Gout: finally, diagnosis and treatment guidelines: a European task force offers the first recommendations on dealing with this painful arthritic condition
Typically considered a disease of affluent and rotund middle-aged men such as King Henry VIII, gout causes sudden, severe attacks of pain, redness, warmth, and swelling in some joints. It usually affects one joint at a time often starting in the big toe. This painful arthritic condition affects approximately 2.1 million Americans. It can occur at any age, but it often strikes men between the ages of 40 and 50, according to statistics from the Arthritis Foundation in Atlanta.
Gout occurs when there is a build-up of too much uric acid in the body, which forms crystals that deposit in joints and cause inflammation. Uric acid normally forms when the body breaks down waste products called purines.
Despite an understanding of its cause and the availability of treatments for both prevention and flares, until now there has been little consensus about how to diagnose and treat this painful, common condition. But the European League Against Rheumatism (EULAR) Gout Task Force now issued a two-part set of recommendations on gout diagnosis and treatment.
When making a diagnosis of gout, taking a medical history alone is not sufficient. Doctors must demonstrate the presence of monosodium urate (MSU) crystals in the synovial fluid in the joints or a deposit of urates in the skin and tissue around a joint, the guidelines state.
Although x-rays can help doctors include gout in a differential diagnosis and may show typical features in chronic gout, they are not useful in confirming the diagnosis of early or acute gout, the guidelines state. Doctors should also look at risk factors for gout and associated conditions, including obesity and high blood sugar. High cholesterol and high blood pressure also should be assessed.
NSAIDS, COLCHICINE FIRST LINE TREATMENT
Gout attacks can occur after drinking too much alcohol, eating too much of certain foods, surgery, sudden, severe illness, crash diets and joint injury. Education on weight loss, diet and reduced alcohol (especially beer) are important parts of a gout treatment plan, the new guidelines state.
First-line treatments for flares should be either oral colchicine and/or nonsteroidal anti-inflammatory agents. These agents can help relieve the acute pain and inflammation of gout attacks. The panel concluded that acute attacks also can be effectively treated by removing fluids from within the inflamed joint or with an injection of a long-acting steroid.
NORMALIZE URIC ACID
At first, gout episodes are usually few and far between, but if the disease is not controlled by medication, episodes may occur more frequently and last longer.
When it comes to preventing gout attacks, drugs designed to normalize uric acid levels are key. If your body produces too much uric acid, your doctor may prescribe a drug called allopurinol to slow the rate of uric acid production. The goal should be to maintain levels of serum uric acid level below 360 [micro]mol /L. Because rapid reductions in serum uric acid levels can trigger flares, the guidelines suggest that colchicine and/or an NSAID be given as prophylaxis against acute attacks during the first months of urate-lowering therapy.
The guidelines recommend long-term allopurinol as an appropriate urate-lowering therapy and advise starting at a low dose (100 mg/day) and escalating by 100 mg every two to four weeks. Theses doses must be adjusted for people with kidney impairment. Alternatives do exist for people who can’t tolerate allpurinol.
FIRST-EVER SET OF GUIDELINES FOR GOUT TREATMENT
MICHAEL A. BECKER, MD, Professor of Medicine, Section of Rheumatology, University of Chicago, Chicago, IL
“This is the first time that there is a coherent set of recommendations for the diagnosis and treatment of gout. I don’t agree with all of them, but they are not unreasonable and, in the aggregate, are useful in setting a target for lowering urate levels, stressing special caution when faced with impaired kidney function, and indicating a need for colchicines (or NSAID) for prophylaxis when initiating urate-lowering. In terms of treatment, the guideline authors suggest that a low-dose colchicine regimen may be sufficient to reverse inflammation in gout flares in a safer way than higher doses. Even though the quoted unit dose of 0.5 mg is not commonly available in the U.S., validation of this type of approach would be important. Still, the guidelines do provide some basis for telling physicians what they should be doing. Overall, there has been a deficit in the management of patients with gout in terms of making a sound diagnosis and treatment, and the guidelines are probably useful in providing the outline to do that. Patients may need to alert their doctors to the existence of these guidelines.”
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