DOI: https://doi.org/10.22263/2312-4156.2017.6.7
Makarenko E.V.
Gout: modern principles of diagnosing and treatment
Vitebsk State Order of Peoples’ Friendship Medical University, Vitebsk, Republic of Belarus
Vestnik VGMU. 2017;16(6):7-22.
Abstract.
Gout is a systemic disease that occurs as a result of the deposition of sodium monourate crystals in tissues. The risk factors include hyperuricemia, genetic predisposition, age, male sex, overweight, dietary characteristics, alcohol consumption and other factors.
The clinical picture of gout includes asymptomatic hyperuricemia, acute gouty arthritis, intercritical period, and chronic tophaceous gout. The “gold standard” for the diagnosis is the identification of sodium monourate crystals in the synovial fluid or tophus aspirate using polarization microscopy. In addition, such imaging techniques as X-ray, ultrasound, computed tomography, magnetic resonance imaging and positron emission tomography are used.
The basic principles of managing patients with gout comprise arresting acute gout attacks, treatment of chronic gout and comorbidities, as well as the prevention of exacerbations. Treatment measures include adherence to diet, life style changes and the use of medicines to reduce serum uric acid levels to target values. This leads to the dissolution of sodium monourate crystals and prevents the exacerbation of the disease.
Key words: gout, prevalence, risk factors, diagnosis, classification criteria, treatment recommendations.
References
1. Neogi T. Gout. Ann Intern Med. 2016 Jul 5;165(1):ITC1-ITC16. doi: http://dx.doi.org/10.7326/AITC201607050
2. Newberry SJ, FitzGerald JD, Motala A, Booth M, Maglione MA, Han D, et al. Diagnosis of Gout: A Systematic Review in Support of an American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2017;166(1):27-36. doi: http://dx.doi.org/10.7326/M16-0462
3. Ragab G, Elshahaly M, Bardin T. Gout: An old disease in new perspective – A review. J Adv Res. 2017 Sep;8(5):495-511. doi: http://dx.doi.org/10.1016/j.jare.2017.04.008
4. Kuo CF, Grainge MJ, Zhang W, Doherty M. Global epidemiology of gout: prevalence, incidence and risk factors. Nat Rev Rheumatol. 2015 Nov;11(11):649-62. doi: http://dx.doi.org/10.1038/nrrheum.2015.91
5. Pascart T, Oehler E, Flipo RM. Gout in French Polynesia: a survey of common practices. Joint Bone Spine. 2014 Jul;81(4):374-5. doi: http://dx.doi.org/10.1016/j.jbspin.2013.12.007
6. Tu FY, Lin GT, Lee SS, Tung YC, Tu HP, Chiang HC. Prevalence of gout with comorbidity aggregations in southern Taiwan. Joint Bone Spine. 2015 Jan;82(1):45-51. doi: http://dx.doi.org/10.1016/j.jbspin.2014.07.002
7. Roddy E, Zhang W, Doherty M. The changing epidemiology of gout. Nat Clin Pract Rheumatol. 2007 Aug;3(8):443-9. doi: http://dx.doi.org/10.1038/ncprheum0556
8. Sicras-Mainar A, Navarro-Artieda R, Ibáñez-Nolla J. Resource use and economic impact of patients with gout: a multicenter, population-wide. Reumatol Clin. 2013 Mar-Apr;9(2):94-100. doi: http://dx.doi.org/10.1016/j.reuma.2012.06.014
9. Annemans L, Spaepen E, Gaskin M, Bonnemaire M, Malier V, Gilbert T, et al. Gout in the UK and Germany: prevalence, comorbidities and management in general practice 2000-2005. Ann Rheum Dis. 2008 Jul;67(7):960-6.
10. Zhu Y, Pandya BJ, Choi HK. Prevalence of gout and hyperuricemia in the US general population: the National Health and Nutrition Examination Survey 2007-2008. Arthritis Rheum. 2011 Oct;63(10):3136-41. doi: http://dx.doi.org/10.1002/art.30520
11. Li C, Martin BC, Cummins DF, Andrews LM, Frech-Tamas F, Yadao AM. Ambulatory resource utilization and cost for gout in United States. Am J Pharm Benefits. 2013 Mar-Apr;5(2):e46-e54.
12. Duskin-Bitan H, Cohen E, Goldberg E, Shochat T, Levi A, Garty M, et al. The degree of asymptomatic hyperuricemia and the risk of gout. A retrospective analysis of a large cohort. Clin Rheumatol. 2014 Apr;33(4):549-53. doi: http://dx.doi.org/10.1007/s10067-014-2520-7
13. Campion EW, Glynn RJ, DeLabry LO. Asymptomatic hyperuricemia. Risks and consequences in the Normative Aging Study. Am J Med. 1987 Mar;82(3):421-6.
14. Singh JA, Hodges JS, Toscano JP, Asch SM. Quality of care for gout in the US needs improvement. Arthritis Rheum. 2007 Jun;57(5):822-9. doi: http://dx.doi.org/10.1002/art.22767
15. Köttgen A, Albrecht E, Teumer A, Vitart V, Krumsiek J, Hundertmark C, et al. Genome-wide association analyses identify 18 new loci associated with serum urate concentrations. Nat Genet. 2013 Feb;45(2):145-54. doi: http://dx.doi.org/10.1038/ng.2500
16. Hak AE, Curhan GC, Grodstein F, Choi HK. Menopause, postmenopausal hormone use and risk of incident gout. Ann Rheum Dis. 2010 Jul;69(7):1305-9. doi: http://dx.doi.org/10.1136/ard.2009.109884
17. Choi HK, Atkinson K, Karlson EW, Curhan G. Obesity, weight change, hypertension, diuretic use, and risk of gout in men: the Health Professionals Follow-up Study. Arch Intern Med. 2005 Apr 11;165(7):742-8. doi: http://dx.doi.org/10.1001/archinte.165.7.742
18. Zhu Y, Zhang Y, Choi HK. The serum urate-lowering impact of weight loss among men with a high cardiovascular risk profile: the Multiple Risk Factor Intervention Trial. Rheumatology (Oxford). 2010 Dec;49(12):2391-9. doi: http://dx.doi.org/10.1093/rheumatology/keq256
19. Choi HK, Atkinson K, Karlson EW, Willett W, Curhan G. Purine-rich foods, dairy and protein intake, and the risk of gout in men. N Engl J Med. 2004 Mar;350(11):1093-103. doi: http://dx.doi.org/10.1056/NEJMoa035700
20. Choi HK, Curhan G. Coffee consumption and risk of incident gout in women: the Nurses' Health Study. Am J Clin Nutr. 2010 Oct; 92(4): 922–927. doi: http://dx.doi.org/10.3945/ajcn.2010.29565
21. Bruderer S, Bodmer M, Jick SS, Meier CR. Use of diuretics and risk of incident gout: a population-based case-control study. Arthritis Rheumatol. 2014 Jan;66(1):185-96. doi: http://dx.doi.org/10.1002/art.38203
22. Choi HK, Soriano LC, Zhang Y, Rodríguez LA. Antihypertensive drugs and risk of incident gout among patients with hypertension: population based case-control study. BMJ. 2012 Jan;344:d8190. doi: http://dx.doi.org/10.1136/bmj.d8190
23. Stamp L, Searle M, O'Donnell J, Chapman P. Gout in solid organ transplantation: a challenging clinical problem. Drugs. 2005;65(18):2593-611.
24. Johnson RJ, Nakagawa T, Jalal D, Sánchez-Lozada LG, Kang DH, Ritz E. Uric acid and chronic kidney disease: which is chasing which? Nephrol Dial Transplant. 2013 Sep;28(9):2221-8. doi: http://dx.doi.org/10.1093/ndt/gft029
25. Goicoechea M, de Vinuesa SG, Verdalles U, Ruiz-Caro C, Ampuero J, Rincón A, et al. Effect of allopurinol in chronic kidney disease progression and cardiovascular risk. Clin J Am Soc Nephrol. 2010 Aug;5(8):1388-93. doi: http://dx.doi.org/10.2215/CJN.01580210
26. Sircar D, Chatterjee S, Waikhom R, Golay V, Raychaudhury A, Chatterjee S, et al. Efficacy of Febuxostat for Slowing the GFR Decline in Patients With CKD and Asymptomatic Hyperuricemia: A 6-Month, Double-Blind, Randomized, Placebo-Controlled Trial. Am J Kidney Dis. 2015 Dec;66(6):945-50. doi: http://dx.doi.org/10.1053/j.ajkd.2015.05.017
27. Zhu Y, Pandya BJ, Choi HK. Comorbidities of gout and hyperuricemia in the US general population: NHANES 2007-2008. Am J Med. 2012 Jul;125(7):679-687.e1. doi: http://dx.doi.org/10.1016/j.amjmed.2011.09.033
28. McAdams-DeMarco MA, Maynard JW, Coresh J, Baer AN. Anemia and the onset of gout in a population-based cohort of adults: Atherosclerosis Risk in Communities study. Arthritis Res Ther. 2012;14(4):R193. doi: http://dx.doi.org/10.1186/ar4026
29. Mariani LH, Berns JS. The renal manifestations of thyroid disease. J Am Soc Nephrol. 2012 Jan;23(1):22-6. doi: http://dx.doi.org/10.1681/ASN.2010070766
30. Martillo MA, Nazzal L, Crittenden DB. The crystallization of monosodium urate. Curr Rheumatol Rep. 2014 Feb;16(2):400. doi: http://dx.doi.org/10.1007/s11926-013-0400-9
31. Wilcox WR, Khalaf AA. Nucleation of monosodium urate crystals. Ann Rheum Dis. 1975 Aug;34(4):332-9.
32. Barskova VG. Diagnosis of gouty arthritis. Rus Med Zhurn. 2011;19(1):614-7. (In Russ.)
33. Choi HK, Niu J, Neogi T, Chen CA, Chaisson C, Hunter D, et al. Nocturnal risk of gout flares. Arthritis Rheumatol. 2015 Feb;67(2):555-62. doi: http://dx.doi.org/10.1002/art.38917
34. Neogi T, Jansen TL, Dalbeth N, Fransen J, Schumacher HR, Berendsen D, et al. 2015 Gout Classification Criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Ann Rheum Dis. 2015 Oct;74(10):1789-98. doi: http://dx.doi.org/10.1136/annrheumdis-2015-208237
35. Dalbeth N, Pool B, Gamble GD, Smith T, Callon KE, McQueen FM, et al. Cellular characterization of the gouty tophus: a quantitative analysis. Arthritis Rheum. 2010 May;62(5):1549-56. doi: http://dx.doi.org/10.1002/art.27356
36. Schlesinger N, Norquist JM, Watson DJ. Serum urate during acute gout. J Rheumatol. 2009 Jun;36(6):1287-9. doi: http://dx.doi.org/10.3899/jrheum.080938
37. Rettenbacher T, Ennemoser S, Weirich H, Ulmer H, Hartig F, Klotz W, et al. Diagnostic imaging of gout: comparison of high-resolution US versus conventional X-ray. Eur Radiol. 2008 Mar;18(3):621-30. doi: http://dx.doi.org/10.1007/s00330-007-0802-z
38. Gentili A. The advanced imaging of gouty tophi. Curr Rheumatol Rep. 2006 Jun;8(3):231-5.
39. Omoumi P, Zufferey P, Malghem J, So A. Imaging in gout and other crystalrelated arthropathies. Rheum Dis Clin North Am. 2016 Nov;42(4):621-644. doi: http://dx.doi.org/10.1016/j.rdc.2016.07.005
40. Choi HK, Gao X, Curhan G. Vitamin C intake and the risk of gout in men: a prospective study. Arch Intern Med. 2009 Mar;169(5):502-7. doi: http://dx.doi.org/10.1001/archinternmed.2008.606
41. Towiwat P, Li ZG. The association of vitamin C, alcohol, coffee, tea, milk and yogurt with uric acid and gout. Int J Rheum Dis. 2015 Jun;18(5):495-501. doi: http://dx.doi.org/10.1111/1756-185X.12622
42. Zhang Y, Neogi T, Chen C, Chaisson C, Hunter DJ, Choi HK. Cherry consumption and decreased risk of recurrent gout attacks. Arthritis Rheum. 2012 Dec;64(12):4004-11. doi: http://dx.doi.org/10.1002/art.34677
43. Khanna D, Fitzgerald JD, Khanna PP, Bae S, Singh MK, Neogi T, et al. 2012 American College of Rheumatology guidelines for management of gout. Part 1: systematic nonpharmacologic and pharmacologic therapeutic approaches to hyperuricemia. Arthritis Care Res (Hoboken). 2012 Oct;64(10):1431-46. doi: http://dx.doi.org/10.1002/acr.21772
44. Perez-Ruiz F, Atxotegi J, Hernando I, Calabozo M, Nolla JM. Using serum urate levels to determine the period free of gouty symptoms after withdrawal of long-term urate-lowering therapy: a prospective study. Arthritis Rheum. 2006 Oct 15;55(5):786-90. doi: http://dx.doi.org/10.1002/art.22232
45. Becker MA, Schumacher HR, Espinoza LR, Wells AF, MacDonald P, Lloyd E, et al. The urate-lowering efficacy and safety of febuxostat in the treatment of the hyperuricemia of gout: the CONFIRMS trial. Arthritis Res Ther. 2010;12(2):R63. doi: http://dx.doi.org/10.1186/ar2978
46. Khanna D, Khanna PP, Fitzgerald JD, Singh MK, Bae S, Neogi T, et al. 2012 American College of Rheumatology guidelines for management of gout. Part 2: therapy and antiinflammatory prophylaxis of acute gouty arthritis. Arthritis Care Res (Hoboken). 2012 Oct;64(10):1447-61. doi: http://dx.doi.org/10.1002/acr.21773
47. Terkeltaub RA, Furst DE, Bennett K, Kook KA, Crockett RS, Davis MW. High versus low dosing of oral colchicines for early acute gout flare: Twenty-four-hour outcome of the first multicenter, randomized, double-blind, placebo-controlled, parallel-group, dose-comparison colchicines study. Arthritis Rheum. 2010 Apr;62(4):1060-8. doi: http://dx.doi.org/10.1002/art.27327
48. Richette P, Doherty M, Pascual E, Barskova V, Becce F, Castañeda-Sanabria J, et al. 2016 updated EULAR evidence-based recommendations for the management of gout. Ann Rheum Dis. 2017 Jan;76(1):29-42. doi: http://dx.doi.org/10.1136/annrheumdis-2016-209707
Information about authors:
Makarenko E.V. – Doctor of Medical Sciences, professor of the Chair of Internal Medicine No. 2 of the Faculty for Advanced Training & Retraining, Vitebsk State Order of Peoples’ Friendship Medical University.
Correspondence address: Republic of Belarus, 210023, Vitebsk, 27 Frunze ave., Vitebsk State Order of Peoples’ Friendship Medical University, Chair of Internal Medicine No. 2 of the Faculty for Advanced Training & Retraining. E-mail: Этот адрес электронной почты защищён от спам-ботов. У вас должен быть включен JavaScript для просмотра. – Elena V. Makarenko.