Gouty arthritis is inflammation of joints due to deposition of uric acid crystals within the joints. It is most common in men over 40 years and women who have attained menopause, especially with a positive family history of gout. It most commonly affects big toe, though ankle, midfoot or knee can also be affected. It can be managed quite effectively with medications.
Causes Of Gouty Arthritis
Gouty arthritis occurs due to increased levels of uric acid in blood. However, not everyone with high uric acid levels goes on to develop gouty arthritis. Only those in whom hard uric acid crystals are formed in joints develop any significant symptoms. Some of the predisposing factors are overweight, excess alcohol intake, excess intake of meat or fish, which are high in purines.
Medications like aspirin, diuretics and niacin can precipitate gouty arthritis. Other disorders associated with gouty arthritis are myeloproliferative disorders (abnormal increase in blood cells in bone marrow), hypothyroidism (decreased levels of thyroid hormones), multiple myeloma (a type of blood cancer characterized by bone pain, fever, weight loss and nausea) and chronic renal disease.
Gouty Arthritis Symptoms
There is pain of affected joint, typically acute in onset. The affected joints are swollen, red and very tender (painful to touch). Fever and chills may be associated. There can be restricted range of motion of affected joint. Weight bearing on the joint is painful.
The attacks last few days to many weeks with pain-free interval of months to years before another attack. After multiple attacks, the affected joints are deformed.
In acute attack, the uric acid level is > 7.5 mg/dL. Sometimes the uric acid level is normal in up to 25% of patients, so it may need to be measured multiple times to confirm diagnosis. White blood cells may be increased. ESR (erythrocyte sedimentation rate) is elevated during the acute attack.
Joint Fluid Examination
Definitive diagnosis is by finding needle like, negatively birefringent (double refraction) urate crystals in aspirated joint fluid.
X-rays can be taken to assess the extent of joint damage, particularly in advanced disease. Narrowing of joint space, cysts, erosions and punched-out defects may be seen.
Gouty Arthritis Treatment
During Acute Attack
An oral nonsteroidal anti-inflammatory drug (NSAID, e.g., indomethacin 25-50 mg every 8 hours for 5-10 days or until symptoms are controlled) can be effective in relieving the pain and is the standard treatment. Alternatively, colchicine (0.5-0.6 mg orally hourly until symptoms are controlled or diarrhea develops, up to a maximum of 8 mg) is helpful, but it should not be used by those having liver or kidney impairment.
Injection of steroid into the joint (e.g., triamcinolone 10-40 mg) can be effective in gouty arthritis affecting a single joint. If multiple joints are involved, an oral steroid is needed (e.g., prednisolone 40-60 mg initially and tapered over 7 days).
Medications that precipitate gouty attacks need to be avoided, such as aspirin, niacin and diuretics. Oral colchicine 0.6 mg twice daily is effective in preventing future attacks.
Probenecid 500 mg initially with gradual increase to 1-2 g, or sulfinpyrazone 50-100 mg twice daily, increasing as needed to 200-400 mg twice daily, are helpful in alleviating pain. Allopurinol 200-300 mg/day for 4 or more months can prevent future attacks.