Treatment of gout

 Diagnosis of gout

 Diagnosis is confirmed

Definite diagnosis of gout as monosodium urate crystals found in synovial fluid or in tophi. Urate crystals shot needles, optical birefringence, in cells during the acute phase but may be smaller and more prisons and outside the cells in the period between acute attacks (see under a microscope polarization - polarized microscopy )


  Standard Bennett and Wood (1968)
(Sensitivity 70%, specificity 82.7%)

  Or find MSU crystals in the joint fluid or tophi.

  Or at least 2 of the following criteria:

• Or current history of at least 2 times a painful swelling of joints with nature with sudden onset, severe pain, and from completely within two weeks
• Current or history of sore big toe joint goals with the above properties.
• There tophi
• Respond to colchicine (reduce inflammation, relieve pain in 48 hours) in history or current

Diagnosis is confirmed to have a standard or two elements of the standard b.

  According to the standards of the American Society of Rheumatology (ACR 1977) [7]
(Sensitivity 70%, specificity 78.8%)

• There urate crystals in synovial fluid characteristics and / or
• Tophi proven to contain urate crystals by chemical methods or polarizing microscope, and / or:
• There 6/12 clinical manifestations, laboratory and x-rays following:

1. OA progression maximum within 1 day
2. Is there more than one round of acute arthritis
3. Inflammation of a joint
4. Do the joints
5. Swollen, sore toe joint goals I
6. Arthritis table toes on one side I
7. Arthritis ankle side
8. Non-visible automotive County
9. Increased blood uric acid (South ≥ 420 mmol / l, women ≥ 360 mmol / l)
10. Swollen joint pain asymmetry
11. Nang subcortical bone, not bone defects
12. Implant-negative bacteria joint fluid

  Differential Diagnosis

- Septic arthritis: a joint injury, the patient may fever, chills sometimes together, often on the road and have an infection, there is an acute gout attack. Fluid may polymorphonuclear leukocytes degradation. Soi swab to detect a joint septic arthritis may be associated with gout.
- Reactive arthritis: a history of infections other agencies previously (urinary, genital), no acute gout attacks
- Rheumatoid arthritis: often in women, joint swelling and pain is not red hot without gout attacks
- Arthritis pseudo gout: is an inflammation of the joints, edge matching software by calcium phosphate crystals, crystal cholesterol ... clinical manifestations are similar acute arthritis gout attacks. However, common in the elderly, combined with many degenerative condition. No non-grain bowl. Tests found crystals of calcium ... (not urate crystals) in synovial fluid or damage location.
- Cellulitis: infection is inflammation of the skin and soft tissue organization under the skin can match or outer edge joints. Common in the lower extremities, with favorable factors such as skin scrapes, blisters, injections before ...

  Treatment of gout

The goal of treatment:

- Treatment of acute gout arthritis
- Provision for recurrent gout, urate deposition prevention in the organization and the prevention of complications

Treatment of acute gout attacks

Determinants effective treatment exacerbations are not drugs that are used time after the onset of illness. If used within the first few minutes, the symptoms can be reduced quickly and ended early exacerbations. But without medication within 48 hours, it will need at least 2 days to control the disease.
 Detoxification gouty

5.1.1.1. Anti-inflammatory:

+ Colchicine tablets 1 mg.

Colchicine has the role of anti-inflammatory treatment for acute gout attacks, gout as a diagnostic test and the role of prophylactic treatment for acute gout attacks.

Before starting dose of 3 mg / 24 hours, divided 3 times in 2 days; Next: 2 mg / 24 h, divided by 2 times in 2 days; then: 1 mg / 24 hours, maintained for 15 days, sometimes 1-2 months to prevent recurrence. The starting dose of such models are now only applicable to diagnostic tests gout.

Currently, several clinical trials have demonstrated the effects of colchicine gout cut no difference compared with the non-steroidal anti-inflammatory drugs, while the tolerance of the non-steroidal anti-inflammatory drug colchicine better. As recommended by the American Association of Rheumatology (ACR 2010), cochicin limitations specified in the said case had the effect good effect before, and should be used as soon as possible, preferably before the first 24 hours of launch found gout [4]. Cochicin recommended dose and low-dose split 0,6mg / 6gio and / or coordinate with other nonsteroidal anti-inflammatory drugs.

Contraindicated in cases of liver failure, severe renal failure, history of drug allergy

Side effects: diarrhea, vomiting, abdominal pain, decreased motility require medication (Imodium 2mg) and ice combined mucosa. Or instead of colchicine by colchimaxO, (colchicine accompanied opium to fight diarrhea). May have low white blood due to colchicine, but nhion rare.

+ Non-steroidal anti-inflammatory drug (CVKS)

As recommended by the American Association of Rheumatology (ACR 2010) is a nonsteroidal anti-inflammatory drugs are the drug of first choice for cutting acute gout attacks. All drugs in this group have anti-inflammatory effects in acute gout attacks. Depending on each individual with risk factors for heart, stomach, and is contraindicated or not but consider the type CVKS use.

If there is no risk factors in the digestive tract, the recommended CVKS not selected, taken early in the first 24 hours would be more effective. For example, naproxen 500mg / 2 times / day, or indomethacin or diclofenac 50 mg / 3 times / day. Halved the dose was effective and used in 7- 10 days.

If in the case of risk factors for gastrointestinal, recommended the use of selective COX2 inhibitors: Celecoxib (Celebrex 200 mg dose member 1 to 2 tablets / day after eating it) or (Etoricoxib (Arcoxia 30, 60 , 90, 120 mg) using 1 capsule / day).

Contraindicated in patients with hepatic impairment, severe renal failure, gastrointestinal bleeding.

+ Steroids:

Commonly prescribed for patients who have contraindications to using colchicine, CVKS (liver failure, severe renal failure) or therapy but not efficient (usually in cases of acute multiple joints, dependence steroids).

Corticosteroids may be given by injection to joints (the joints 1-2 inflammation, but should exclude joint infection before vaccination)

Corticoid steroid short days (2-3 days, then reduce the dose of 5-7 days). Orally or intravenously at a dose of 30 -50 mg / day first, then reduce the dose according to response quickly and used for 5-7 days. Intravenous Medications: solumedrol tube 40mg, tablets: 5mg prednisone, medrol 4mg member, 16mg. However, only limited need for systemic corticosteroids because of side effects and dependency status corticoid.

 Analgesic

In acute gout attacks can be combined with anti-inflammatory analgesics to relieve pain quickly. Using painkillers WHO analgesic ladder.

• Tier 1 - paracetamol 500 mg / day orally 4 to 6 times, no more than 4 grams / day
• Tier 2 - paracetamol + codeine (efferalgan codeine, tramadol)
• Tier 3 - Opiat and derivatives opiat

 Prophylactic treatment of recurrent gout attacks  Control diet, activity

- Principles:
+ Reduced protein diet (meat eating less than 150 g / day)
+ Fat reduction mode
Gain key + l * can drink at physiological levels, reduce calories if you eat fat
+ Drink lots of water, especially alkaline mineral water
+ Avoid foods high in purines

- Specific diet:
Avoid foods high in purine: viscera of animals (pig heart, blood pudding, liver, kidney, brain, stomach), red meat (beef dogs, goats, buffalo, calf), seafood (shrimp, crab, fish fat), beans nuts, dried mushrooms, chocolate.
+ Moderate eating foods that are relatively low in purines (pork, beef, veal, lamb, chicken, duck, bird, fish). Every day eat meat no more than 100-150 g.
+ Drink plenty of water daily, preferably alkaline mineral water. Drink 2 3 LOT / day.
+ Eat more vegetables, vegetables artichoke, lettuce, carrots, cabbage, cucumber, melon, green beans, potatoes, tomatoes, fresh mushrooms, bamboo shoots.
+ It is possible to eat eggs, milk and related products, fermented white cheese, lean fish, snails shells.
+ Eat cereals, white bread, rice, flowers, fruits or drink tea or coffee.

- Mode of living:
+ In addition to diet, to maintain a moderate mode of living, working gently, avoid cold, avoid tired both mentally and physically (excessive labor, * injury ...).
+ Control your weight, blood sugar, blood pressure, blood uric acid, blood fat.
+ When you have surgery or suffering from a systemic disease that must be tuned regularly uric acid to adjust the time.
+ Eliminate risk factors such as smoking, drinking alcohol

 Measures medication

- Use of preventive cochicin gout
+ According to the recommendations, Colchicine may be extended by 6 months use after controlling blood uric acid levels were normal backup recurrent gout attacks. Only use in the prevention of attacks CVKS when patients can not tolerate colchicine.
Colchicine dose for prophylaxis of 0.6 mg / 2 times / day (however, no members in Vietnam 0,6mg content, which may use ½ tablet 1mg / 2 times / day). Patients with renal impairment, the dose should be reduced colchicine: a dose of 0.5 mg / day with glomerular filtration rate 35-49ml / min (CKD level II); 0.5 mg / every 2-3 days in patients with glomerular filtration rate 10-34ml / min (CKD level III). Contraindicated in patients with renal failure without dialysis IV level.

- Use of drugs reduce blood uric acid (see section 5.2. Treatment of chronic gout: 5.2.2)
+ Should this group designated smoking about a week after the onset of acute gout attacks, when inflammation was relieved to avoid severe bout GYT-onset gout level and the next level

- Alkaline urine
+ Make sure to water filtration by the kidneys, so that the urinary uric acid levels do not exceed 400 mg / l.Increase the volume of urine, thereby increasing the excretion of uric acid and reduce the risk of kidney stones.
+ Cuticle of urinary alkaline mineral water (drinking) water or alkaline 1.4% (intravenous). Currently, no studies have also pointed out the role alkaline urine actually reduce uric acid levels, sometimes just to increase urinary volume. - Avoid using certain drugs can increase blood uric acid: + Diuretics: hypothiazid, furocemide ... + The steroids: prednisone, hydrocortisone, dexamethasone ... these drugs can reduce joint pain and swelling quickly, but in the long run will make up ill. + Some other drugs: aspirin , pyrazinamide, ethambutol. + Generally people with gout are or allergy medicine, so be cautious when using any drugs whatsoever. 5.2. Treatment of chronic gout treatment goal: control uric acid levels below 360 mmol / l (60 mg / l) with no knots and non-grain bowl below 320 mmol / l (50 mg / l) when grain bowl gout Non. 5.2.1. Control diet, activity ( see Section 5.1.2. Prophylactic treatment of recurrent gout attacks: 5.1.2.1 ) If the diet effective, ie no GYT attacks, blood uric acid less than 60 mg / l, no tophi, frames, only kidney damage sustained mode. 5.2.2. Measures up drugs - anti-inflammatory drugs: Used when there is acute gout attacks and prevention of acute gout attacks (see Section 5.1.1. Treatment of acute gout attacks cut (5.1.1.1. Anti-inflammatory) and Section 5.1.2 . Prophylactic treatment of recurrent gout attacks) - The drug reduces blood uric acid: + synthesis inhibitors uric acid drugs designated groups depending on the amount of uric acid, the condition of the patient (frequency of attacks acute gout, tophi ...). Maintenance of drug groups until reaching the blood uric acid below 60 mg / l (360 mmol / l), even 50 mg / l (320 mmol / l) in the case of chronic gout non-grain bowl. This therapy can inhibit the gouty attacks, tophi and the disappearing. Often used continuously for 1-2 months. Then, depending on the amount of uric acid that dose adjustment. There are cases to sustain life if patients do not adhere to the strict diet, blood uric acid to normal. Allopurinol : Proprietary medicine Zyloric 100 members -300mg Mechanism: xanthine- oxidase enzyme inhibitors Indications: all cases of gout, especially in cases with increased urinary uric acid, kidney stones, kidney failure. But should not take Allopurinol even while you are in acute, but should wait about a week later, while reducing inflammation, a new start for the onset of allopurinol to prevent gout attacks. If you are taking Allopurinol that exacerbations, continued use. Dose: 100 mg- 900 mg / 24 hours, the interior is average dose of 300 mg / day. In patients with renal impairment, the recommended dose is as follows:

Table 5.1. The dose of allopurinol in patients with renal impairment [3]

Glomerular filtration rate	Dose (mg / day)	Adjust dose (mg / 2-3 weeks)
≥ 90 ml / PHYT	100-300	100
60-89 ml / PHYT	100-200	100
30-59 ml / PHYT	100	50-100
10-29 ml / PHYT	50	50
<10 ml / PHYT	0	0

Side effects:
+ gout by lowering uric acid levels abruptly
+ Increase sensitive skin: ban, rash, urticaria
+ Even as severe allergy syndrome Stevens - Johnson, anaphylaxis. Do owls drug Koo waste time selling their long-time allergy sometimes appear rather late, after a few days or 1-2 weeks of dosing.
+ vascular inflammation, hepatitis (rare) Febuxostat: xanthine oxidase inhibitors new, has many advantages over Allopurinol. Drugs metabolized in the liver should be used for patients with mild to moderate renal impairment. Doses up 40 -120 mg / day. But the spot-expensive basket nhion currently no drugs in Vietnam are spot. + The drug increases uric acid probenecid (500 mg x 1-2 tablets / 24 h), Anturan (2-3 x 100 mg capsules / 24 h ), Mechanisms: This group of drugs may increase the effect of uric acid by the kidneys, and inhibition of renal tubular absorption, reduce uric acid levels, but increased urinary uric acid Indication: The case of ineffective or allergic to the synthetic inhibitor of uric acid Contraindications: gout nephropathy or urinary uric acid levels (above 600 mg / 24 h), GYT shot kidney stones. Currently there are no drugs on the market and Vietnam + Drugs that uric acid: Special pharmaceutical Uricozyme mechanism: this is uricase enzyme that converts uric acid to allantoine have high solubility and easily excreted from the body. Indications: the case of increased uric acid levels in patients the blood. Must be used in hospitals. Overall very rarely used and there is no market in Vietnam. Alkaline urine (see Section 5.1.2. Treatment plans Phung attack GYT garlic phosphate levels) 5.2.3. Treated with surgical resection designation tophi in chronic gout is very limited because of difficult healing and the deposition of urate crystals constantly making it difficult to heal wounds. So when tophi surgery: tophi with infectious complications, the particles to affect motor function and deformity, non-grain bowl as much pain. VI. Prevention The preventive measures should be applied right from a very young age to prevent early stage hyperuricemia no symptoms, prevent the onset of acute gout attacks, not to occur with chronic gout. Prevention is make good healthy lifestyle, eliminating the risk factors (alcohol restrictions, many foods containing purines ...). Management and timely treatment when the disease gout attacks and other combinations. References: