The Hip: Preservation, Replacement and Revision

Management of Gout

- Anti-Gout Meds:
     - Allopurinol
     - Colchicine
     - Indomethacin
     - Probenecid
     - Sulfinpyrazone

- Discussion:
    - inflammatory response to MSU crystals can be interrupted w/ joint rest, anti-inflammatory drugs, or administration of colchicine;
    - colchicine: for all pts w/ gout, whether it is primary or secondary, it removes factors that commonly precipitate attacks;
    - vitamin C:
         - 500 mg of vitamin C qd may reduce serum uric acid by 0.5 to 0.7 mg/dL
         - ascorbic and uric acid are reabsorbed through ion-exchange in the proximal renal tubules;
         - these molecules compete with each other to be reabsorbed, and uric acid loses;
         - references:
                  - What’s New With Gout?
                  - Vitamin C intake and the risk of gout in men: a prospective study
                  - The effects of vitamin C supplementation on serum concentrations of uric acid: results of a randomized controlled trial.
                  - Vitamin C intake and serum uric acid concentration in men

- Acute Treatment:
    - NSAIDS: indomethacin
    - colchicine: prophylactic administration may reduce frequency of multiple attacks;
    - steroids may be indicated if NSAIDS and colchicine cannot be given;
    - contra-indicated medications: allopurinol and probenecid may worsen symptoms during acute attack;
          - these medications may cause precipitation of urate if given during the acute attack;
    - references:
          - Systemic steroid therapy for acute gout: a clinical trial and review of the literature.
          - Local ice therapy during bouts of acute gouty arthritis.

- Recurrent Attacks:
    - requires reduction of miscible pool of urate;
    - goal is to reducing serum urate concentrations to less than 6.0 mg /dl (360 µmol / lit);
          - if trophi are present, then uric acid level needs to be lower than 5.0 mg / dl (300 µmol per liter)
    - need to determine whether pt w/ recurrent gouty episodes is:
          - over producer (10% of primary gout);
                - allopurinol (xanthine oxidase inhibitor) is indicated in patients with increased urate production
                - uricosuric drugs (probenecid) are contraindicated in these type patients;
          - underexcreter of uric acid (90% primary gout) or ....
                - treated with probenecid, sulfinpyrazone, or allopurinol;
                - for pts w/ normal urinary urate excretion, then use probenecid;
                       - blocks renal resorption of uric acid, thus increasing net excretion;
                       - probencid is contraindicated for pts w/ history of renal stones or elevated urinary urate excretion rates;
                - alternatively, allopurinol is also effective for these patients as well;

- Chronic Gout:
    - Allopurinol
         - administered on long-term basis to pts w/ gout to block purine degradation;
         - inhibits xanthine oxidase which increases blood levels of xanthine and hypoxanthine which are excreted in urine;
    - Uloric
    - references:
         - Relation between adverse events associated with allopurinol and renal function in patients with gout.

- Management of Trophi:
    - allopurinol can dissolve these masses;
    - trophi can be located in soft tissue or bone;
    - in bone, they form well demarcated cysts w/o adjacent osteoporosis;
    - aspirated fluid will usually demonstrate birefringent crystalloids
    - surgery is usually not required,  & drainage with ATB is not required unless there is a concomitant infection

Dropping Acid

Systemic steroid therapy for acute gout: a clinical trial and review of the literature.

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Clifford R. Wheeless, III, MD on Sunday, August 11, 2013 8:56 am