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PubMed1998

Gout in the elderly. Clinical presentation and treatment.

Gout in the elderly differs from classical gout found in middle-aged men in several respects: it has a more equal gender distribution, frequent polyarticular presentation with involvement of the joints of the upper extremities, fewer acute gouty episodes, a more indolent chronic clinical course, and an increased incidence of tophi. Long term diuretic use in patients with hypertension or congestive cardiac failure, renal insufficiency, prophylactic low dose aspirin (acetylsalicylic acid), and alcohol (ethanol) abuse (particularly by men) are factors associated with the development of hyperuricaemia and gout in the elderly. Extreme caution is necessary when prescribing nonsteroidal anti-inflammatory drugs (NSAIDs) for the treatment of acute gouty arthritis in the elderly. NSAIDs with short plasma half-life (such as diclofenac and ketoprofen) are preferred, but these drugs are not recommended in patients with peptic ulcer disease, renal failure, uncontrolled hypertension or cardiac failure. Colchicine is poorly tolerated in the elderly and is best avoided. Intra-articular and systemic corticosteroids are increasingly being used for treating acute gouty flares in aged patients with medical disorders contraindicating NSAID therapy. Urate-lowering drugs are indicated for the treatment of hyperuricaemia and chronic gouty arthritis. Uricosuric drugs are poorly tolerated and the frequent presence of renal impairment in the elderly renders these drugs ineffective. Allopurinol is the urate-lowering drug of choice, but its use in the aged is associated with an increased incidence of both cutaneous and severe hypersensitivity reactions. To minimise this risk, allopurinol dose must be kept low. A starting dose of allopurinal 50 to 100mg on alternate days, to a maximum daily dose of about 100 to 300mg, based upon the patient's creatinine clearance and serum urate level, is recommended. Asymptomatic hyperuricaemia is not an indication for long term urate-lowering therapy; the risks of drug toxicity often outweigh any benefit.

Aged↗
PubMed2005

Overview of hyperuricaemia and gout.

In most mammals purine degradation ultimately leads to the formation of allantoin. Humans lack the enzyme uricase, which catalyzes the conversion of uric acid to allantoin. The resulting higher level of uric acid has been hypothesized to play a role as an antioxidant. Hyperuricaemia is usually an asymptomatic condition which is hypothesized to play a role in cardiovascular disease and hypertension. Some hyperuricaemic individuals develop gout, an inflammatory arthritis caused by the deposition of monosodium urate crystals in joints. Over time, acute intermittent gouty arthritis can develop into a chronic condition with deposits of monosodium urate (MSU) crystals in joints and as tophi. The mechanisms by which MSU crystals lead to an acute inflammatory arthritis are under investigation and current knowledge is reviewed here. Treatment of gout includes management of acute flares with anti-inflammatory medications such as non-steroidal anti-inflammatory drugs or corticosteroids and long term management with urate-lowering therapy when indicated. Future directions in the treatment of gout, in part guided by a better understanding of pathophysiology, are discussed.

Antioxidants↗
PubMed1976

Lesions resembling gout in patients with rheumatoid arthritis.

Although roentgenographic appearances are seldom important in establishing the diagnosis of rheumatoid arthritis or gout, atypical appearances of individual lesions may confuse the distinction between these two conditions. Sixteen patients with rheumatoid arthritis were selected to illustrate joint and soft tissue lesions which resemble gout. The lesions are divided into five broad categories on the basis of the appearance and sites of bone erosion as well as the nature of soft tissue changes. Symmetrical bilateral joint involvement was found to be especially helpful in distinguishing rheumatoid arthritis from gout.

Arthritis, Rheumatoid↗
PubMed2005

Topacheous gout as a rare cause of spinal stenosis in the lumbar region. Case report.

Despite the fact that gout is a common metabolic disorder, because its involvement of the axial skeleton is rare the diagnosis is often delayed, even in patients with long-standing gout who present with neurological deficits. The authors report the case of a woman with a history of extensive gout, emphasizing the clinical, radiological, and pathological features of a lumbar spinal stenosis.

Biopsy↗
PubMed2005

A large, erosive intraspinal and paravertebral gout tophus. Case report.

Symptomatic gout tophi of the spine are a rare but well-characterized complication of tophaceous gout. The authors report the case of a 29-year-old previously healthy man who presented with L-5 radiculopathy. Lumbar magnetic resonance (MR) imaging revealed a 4.5 x 4.5 x 2.8-cm large gout tophus mimicking a malignant spinal tumor or abscess. The tophus completely destroyed both L-4 and L-5 facet joints and the left L-4 lamina and spread epidurally from L-3 to L-5, compressing the left L-5 nerve root. There has been no similar case reported so far with respect to the extent of bone destruction. The authors describe the case history and present intraoperative, MR imaging, and histological findings.

Abscess↗
PubMed2006

Effect of fenofibrate in combination with urate lowering agents in patients with gout.

BACKGROUND: To assess the efficacy of fenofibrate treatment in combination with urate lowering agents in patients with gout. METHODS: Fourteen male patients with chronic tophaceous or recurrent acute attacks of gout were evaluated in an open-label pilot study of the hypolipidemic agent, fenofibrate (Lipidil Supra 160 mg/d). Patients were stable on urate lowering agents (allopurinol or benzbromarone) for > or = three months without acute attack for the most recent one month before participating. All patients were being treated with established doses of urate lowering agents without modification throughout the study. Clinical and biochemical assessments including serum uric acid, creatinine, liver function test and fasting serum lipid were measured at (1) baseline (2) after two months of fenofibrate treatment and (3) two months after fenofibrate was withdrawn. RESULTS: Serum uric acid was lowered by 23% after two months of fenofibrate treatment (6.93 +/- 2.16 vs. 5.22 +/- 1.16 mg/dL; p = 0.016). Triglyceride levels were also reduced after fenofibrate treatment (p = 0.001). However, this effect was reversed after the withdrawal (p = 0.002) of the drug. Alkaline phosphatase was reduced after fenofibrate treatment (p = 0.006), but increased 21% after the withdrawal of the drug (p = 0.002). By contrast, serum levels of high density lipoprotein and creatinine were increased 9% (p = 0.018) and 12% (p = 0.006), respectively; however, both levels were significantly decreased to the baseline levels upon withdrawal of fenofibrate. CONCLUSIONS: Fenofibrate can effectively reduce uric acid levels in addition to its known hypolipidemic effect. Fenofibrate may be used as a potential urate lowering agent in patients with gout, especially in those with coexisting hyperlipidemia.

Adult↗
PubMed1984

Therapeutics of hyperuricaemia and gout.

Environmental factors, including diet, fluid intake and alcohol consumption, often contribute significantly to the development of hyperuricaemia. The contribution of these factors, together with body size and the renal excretory capacity for urate, can be assessed on the basis of the clinical history and examination, together with simple investigations. These include the measurement of both serum levels of urate and the urinary excretion of urate, and the effect of purine restriction on these measurements. Recognition of causative factors provides the potential for their correction. Should gout develop, serum urate levels must be reduced to normal. This usually, but not invariably, necessitates prolonged drug treatment. The major problem in maintaining serum urate levels within the normal range is that this depends upon the cooperation of the patient. Acute gout needs to be managed on its own merits, irrespective of the use of drugs which alter the serum urate concentration. Prophylactic therapy with colchicine reduces the frequency of acute attacks of gout, whether the serum urate level is normal or elevated.

Acute Disease↗
PubMed1979

Management of gout.

The diagnosis of gout depends on showing urate crystals in synovial effusions or, with less certainty, recognizing a characteristic clinical presentation. The management of gout has four phases: control of inflammation, diagnostic evaluation, education of the patient, and treatment for the hyperuricemia. Sound logical principles guide each aspect. Careful attention to these four phases of management should lead to highly satisfactory control of the syndrome of gout.

Adrenal Cortex Hormones↗
PubMed1991

Chronic tophaceous gout. A case report.

A review of gout is presented, followed by a discussion of the current medical literature on diagnosis, differential diagnosis, staging, and treatment. Chronic tophaceous gout is not as prevalent as it once was because of early diagnosis and treatment, but it is still encountered in the podiatric practice. A severe case of chronic tophaceous gout is presented. The patient was successfully treated by surgical intervention. Although surgery may be avoided in most cases, it is indicated when intractable pain, loss of motion, and massive joint destruction are present.

Chronic Disease↗
PubMed2000

Effect of low level lead exposure on hyperuricemia and gout among middle aged and elderly men: the normative aging study.

OBJECTIVE: To determine whether longterm lead accumulation is associated with hyperuricemia and gouty arthritis among middle aged and elderly men. METHODS: In a retrospective cohort study, 777 male participants were evaluated between August 1991 and October 1996 in the Department of Veterans Affairs Normative Aging Study, a 35 year longitudinal study of aging. We examined the development of gout and an increased uric acid level in relation to lead, adjusting for other known risk factors. Lead levels were measured in blood and by K x-ray fluorescence (K-XRF) technique in tibial (cortical) and patellar (trabecular) bone. RESULTS: Blood lead levels in this mostly Caucasian (97%) population were low (mean 5.9 microg/dl, SD 3.5). Bone lead levels were comparable to those described in other general populations. In a multivariate analysis adjusting for the risk factors, age, body mass index, diastolic blood pressure, alcohol intake, and serum creatinine level, there was a positive association between patellar bone lead and uric acid levels (p = 0.02). Of 777 participants, 52 (6.7%) had developed gouty arthritis. In logistic regression of similar covariates, body mass index (p < 0.0001) and serum creatinine level (p = 0.005) were the strongest determinants of gout; neither bone nor blood lead levels predicted gout in this cohort. CONCLUSION: The longterm accumulation of lead is associated with an increased uric acid level in middle aged and elderly men. However, this study shows no association between lead and gouty arthritis at the levels arising from community exposure.

Age Factors↗
PubMed1975

Decreasing prevalence of tophaceous gout.

Retrospective analysis of newly diagnosed gout cases seen at the Mayo Clinic from 1949 through 1972 shows a progressive decline in tophaceous gout, from 14% to 3%. Gout diagnoses remained stable in a range of 1.5 to 2.2/1,000 patients seen.

Colchicine↗
PubMed2000

[Case report of a patient with knee gout].

A 46-years old male presented with an attack of gout (knee arthritis or gonagra). It is interesting that the patient was HLA B27 positive antigen found a couple of years ago, but on admission he had a normal findings of uric acid in serum, while cytological examination of synovial fluid obtained from knee joint no urates were found. Therefore, diagnostically besides gout arthritis a reactive arthritis as well as other connective tissue diseases were considered. In further diagnostic procedure arthroscopy was performed and in biopsy specimen from the cyst of lateral condyle of right femur urates were found. One day after the arthroscopy was performed a clear clinical picture of podagra developed. After the diagnosis was made the treatment of gout arthritis with Indometacyn began, and with improvement of inflammation, surgery was performed--cyst excochelation of lateral condyle of right femur with filling of the defect with an autologous graft from iliac crest.

Gout↗
PubMed2000

[Pleural effusion of gout].

OBJECTIVE: To investigate the lung complication of patients with gout. METHODS: Laboratory, radiation and pathology examining were exerted to 11 patients with gout and lung injury. RESULTS: Uric acid crystal was found in four patients pleural effusion and stones in two patients' spittle which were consist of monosodium urate (MSU). Uric acid salt crystal was found sputum in five patients as well as fibrosis was found in the patients' lung by radiation and pathology examination. CONCLUSIONS: The diagnoses of lung complications in eleven patients with gout were reliable.

Adult↗
PubMed2002

[The Dutch College of General Practitioners' "Gout" Standard: a response from general practitioners].

Although gout has a long nosological history, there are still many uncertainties regarding its pathophysiology, causative factors and most common therapies. Therefore, composing an evidence-based guideline on gout is a challenge. There is a lack of good clinical research, especially in primary care populations where most gout patients are diagnosed and treated. Far more insight is required into the mechanisms which underlie increasing and decreasing serum uric acid levels which, via the blood-synovium barrier, should increase or decrease urate crystals with inflammatory potency. In view of this lack of information, it would have been more appropriate for the Standard not to contain unproven facts and therapeutic recommendations. Guidelines should be kept simple until good clinical research proves the opposite.

Evidence-Based Medicine↗
PubMed2002

[Gout: current views. Stage oriented treatment].

Gout is a common disease arising due to abnormal purin metabolism and excessive accumulation of uric acid in the blood (hyperuricemia) and manifesting with attacks of acute gouty arthritis. In long duration of gout uric acids accumulate in the bones and periarticular tissues as tophuses. Repeat attacks lead to development of chronic gouty arthritis. Purins restriction diet is an important component of gout treatment. Treatment of acute arthritis should be started early, in initial pains before the development of the attacks. Gouty arthritis in the presence of continuous hyperuricemia, tophyses and urolithiasis is treated with allopurinol. Its intake should be long and controlled by the blood level of uric acid. Balneotherapy is recommended for patients with chronic gouty arthritis associated with cardiovascular diseases, urolithiasis.

Acute Disease↗
PubMed1975

[The simultaneous occurrence of psoriasis, sarcoidosis and gout. Report of 3 cases].

The author reports three further cases of simultaneous occurence of psoriasis, sarcoidosis and gout, additionally to the hitherto known observations. The occurence of gout is questionable in this connection, relevant seems to be only the coincidence of psoriasis and gout. A probable causal connection is discussed. This could theorectically be due to a common genetic sphere, to similar pathophysiological principles or to an alternatively manifestation of each other.

Adult↗
PubMed2002

A simple method of selecting gout patients for treatment with uricosuric agents, using spot urine and blood samples.

OBJECTIVE: To develop a simple means of selecting gout patients for treatment with uricosuric agents. METHODS: In 124 gout patients, spot urine and blood were sampled before breakfast and after overnight fast (except water) on the day of 24 h urine collection. Spot urine uric acid/creatinine ratio (Ua/Cr mmol/mmol) and serum creatinine x Ua/Cr (Scr*Ua/Cr micromol/l) were calculated together with 24 h urinary uric acid excretion/body surface (24 Ua/S). The patients were then classified either below or above 2.84 mmol/m2/day for 24 Ua/S. RESULTS: Classifications based on spot urine Ua/Cr (cut off value set at 0.34), spot urine Scr*Ua/Cr (cut off value set at 28.1), and a combination of spot urine Ua/Cr and Scr*Ua/Cr were found to be not significantly different in diagnostic accuracy for the detection of patients with 24 Ua/S below 2.84 mmol/m2 (77%, 81%, and 81%, respectively) and sensitivity (80%, 83%, and 76%, respectively). However, specificity by a combination of spot urine Ua/Cr, and spot urine Scr*Ua/Cr was higher than by spot urine Ua/Cr alone (91% vs 74%, P < 0.05), although the specificity was not significantly different between a combination and spot urine Scr*Ua/Cr alone (91% vs 78%) or between spot urine Ua/Cr and spot urine Scr*Ua/Cr (74% vs 78%). CONCLUSION: A combination of spot urine Ua/Cr and spot urine Scr*Ua/Cr may be clinically useful in selecting gout patients with 24 Ua/S below 2.84 mmol/m2 for treatment with uricosuric agents without adverse effects.

Adult↗
PubMed2003

[Changes in blood hormone levels in gout and methods of their correction (an experimental and clinical study)].

Gout belongs to often-occurring rheumatic pathologies and its incidence among the male population of Europe has been rapidly increasing during the recent years. The pathogenesis of the disease is insufficiently studied and the existing methods of pathogenetic therapy are low effective. The disease pathogenesis with regard for dishormonal disorders has been recently under discussion. 107 patients with primary gout and 70 white outbred male rats were examined. Disorders in the hypophysis-gonad system (i.e. hyperproduction of progesterone, and suppression of the synthesis of testosterone and estradiol, which are to a great extent typical for patients with chronic arthritis and with nephropathy of the proteinuric type) developed in men with gout. Similar changes were provoked experimentally by purine-exchange violations, which is indicative of their secondary nature. An exogenous administration of androgens at experimental hyperuricemy led to the normalization of purine exchange and of blood hormones, it also ensured an alleviation of pronounced morphological signs of arthritis. The application of testosterone and its analogues for people exceeds, by their effectiveness, the known treatment methods.

Androgens↗