Treatment
Of GoutGout treatment involves several steps as is summarized in this
table and explained in the text in more detail. | |
| Therapeutic steps in
treating gout | | Therapeutic
step: | Comments: |
| pain control | colchicine
and NSAIDs; also IceWave patches
from Lifewave | | lowering
uric acid level | allopurinol, probenecid
or sulfinpyrazone | | dietary
changes | increase fluid intake, reduce purine
rich foods (liver etc.) and avoid alcohol |
| treat concomitant medical illness | control
diabetes, treat hypertension etc. | | kidney
stones | treat with allopurinol maintenance
program | | resistant
kidney stones | treat with extracorporal shock
wave lithotripsy | | large
tophi | plastic surgery to remove tophi |
|
1.Treating the pain: The
most important step is to treat the acute gout pain with anti-inflammatory medications,
to minimize the soft tissue damage in the body and to help the patient overcome
the severe pain. This is achieved by colchicine, which usually controls
the joint pains within 12 to 48 hours. Side-effects of colchicine therapy are
diarrhea, which can lead to electrolyte disturbances, and bone marrow suppression.
In patients with compromised kidney function the physician must carefully monitor
for toxicity as in severe cases of kidney malfunction respiratory depression and
cardiotoxic effects could lead to death. On the other hand colchicine in
the appropriate patient can be very effective and impressively takes the pain
away through the specific suppression of the inflammatory response to the uric
acid crystals. Colchicine is taken up in leukocytes and the inflammatory infiltration
of leukocytes, which would have lead to kinin release and pain, is inhibited.
Colchicine can also be taken for prevention of an attack or again when another
gout attack flares up. However, colchicine has limits. It does not lower uric
acid levels and does not prevent progression to chronic gout. 2.
Lowering the uric acid level: This is achieved most reliably with
allopurinol (brand name: Zyloprim, Lopurin) which inhibits the synthesis of uric
acid and also inhibits the formation of purin in the body. All of this leads to
lower serum uric acid levels and the dosage can be titrated by repeat blood tests
that your physician will order. The level should be kept at around 4.5 mg/dL (or
0.26 mmol/L) or lower. Another approach to lower uric acid levels is to
increase uric acid elimination via the urine, this is called "uricosuric
therapy". Two medicines can be used for this purpose: probenecid (brand names:
Benemid and Benuryl) and sulfinpyrazone (brand name: Anturan). Salicylates such
as ASA or non-steroidal antiinflammatory drugs (NSAIDs) counteract this uricosuric
effect and should be avoided when this medication is given. Your doctor would
know best what medication to use in your case and could also explain the allopurinol
side effects and side effects of the other drugs. 3. Control inflammation: In the first
few days or weeks the joint inflammation and inflammation of the affected connective
tissue is causing a great deal of pain and discomfort. It is here where some anti-inflammatories
such as NSAIDs may have a place. However, as NSAIDs are eliminated through
the kidneys and can on the longterm cause a nephropathy (kidney damage) themselves,
this needs to be discussed with the treating physician. Kidney function can be
assessed by measuring creatinine and BUN levels as well as electrolytes. If there
are doubts based on these tests, a 24-hour urine collection can be done to determine
the creatinine clearance, which would give a snapshot in time of how well the
kidneys are functioning. Every couple of years the creatinine clearance test can
be done again to follow the kidney function. Indomethacin (brand name: Indocid)
is particularly effective in the acute gouty arthritis, but naproxen (brand names:
Naprosyn or Rhodiaprox) is also useful. The COX-2 inhibitory drug (brand name:
Celebrex) is also useful. Keep an eye on side-effects of the COX-2 inhibitory
medications as one of these drugs (VIOXX)
was pulled from the market in October of 2004. The VIOXX link explains this story
in detail.
4. Increased fluid intake: As
uric acid is not very soluble, it is advisable to take in fluids of more than
3 L per day, particularly patients who also pass kidney stones (uric acid stones
or calcium oxalate stones). Alkalinization of the urine also helps and the physician
may want to advise the patient to take 500 mg of acetazolamide at bedtime to make
the nighttime urine alkaline, which increases solubility for uric acid in the
urine and prevents kidney stones. 5. Other measures: To
help with large tophi such as in the elbow region, a surgeon may be able to remove
these surgically, if lowering of uric acid in the blood is not successful in melting
this away. Also patients with large kidney stones in the center of the kidney
(called the "renal pelvis") can be trated with extracorporal shock wave
lithotripsy, where special ultrasond shock waves cause a resonance and the large
kidney stone is broken into sand-like particles that are easily passed with the
urine. 5. Controlling pain: Physiotherapy treatments are used
to remobilize the joints of the foot. Acupuncture may be useful for pain control
as well. Anti-inflammatories are used during the acute phase. | 
