Gout surgery. Tophi removal surgery. Joint fusion surgery. Joint replacement surgery. Read this next. Gout Diagnosis. Medically reviewed by Graham Rogers, M. Gout: Symptoms, Causes, and Treatments. Medically reviewed by Alana Biggers, M. Gout Treatment and Prevention. Medically reviewed by Natalie Butler, R. Foods to Avoid if You Have Gout. Gout Symptoms and Triggers. Medically reviewed by Nancy Carteron, M. Does Eating Tomatoes Affect Gout? Medically reviewed by Amy Richter, RD. Understanding Gout Crystals.
Medically reviewed by Stella Bard, MD. Gout vs. Although some patients develop a mild rash to allopurinol that remains mild over time, or respond to antihistamines, continuing the allopurinol despite a rash is not advised, since the rash can worsen unpredictably. If none of the above options is possible or successful, physicians often seek a clinical trial of a new agent for gout, if available, for their patient to enter. See section 7 below for a discussion of agents presently under study for gout.
Online resources, such as ClinicalTrails. Cherry juice , which has long been an alternative remedy and which had anecdotal support, now has been studied. At the American College of Rheumatology meeting in November data available there were two studies looking at cherry juice. It appears that cherry juice may have a small effect in decreasing production of uric acid.
It also, possibly through its Vitamin C content, can increase the excretion of uric acid by the kidney. In separate earlier study, Vitamin C itself did appear to increase uric acid excretion. However, the effect using mg a day dosing was small--only a drop in blood uric acid level of about 0.
These early studies of cherry juice are interesting, and might be relevant for a patient who was "almost there" in their uric acid goal, but a gout sufferer should be very careful about trusting to cherry juice to manage their uric acid. Based on the data, the result is likely not going to be sufficient. Diet has been discussed in more detail above, and gout is clearly one of the rheumatic diseases where diet is unequivocally important.
The main message of this review is to emphasize how dramatically effective standard medication is for gout, both in acute treatment and prevention. Many of my patients have explored a variety of non-traditional approaches to gout, often in combination with traditional measures.
Our present agents, such as allopurinol and probenecid, are so effective, and reasonably safe and predictable, that it seems unlikely that they will be fully displaced in the future.
However, there are a small but very important group of patients who cannot tolerate these present agents. The development of new uric acid-lowering treatments, with even fewer side-effects than our present agents, would be heartily welcomed. The question of surgery for gout most commonly comes up when a patient has a large clump of urate crystals a tophus , which is causing problems.
This may be if the tophus is on the bottom of the foot, and the person has difficulty walking on it, or on the side of the foot making it hard to wear shoes. An especially difficult problem is when the urate crystals inside the tophus break out to the skin surface.
This then can allow bacteria a point of entry, which can lead to infection, which could even track back to the bone. Whenever possible, however, we try to avoid surgery to remove tophi. The problem is that the crystals are often extensive, and track back to the bone, so there is not a good healing surface once the tophus is removed.
In some rare cases, such as when a tophus is infected or when its location is causing major disability, surgical removal may be considered. Since it is hard to heal the skin after a tophus is removed, a skin graft may be needed.
For this reason, we often try hard to manage the tophus medically. If we give high doses of medication to lower the urate level, such as allopurinol, over time the tophus will gradually reabsorb.
Fortunately, present medications are successful in the vast majority of gout patients. But some patients cannot tolerate our present arsenal of gout medications. For others, these agents are not sufficiently effective.
Therefore, new treatments are continually being sought. Some of the more promising include anakinra, rilonacept, canakinumab, BCX and arhalofenate. Gout is a common disease and appears to be becoming more common over time. We are fortunate to have a strong armamentarium against this condition, with newer agents in development.
In view of the effectiveness of our treatments, it is important for a correct diagnosis to be made as early as possible, and therapy begun quickly, when appropriate. Other conditions for example, pseudogout which can mimic gout, should be definitively ruled out through crystal identification in joint fluid whenever possible.
Non-medication treatments for gout are important, such as staying off the foot when it is inflamed and attending to diet both to reduce purine intake and to lose weight when indicated. For acute attacks of gout, a key is treating as quickly as possible and choosing a medication least likely to cause side-effects, with special attention to individual co-morbidities. For chronic prevention of gout, the essential message is that present treatments work in a huge majority of patients, and are generally well-tolerated.
It is important for patients to understand the four stages of gout See Figure 1 since the treatment of each is different. It is also important for patients with gout to be carefully counseled to communicate any changes in the frequency of gout attacks to their practitioner. A primary care practitioner can often manage gout without a consultation with a rheumatologist, but consultation should be considered if the diagnosis is unclear, there is uncertainty as to whether or not to start uric acid-lowering medication, attacks continue to occur despite treatment, or possible medication side-effects are making treatment difficult.
He receives no compensation related to sales or prescription of any medications. Gout: Risk Factors, Diagnosis and Treatment. By Theodore R. What is gout? What causes gout? Who gets gout? Which joints are involved in gouty arthritis? What does a gout attack look and feel like? How is gout diagnosed?
How can an attack of gout be treated? How can a gout attack be prevented? When is surgery considered for gout? What are future possible treatments of gout? Summary Disclosures More information. The four stages of gout Gout is best understood by seeing it as having four phases or stages See Figure 1: Stages of Gout : Stage 1: High uric acid Elevated uric acid without gout or kidney stone, this stage has no symptoms and is generally not treated.
Stage 2: Acute flares This stage is marked by acute gout attacks causing pain and inflammation in one or more joints. Stage 3: Intercritical periods These are periods of time between acute attacks, during which a person feels normal but is at risk for recurrence of acute attacks. Schneiter J. Reachment Publications; In addition to comprehensive lists of foods lower, relatively high, and highest in purines, this book offers nearly low-purine recipes.
Reachment Publications: More recipes from the same author. This book is useful since people often find the recommendations about low purine diets confusing and difficult to follow.
Lavoisier Booksellers, Cachan Cedex, France, A detailed review of the various types of crystal-induced arthritis, targeted at a professional audience. Oxford University Press, London: A kidney specialist with special interest in gout explains the condition in detail for a lay audience. Icon Health Publications, A source covering a wide variety of sources of information about gout, including a glossary and research summaries. Yale University Press, A socio-medical history of gout, including the famous figures who suffered from it, such as Benjamin Franklin and Thomas Jefferson.
Wortmann RL. Effective management of gout: an analogy. Am J Med. Modified from Wallace, SL, et al: Preliminary criteria for the classification of the acute arthritis of primary gout. Arthritis Rheum. Baker et al: Serum uric acid and cardiovascular disease: Recent developments, and where do they leave us? Am J Med, , A review article concluding that uric acid is an independent risk factor for coronary disease.
Shoji et al: A retrospective study of the relationship between serum urate level and recurrent attacks of gouty arthritis: evidence for reduction of recurrent gouty arthritis with antihyperuricemic therapy. Arthritis Rheum, 51 3 , This is one among a group of studies demonstrating the benefit of keeping uric acid below 6.
Choi HK et al: Purine-rich foods, dairy and protein intake, and the risk of gout in men. New Engl J Med, 11 , This article emphasizes the finding that red meat and shellfish increase gout risk while low-fat dairy intake seems to decrease it. Choi HK et al: Alcohol intake and risk of incident gout in men: a prospective study. Lancet, , This article pinpoints beer as being a particular risk factor for gout.
Arthritis Res Ther 8 Suppl 1:S2, This article reviews lifestyle modifications that can influence gout risk, including weight loss, alcohol and diet. N Engl J Med , A review of a recently recognized pathway by which colchicine inhibits the inflammatory process of gout. Arthritis Rheum , This article stresses the importance of kidney abnormality as a risk factor in allopurinol hypersensitivity, and the importance of reducing allopurinol dose in patients with kidney dysfunction and of making sure that only patients who meet appropriate criteria get treated with allopurinol.
Dalbeth N and Stamp L. Seminars in Dialysis , , This review emphasizes that it has not been proven that severe allopurinol allergic reactions relate to dose or that they are more common in patients with kidney problems.
The authors also stress that keeping doses of allopurinol too low often leads to inadequate control of uric acid levels. Arthritis Rheumatol. Demonstration of effectiveness of lesinurad, in combination with allopurinol, in getting patients to their uric acid goal. Arthritis Rheum , , Early data that anakinra was effective in gout flares. Terkeltaub R et al: The interleukin 1 inhibitor rilonacept in treatment of chronic gouty arthritis: results of a placebo-controlled, monosequence crossover, non-randomised, single-blind pilot study.
Theodore R. Schiavo et al. A year after the sleeve gastrectomy, the low-purine diet group no longer required allopurinol therapy, and suffered no gout attacks. Table 1 presents studies published over the years in which various types of bariatric surgery in obese gout patients affected serum uric acid levels as well as the frequency of gout attacks. Bariatric surgery was associated with a reduced incidence of gout compared with usual care adjusted HR 0. The incidence of early gouty attack in the first month after surgery was significantly higher in the bariatric group than the nonbariatric group Reduced uric acid serum levels and reduced inflammatory responses to Monosodium Urate MSU crystals upon mean follow-up of days.
Gout attacks may develop in the early post-operative period, within 8 days after surgery. Kang et al. Postoperative gout attacks were found in patients who demonstrated higher pre-surgical serum uric acid levels and a more rapid and profound decrease in uric acid levels after surgery.
The authors suggested that post-surgical gout attacks could be prevented by controlling pre-surgical uric acid levels.
Nevertheless, some studies have demonstrated that the effect of bariatric surgery on serum uric acid levels and the frequency of gout attacks vary in time after the procedure.
Immediately after the surgical procedure, a significantly higher frequency of gout attacks was observed in the bariatric surgery group compared to that observed in patients who underwent other procedures.
However, the incidence significantly decreased after the first postoperative month up to 1 year. Remarkably, a significant reduction in serum uric acid levels was observed months after bariatric surgery.
It is thus suggested that the immediate post-surgery rise in serum uric acid levels is due to renal dysfunction associated with the surgery procedure and as a response to surgical tissue disruption, as well as metabolic effects, catabolism, or dehydration from fasting or rapid weight loss. Additionally, dramatic changes in serum uric acid levels might trigger gout attacks. In conclusion, the literature contains solid data indicating that obesity is associated with the increased risk of developing gout.
Many studies have revealed that weight loss following bariatric surgery resulted in reduced serum uric acid levels and the amelioration of inflammatory responses to MSU crystals. Consequently, a decreased in risk to develop gout as well as lowering the frequency of gout attacks is demonstrated.
Thus, in view of these findings we recommend that preoperative prophylactic treatment should be administered to patients with a history of gout. Moreover, serum uric acid levels should be followed shortly after the surgery and treated accordingly in order to prevent an increase in the incidence of gout attacks.
This is an open access article distributed under the terms of the, which permits unrestricted use, distribution, and build upon your work non-commercially. Withdrawal Guidlines. Publication Ethics.
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