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Gout- diagnosis and treatment

Although classic gout- ie. gout appearing as a painful, swollen, and red big toe- is easily recognized by most people, gout does not always present in this fashion. Similarly, treatment of gout may seem straight forward at first, but there are so many details to consider depending on the individual, their co-morbidities, and the way their gout behaves. Therefore, gout diagnosis and treatment often require an expert’s touch!

 

Diagnosing gout

Gout is suspected when someone has acute onset of a red, hot, swollen and tender joint. If the affected joint is a great toe, the suspicion is even stronger. Blood tests may show an elevated uric acid level which would be expected with gout. Xrays may be normal or may show evidence of joint destruction from tophi.

 

Although at times the clinical picture is all the information we have to make the diagnosis, relying on the uric acid levels alone may be misleading. Uric acid levels may be spuriously low during an attack, giving us a false negative. Also, most people with an elevated uric acid may not have gout, so there is a high chance of false positives. Other types of arthritis, including infection of a joint, can also look like gout clinically.

Needle-shaped uric acid crystals photographed under polarized light from a synovial fluid of a person with gout. From: Bobjgalindo
Needle-shaped uric acid crystals photographed under polarized light from a synovial fluid of a person with gout.
From: Bobjgalindo

 

 

The gold standard of gout diagnosis is presence of monosodium urate crystals in the fluid from a joint. These crystals are needle-shaped structures that look either blue or red- depending on their orientation- under a polarized microscope. To find these crystals, a sample of the fluid is removed from the joint with a needle and looked at under the microscope.

 

How is gout treated?

Acute gout

The goal in treatment of an acute gout attack is to relieve symptoms quickly. Some of the ways this is achieved are:

  • Non-steroidal anti-inflammatory drugs (NSAIDs)– example: ibuprofen (advil), indomethacin (Indocin), Naproxen (Naprosyn), etc.
  • Colchicine (Colcrys)
  • Steroids – example: prednisone
  • Pain medications like vicodin
  • Cold packs

 

NSAIDs should be used with caution in people with kidney disease, heart disease, history of gastric ulcers, and cannot be used in people who take blood thinners. Colchicine should be used carefully in people with kidney disease. Steroids can elevate blood sugar so people with diabetes will need to be monitored on this medication.

 

Large doses of colchicine can cause diarrhea. In the past, people with acute gout were instructed to take a tablet of colchicine every hour until they developed diarrhea. The new recommendations are to take about two tablets per day, which seems to be just as effective as the higher dose with much less side effects.

 

Chronic gout

If gout attacks become chronic, long-term medications are used to lower uric acid and prevent future attacks. These include:

  • Probenacid– increases uric acid filtration through the kidneys
  • Allopurinol– prevents formation of uric acid in the blood
  • Febuxostat (Uloric)– similar to Allopurinol, but can be used more safely in people with poor kidney function
  • Colchicine (Colcrys)– Low dose colchicine can also be used long term as a prophylaxis drug for gout. Many rheumatologist will combine colchicine with the other long term drugs for the first few months to prevent gout flares as the uric acid level is lowered.
  • Pegloticase (Krystexxa)- breaks down uric acid into a product that is more easily eliminated. Since this IV drug can potentially cause severe allergic reactions, it is reserved for very severe cases of gout not otherwise controlled.

 

Gout prevention

Diet and lifestyle changes can have a large impact on management of gout. See:

 The Gout diet – simplified

 

Reference:

UpToDate http://www.uptodate.com/contents/gout-beyond-the-basics?source=search_result&search=gout+patient&selectedTitle=1%7E150

PubMed Health http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001459/

Wikipedia http://en.wikipedia.org/wiki/Gout

Web MD http://arthritis.webmd.com/tc/gout-topic-overview

 

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Plantar fasciitis? Blame the shoes!

Plantar fasciitis: The aching feet

What is plantar fasciitis?

Plantar fascia is the thick, fibrous tissue that runs along the arch of the foot, from the heel to the toes. This tissue can become inflamed from overuse and other mechanical injuries. The pain is usually sharp, severe, and worse in the morning. People often describe the pain onset as “the minute I step off the bed”.
Apparently there has been a recent epidemic of plantar fasciitis among Americans. Experts believe the culprit is “flimsy shoes that don’t support the arch”- like flat shoes, flip-flops, and old shoes that have lost their cushioning.

What can you do?

  1. Change your shoes! Consider shoes with better arch support. If you exercise often, change your exercise shoes every 4-6 months.
  2. Insoles- to add extra arch support. You can get these either from a drugstore (like Dr. Scholl’s shoe inserts) or custom-made by your doctor
  3. NSAIDs- non-steroidal anti-inflammatory drugs like advil, ibuprofen, or aleve
  4. Stretching- stand against a wall and stretch out the affected foot every morning
  5. Shock-wave therapy- this is the use of acoustic shock waves in the affected areas to decrease inflammation
  6. Corticosteroid injections by your rheumatologist or podiatrist
  7. Surgery

 

Personally, I would start with more foot-friendly shoes!

http://www.latimes.com/health/la-he-feet-20130309,0,5785167.story

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Gout- for both the prince and the pauper

Gout- symptoms, etiology, diagnosis and treatment

 

What is gout?Gout

Gout is a type of arthritis that causes sudden onset of pain, redness, heat, and swelling in a joint. It is more common in men, and is rare in women before menopause. Although gout is caused by elevated levels of uric acid in the blood (called hyperurecemia), most people with hyperurecemia will never develop gout. The reason for this is not clear.

 

What causes gout?

Uric acid is a by-product of pruines, which is a component of the foods we eat. Uric acid is filtered and excreted through the kidneys. There is usually a fine balance between the production of the uric acid and its filtration in the kidneys, so the level stays constant. If this balance is altered, we can end up with too much uric acid. For example, eating foots with high purine content or kidney failure can lead to buildup of uric acid. Most gout cases are caused by underexcretion of uric acid through the kidneys.

 

Risk factors:

Gout used to be known as the disease of the kings. Now we know that is probably because historically the majority of people could not afford an abundance of meat and alcohol in their diet, except when they were wealthy. Now that purine-rich foods are accessible to more people, it can affect everyone- princes and paupers alike. These are some of the risk factors for developing gout:

  • Diet- large amounts of beef, seafood, high-fructose corn syrup (like sodas)
  • Alcohol- particularly beer. More than 1 drink/day for women and 2 drinks/day for men
  • Gender- gout is more common in men than in women. After menopause, women catch up!
  • Kidney disease
  • Obesity
  • Certain medications that can affect uric acid levels (like diuretics or water pills)
  • Low dose aspirin use
  • Injury
  • Recent surgery
  • Blood cancers

 

Gout symptoms

Acute gout

Sudden onset of severe pain in a joint, often associated with redness, swelling, and heat. The most common affected joint is the 1st toe, but any joint can be involved. The pain is worse at night, and may be so severe that one is not able to bear their bed sheets on their toe. Symptoms usually peak within 24 hours and resolve in 10-14 days.

 

Chronic gout

Whereas at the beginning, gout involves one joint at a time and there may be 1-2 years between attacks, as hyperurecemia and gout become chronic the gout-free periods shorten and more than one joint at a time may be affected. In severe cases, one attack can lead to another and there may be no gout-free period.

 

Tophaceous gout

After several years, large amounts of uric acid crystals deposit to form rock-like masses- or tophi- in the joints and their surrounding tissues. Tophi can cause erosion (eating away) of the joint and significant deformity.

 

Complications

People with gout are at increased risk of developing uric acid-containing kidney stones. Deposits of uric acid in the kidneys can also cause damage to the kidneys (urate nephropathy).

 

Reference:

UpToDate   http://www.uptodate.com/contents/gout-beyond-the-basics?source=search_result&search=gout+patient&selectedTitle=1%7E150

PubMed Health    https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0022793/

Wikipedia  http://en.wikipedia.org/wiki/Gout

Web MD   http://arthritis.webmd.com/tc/gout-topic-overview

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The essentials of fibromyalgia treatment

Fibromyalgia treatment- not easy, but possible!

How is fibromyalgia treated?

There is no cure for fibromyalgia. However, symptoms can be treated with lifestyle changes and medications. Fibromyalgia can be a chronic condition and as such sometimes difficult to treat. There is no magic bullet for fibromyalgia treatment. Much of the success in treatment depends on your motivation and persistence.

Let’s divide treatment options into non-pharmacological (ie no drugs) and pharmacological therapies.

 

Non-pharmacological treatment

I think this is the most important aspect of fibromyalgia treatment. Since we know that stress, poor sleep, and physical inactivity exacerbate fibromyalgia, no fibromyalgia treatment is complete without addressing all of these issues. Think of fibromyalgia as a lake, where each of these factors is a stream feeding into the lake. To dry up the lake, we must first take care of these streams.

 

Immobility, Stress, and Poor sleep are 3 streams that feed into the fibromyalgia lake.
Immobility, Stress, and Poor sleep are 3 streams that feed into the fibromyalgia lake.

 

  1. Improve your sleep

Refreshing sleep is helpful in reducing the pain of fibromyalgia. If you snore, you may have sleep apnea interrupting your sleep even if you don’t realize it. Restless leg syndrome is not uncommon in people with fibromyalgia. Having a sleep study may help diagnose these problems. If pain wakes you up at night, you can try Tylenol-PM before going to bed (if there are no contraindications).  Everyone, including people with fibromyalgia, needs good sleep hygiene. These are some important steps for good sleep hygiene:

  • Have a regular bed-time
  • Stop drinking caffeine at least 6 hours before going to bed
  • Lighten up dinner, and avoid eating 3 hours before bed time
  • Avoid vigorous physical activity or exercise close to your bed time
  • Make your bedroom a sanctuary for sleep. This means taking out EVERYTHING that is not related to sleep- including your TV. Your bed is your place for sleeping, not for talking on the phone, eating, watching TV, or talking on the phone.
  • Turn your clock away from you. If you cannot sleep, DO NOT check out the time!
  • Avoid taking naps during the day. This just makes you not be tired at night.

 

2.   Exercise!

Many people with fibromyalgia have a hard time exercising because of the pain. Other reasons for lack of exercise may include long work hours, busy family life, fatigue after a long day, etc.  However, exercise is one of the best treatments for fibromyalgia. Exercise helps tone and condition your muscles. In addition, it increases the levels of natural chemicals in the body that reduce pain and fatigue. People with fibromyalgia will need to start exercise lightly and build slowly over time. Expect some discomfort initially, but not pain. Most people with fibromyalgia find exercises in the water most tolerable, because water cushions the impact. Water-aerobics and Aquatherapy are excellent ways to start. Stretching and yoga are also very helpful. Other low-impact exercises include walking, biking, and Pilates. The goal is to exercise at least 30 minutes, 3 times per week.

 

3.  Reduce your stress

Relaxation techniques, Yoga and Tai-Chi may be very helpful in stress reduction and can significantly improve symptoms of fibromyalgia. Biofeedback and cognitive behavioral therapy are also two evidence-based modalities that have been successful in improvement of fibromyalgia symptoms. In biofeedback, persons with fibromyalgia gain awareness of their typically unconscious bodily responses to stress, such as breathing and heart rate, and learn to modify these responses to physical and emotional stress. The goal of cognitive behavioral therapy is to change the way a person thinks about (cognitive) and responds to (behavioral) their disease.

 

4.  Other therapies…

    • Acupuncture
    • Some studies have shown benefits of acupuncture in treatment of fibromyalgia pain.

 

Pharmacological treatment

Medications used in fibromyalgia:

  • Anticonvulsants: Gabapentin (Neurontin) and Pregabalin (Lyrica)

It is thought that these medications reduce pain by blocking certain chemicals that increase pain transmission.

 

  • Serotonin/Norepinephrine reuptake inhibitors: Duloxetine (Cymbalta) and Milnacipran (Savella)

These medications block the re-uptake of both serotonin and norepinephrine by nerve cell endings and can help with pain and fatigue.

 

  • Tricyclic antidepressants: Amitriptyline (Elavil), Nortriptyline (Pamelor)

The most common side effects are dry mouth and grogginess.

 

  • Selective serotonin reuptake inhibitors (SSRIs): Fluoxetine (Prozac), Paroxetine (Paxil), others

These are antidepressants that work by increasing serotonin levels in the brain and have been helpful in fibromyalgia.

 

  • Muscle relaxant: Cyclobenzaprine (Flexeril), Carisoprodol (Soma)

Usually used in combination, these drugs can help relieve muscle tension.

 

  • Other medications:

Nonsteroidal anti-inflammatory drugs (NSAIDs): Ibufprofen, Meloxicam, etc.

Topical analgesic creams and patches: Capsacin, Aspercreme, Voltaren gel, Flector patch, etc.

Analgesics: Tramadol (Ultram)

Opioids/narcotics: I usually do not recommend these medications for a chronic pain condition like fibromyalgia.

 

Also read:

 

What is fibromyalgia

 

Fibromyalgia- diagnosis

 

 

Reference:

American College of Rheumatology http://www.rheumatology.org/practice/clinical/patients/diseases_and_conditions/fibromyalgia.asp

Arthritis foundation  http://www.arthritis.org/

Uptodate http://www.uptodate.com/contents/fibromyalgia-beyond-the-basics?source=search_result&search=fibromyalgia+patient&selectedTitle=1%7E150

F Wolfe, DJ Clauw, MA Fitzcharles, DL Goldenberg, RS Katz, P Mease, AS Russell, J Russell, JB Winfield, MB Yunus. The American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity. Arthritis Care & Research,Vol. 62, No. 5, May 2010, pp 600–610

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