allopurinol as
described above. You may continue to have gout
attacks until all the existing crystals have
dissolved, which is perfectly normal. If this
does happen, you shouldn't lose confidence in the
effectiveness of ULT. It's important to persevere
with treatment to achieve the maximum benefit. If
you do develop a flare-up of gout while taking
allopurinol, continue taking the medication while
your doctor prescribes additional treatment to
settle the attack.
  • Although allopurinol is taken without any side
    effects in most patients, around 10 do
    experience problems. A skin rash is the most
    common side effect. In most cases, this is mild
    and soon goes away.
  • However, in a small number of cases, it can be a
    sign of an allergic reaction. If you develop a
    skin rash while taking allopurinol, stop taking
    the medication immedi- ately and contact your GP
    for advice. It may be necessary to stop taking
    allopurinol and try an alternative ULT.
  • Other possible side effects of allopurinol
  • indigestion
  • headache
  • diarrhoea
  • You will probably not be able to take allopurinol
    for safety reasons if you are currently being
    treated with immunosuppressant medications (often
    used to prevent your body rejecting a donated
    organ) or a type of medication called cyclo-
    phosphamide (used in the treatment of some
  • Patients with kidney problems may be started on a
    lower dose (50mg daily) and have lower monthly
    increases (50mg) of allopurinol.
  • Allopurinol may also not be suitable if you have
    severe kidney disease. Those with severe kidney
    disease may not even be started on allopurinol,
    but prescribed an alternative ULT such as

  • Febuxostat
  • Febuxostat acts in the same way as allopurinol by
    inhibiting the enzyme (xanthine oxidase) that
    produces uric acid and reducing the body's
    production of uric acid.
  • However, unlike allopurinol, it is mainly broken
    down by the liver rather than the kidney, which
    is why it can be used more easily in patients
    with kidney disease.
  • Febuxostat may be very effective at lowering the
    serum uric acid level. As with allopurinol,
    febuxostat may cause temporary wors- ening of
    your symptoms when you first start taking it.
  • To try to reduce the frequency and severity of
    this side effect, your doctor may prescribe you
    regular daily oral NSAIDs or colchicine (one to
    two tablets daily) for up to six months following
    the start of febuxostat as preventative treatment
  • Common side effects of febuxostat include
  • an increased number of acute gout attacks
  • diarrhoea
  • headache
  • feeling sick
  • skin rash
  • If you experience more serious symptoms, such as
    breathing difficulties or facial swelling, stop
    taking febuxostat and contact your GP for advice.
  • Currently, febuxostat is not considered to be
    suitable for people with heart problems,
    especially heart failure.
  • Less commonly used ULT medications include
  • benzbromarone
  • sulphinpyrazone
  • probenecid
  • They work by helping the kidneys to remove uric
    acid from the body.

  • Some foods are high in purines. Avoiding eating
    the foods below can help reduce the risk of a
    gout attack
  • offal liver and kidneys, heart and sweetbreads
  • game rabbit, pheasant and venison
  • oily fish anchovies, herring, mackerel,
    sardines, sprats, whitebait and trout
  • seafood mussels, crab, shrimp and other
    shellfish, fish roe and caviar
  • foods or supplements that contain yeast or meat
    extract Marmite, Bovril, commercial gravy and

WEIGHT If you are overweight, the levels of uric
acid in your blood often rise. Losing weight will
help reduce your uric acid levels signifi-
cantly. If you need to lose weight, it is
important to follow a balanced,
calorie-controlled diet. Do not crash diet. A
high-protein, low- carbohydrate diet should be
avoided, because high-protein foods often contain
high levels of purines. Ensure you get plenty of
regular exercise. Not only will this reduce your
urate levels and decrease your risk of developing
gout, it will also make you feel more energised
and healthier. If you have a gout attack, keep
the joint rested and elevated (raised). Avoid
exercise that puts strain on the affected muscles
or joints. Swimming is a good way to stay fit
without putting pressure on your joints, as the
water supports your weight.
Lifestyle changes
WATER It is important to drink plenty of water to
avoid dehydration. Aim to drink about 1.2 litres
(six to eight glasses) a day, or more if you are
exercising or when it is hot. Keeping yourself
well hydrated will reduce the risk of crystals
forming in your joints. ALCOHOL Some types of
alcoholic drinks are associated with a greater
risk of developing gout than others. Beer and
stout, which contain significant quantities of
purines, carry a greater risk for the development
of gout than equivalent units of spirits, such as
vodka and whiskey. Studies have shown that, as
long as you stick to the maximum recommended
levels of alcohol intake, wine is not associated
with an increased risk of developing
gout. However, binge drinking of any kind of
alcohol can bring on an attack in people who have
previously suffered with gout. Men should not
drink more than three to four units of alcohol a
day and women no more than two to three units a
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