Gout (Gouty Arthritis) (cont.)

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How is gout diagnosed?

The most reliable method to diagnose gout is by demonstrating uric acid crystals in joint fluid that has been removed from an inflamed joint. Specially trained physicians, such as a rheumatologist or orthopedist, can carefully remove fluid from the joint. A doctor with expertise in gout can then examine the fluid under a microscope to determine if uric acid crystals are present. This is important because other diseases, such as pseudogout (a type of arthritis caused by the deposition of calcium pyrophosphate crystals) and infection, can have symptoms similar to gout.

When should gout be treated?

Changes in lifestyle, such as limiting foods associated with gout, should be initiated in anyone who has had a gouty attack in the past. Treatment of gout with medications is necessary when frequent disabling gouty attacks occur, when kidney stones caused by uric acid are present, when there is evidence of joint damage from gout on X-rays, or when tophi are present. Treatment should be individualized to the patient.

What is the treatment for gout?

When gout is mild, infrequent, and uncomplicated, it can be treated with diet and lifestyle changes. When attacks are frequent, uric acid kidney stones are present, the uric acid level is very high, tophi are present, or there is evidence of joint damage from gout, medications are necessary to treat gout. Studies have shown that even the most rigorous diet does not lower the serum uric acid enough to control gout, and therefore medications are generally necessary for gout treatment in these instances.

Medications for the treatment of gout generally fall into one of three categories: uric-acid-lowering medications, prophylactic medications (medications used in conjunction with uric-acid-lowering medications to decrease the risk for a gout flare during the first six months of treatment), and rescue medications to provide immediate relief from gout pain.

Uric-acid-lowering medications are the cornerstone of treatment for gout. These medications decrease the total amount of uric acid in the body and subsequently lower the serum uric acid level. For most patients, the goal of uric-acid-lowering medication is to achieve a serum uric acid level of less than 6. For some patients, the goal may be even lower. These medications also are effective treatments to decrease the size of tophi, with the ultimate goal of eradicating them. Uric-acid-lowering medications include allopurinol (Zyloprim, Aloprim), febuxostat (Uloric), probenecid, and pegloticase (Krystexxa).

Prophylactic medications are used during approximately the first 6 months of therapy with a uric acid lowering medication to either prevent gout flares, or decrease the number and severity of flares. This is because any medication or intervention that either increases or decreases the uric acid level in the bloodstream can trigger a gout attack. The uric acid lowering medications described above therefore can trigger an attack of gout because they lower the uric acid level. Colcrys (colchicine) and any of the NSAIDs (non-steroidal anti-inflammatory drugs) such as indomethacin (Indocin, Indocin-SR), diclofenac (Voltaren, Cataflam, Voltaren-XR, Cambia), ibuprofen (Advil), or naproxen sodium are frequently used as prophylactic medications. By taking one of these prophylactic or preventative medications during the first 6 months of treatment with allopurinol, febuxostat or probenecid, the risk of having a gout attack during this time is decreased. Prophylactic medications are not used in combination with Krystexxa.

The third category of medications are those used during an acute gout attack to decrease pain and inflammation. Both colchicine (Colcrys) and NSAIDs can be used during an acute gout attack to decrease inflammation and pain. Steroid medications, such as prednisone and methylprednisolone (Medrol), also can be used during an acute gouty flare. However, the total dose of steroids is generally limited due to potential side effects such as cataract formation and bone loss. Steroid medications are extremely helpful in treating gout flares in patients who are unable to take colchicine or NSAIDs.

Medically Reviewed by a Doctor on 12/3/2013

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