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The serum uric acid is elevated (> 75 mg/dL) in 95% of patients who have serial measurements during the course of an attack However, a single uric acid determination is normal in up to 25% of cases, so it does not exclude gout, especially in patients taking uricopenic drugs During an acute attack, the ESR and white cell count are frequently elevated Identification of sodium urate crystals in joint fluid or material aspirated from a tophus establishes the diagnosis The crystals, which may be extracellular or found within neutrophils, are needle-like and negatively birefringent when examined by polarized light microscopy
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Early in the disease, radiographs show no changes Later, punched-out erosions with an overhanging rim of cortical bone ( rat bite ) develop When these are adjacent to a soft tissue tophus, they are diagnostic of gout
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Acute gout is often confused with cellulitis Bacteriologic studies usually exclude acute pyogenic arthritis Pseudogout is distinguished by the identification of calcium pyrophosphate crystals (positive birefringence) in the joint fluid, usually normal serum uric acid, and the radiographic appearance of chondrocalcinosis Chronic tophaceous arthritis may resemble chronic rheumatoid arthritis; gout is suggested by an earlier history of monarthritis and is established by the demonstration of urate crystals in a suspected tophus Likewise, hips and shoulders are generally spared in tophaceous gout Biopsy
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Treatment during symptom-free periods is intended to minimize urate deposition in tissues, which causes chronic
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There are two indications for daily colchicine administration First, colchicine can be used to prevent future attacks For the person who has mild hyperuricemia and occasional attacks of gouty arthritis, chronic colchicine prophylaxis may be all that is needed The usual dose is 06 mg either once or twice a day Patients who have coexisting moderate renal insufficiency or heart failure should take colchicine only once a day in order to avoid the peripheral neuromyopathy that can complicate the use of higher doses Second, colchicine can also be used when uricosuric drugs or allopurinol (see below) are started, to suppress attacks precipitated by abrupt changes in the serum uric acid level 4 Reduction of serum uric acid Indications for a urate lowering intervention include frequent acute arthritis not controlled by colchicine prophylaxis, tophaceous deposits, or renal damage Hyperuricemia with infrequent attacks of arthritis may not require treatment If instituted, the goal of medical treatment is to maintain the serum uric acid at or below 5 mg/dL, which should prevent crystallization of urate Two classes of agents may be used to lower the serum uric acid the uricosuric drugs and allopurinol (neither is of value in the treatment of acute gout) The choice of one or the other depends on the result of a 24-hour urine uric acid determination A value under 800 mg/d indicates undersecretion of uric acid, which is amenable to uricosuric agents if renal function is preserved Patients with more than 800 mg of uric acid in a 24-hour urine collection are overproducers and require allopurinol a Uricosuric drugs These drugs, which block the tubular reabsorption of filtered urate thereby reducing the metabolic urate pool, prevent the formation of new tophi and reduce the size of those already present When administered concomitantly with colchicine, they may lessen the frequency of recurrences of acute gout The indication for uricosuric treatment is the increasing frequency or severity of acute attacks Uricosuric agents are ineffective in patients with renal insufficiency, with a serum creatinine of more than 2 mg/dL The following uricosuric drugs may be used: (1) Probenecid, 05 g orally daily initially, with gradual increase to 1 2 g daily; or (2) sulfinpyrazone, 50 100 mg orally twice daily initially, with gradual increase to 200 400 mg twice daily Hypersensitivity to either with fever and rash occurs in 5% of cases; gastrointestinal complaints are observed in 10% Probenecid also inhibits the excretion of penicillin, indomethacin, dapsone, and acetazolamide Precautions with uricosuric drugs include maintaining a daily urinary output of 2000 mL or more in order to minimize the precipitation of uric acid in the urinary tract This can be further prevented by giving alkalinizing agents (eg, potassium citrate, 30 80 mEq/d orally) to maintain a urine pH of above 60 Uricosuric drugs are avoided in patients with a history of uric acid nephrolithiasis Aspirin in moderate doses antagonizes the action of uricosuric agents, but low doses (325 mg or less per day) do not; doses greater than 3 g daily are themselves uricosuric b Allopurinol The xanthine oxidase inhibitor allopurinol promptly lowers plasma urate and urinary uric acid concentrations and facilitates tophus mobilization
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tophaceous arthritis, and to reduce the frequency and severity of recurrences 1 Diet Potentially reversible causes of hyperuricemia are a high-purine diet, obesity, alcohol consumption, and use of certain medications (see below) Beer consumption appears to confer a higher risk of gout than does whiskey or wine Higher levels of meat and seafood consumption are associated with increased risks of gout, whereas a higher level of dairy products consumption is associated with a decreased risk Although dietary purines usually contribute only 1 mg/dL to the serum uric acid level, moderation in eating foods with high purine content is advisable (Table 20 5) A high liquid intake and, more importantly, a daily urinary output of 2 L or more will aid urate excretion and minimize urate precipitation in the urinary tract 2 Avoidance of hyperuricemic medications Thiazide and loop diuretics inhibit renal excretion of uric acid and should be avoided in patients with gout Similarly, low doses of aspirin aggravate hyperuricemia, as does niacin 3 Colchicine Patients with a single episode of gout who are willing to lose weight and stop drinking alcohol are at low risk for another attack and unlikely to benefit from chronic medical therapy In contrast, older individuals with mild chronic renal failure who require diuretic use and have a history of multiple attacks of gout are more likely to benefit from pharmacologic treatment In general, the higher the uric acid level and the more frequent the attacks, the more likely that chronic medical therapy will be beneficial
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