Arthritis gout knee

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit

Gouty arthritis is a metabolic disease characterized by deposits of monosodium urate in the joints and other tissues. The disorder causes painful arthritis, most commonly in the joints of the feet and legs.

Gout is caused by a defect in purine metabolism that results in an overproduction of uric acid or a reduced ability of the kidney to eliminate uric acid. The exact cause of the metabolic defect is unknown. The condition is associated with diseases such as diabetes, obesity, sickle cell anemia, hyperlipidemia, hypertension, and kidney disease, or it may follow drug therapy that interferes with uric acid excretion (eg. chemotherapy).

Gout occurs in 4 stages: asymptomatic (without symptoms), acute, intercritical, and chronic.

In acute gouty arthritis, symptoms develop suddenly and usually involve only one or a few joints. The pain frequently starts during the night and is often described as throbbing, crushing, or excruciating. In other words… very painful! The joint appears inflamed with signs of warmth, redness, and tenderness.

The attacks of painful joints may subside in several days, but may reoccur at irregular intervals. Subsequent attacks usually have a longer duration. Some people may progress to chronic gouty arthritis, while others may have no further attacks.

The risk is greater in men, postmenopausal women, and people who drink excessive amounts of alcohol.

Symptoms include the following:

Joint pain which begins suddenly and affects one or more joints (hip, knee, ankle, foot, shoulder, elbow, wrist, hand, or other joints). The big toe, knee, or ankle joints are most often affected.

Joint swelling and stiffness of the affected joints occur as do warmth and redness. Fever may be present.

Skin lumps, called tophi, may develop. Tophi are collections of monosodium urate crystals, fibrin, and inflammatory cells.

Physical examination of the joints shows acute arthritis. Aspiration of synovial fluid from an inflamed joint is the most definitive diagnostic procedure. Examination of synovial fluid shows uric acid crystals. The uric acid in the blood may also be elevated. However, during an acute attack, the serum uric acid can be normal.

It is critical to inspect the joint fluid carefully . Pseudogout, another crystal-induced form of arthritis, can mimic gout and the treatment is very different. Pseudogout is due to crystals of calcium pyrophosphate. Pseudogout is particularly common in the knee. X-rays may show calcification in the menisci of the knee.

Joint X-rays may be normal.

The goals of treatment are mainly to stop the pain and inflammation associated with the initial attack, and to prevent future attacks.

Colchicine is one of the medications that is effective in reducing the pain, swelling, and inflammation associated with acute gout attacks. The pain often subsides within 12 hours of starting treatment, and is completely relieved in 48 hours.

The medication works by decreasing the inflammation caused by uric acid crystals within the joint. However, it does not decrease the uric acid levels in the bloodstream. The only preparation available now is Colchrys. It is fairly expensive.

Non-steroidal anti-inflammatory drugs (NSAIDs) can be very effective in treating the pain and inflammation of an acute gout attack if taken soon after symptoms start.

Corticosteroids can also be very effective. They may be taken by mouth or injected directly into an inflamed joint.

Codeine or other analgesics may occasionally be prescribed for pain relief. Increased fluid intake prevents the formation of kidney stones.

Sometimes, a diet low in purines is prescribed. Organ meats, beer, wine, and certain types of fish contain high levels of purines.

If not treated, the acute form of the disease may progress to chronic disease. Since uric acid is normally eliminated by the kidneys, chronic gout may lead to formation of uric acid kidney stones.

Complications from gout are related to the following:

• Side effects of medications
• Chronic gouty arthritis
• Kidney stones
• Kidney dysfunction

Some precipitating factors may include trauma, alcohol consumption, and dietary purines.

Uric acid lowering therapies such as allopurinol, febuxostat (Uloric), and probenecid are the drugs that are most commonly prescribed. For patients with tophaceous gout, Krystexxa is an intravenous drug that helps with this problem.

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