- Who most often suffers from gout?
- The main cause of gout
- What happens in the joint?
- Classification of gout
- Diagnosis of gout
- What diseases can be taken for gout?
- Treatment of gout
- Medication Therapy
- Diet for gout
- Lifestyle of the patient with gout
- Pyrophosphate arthropathy
Gout - a systemic, that is, affecting the whole body, a disease in which crystals of salt of uric acid - sodium monourate are deposited in various tissues. In this case (in the presence of provoking factors) in patients with elevated levels of uric acid in the blood serum inflammation of the joints develops.
Who most often suffers from gout?
It is believed that the classic portrait of a patient with gout is a large middle-aged man, wealthy enough to regularly eat good red wine and young meat. I remember English kings and dukes, our compatriots - the emperors Peter I and Anna Ioannovna. But research convincingly proves: the incidence of gout is determined not only by the diet and well-being of patients. It is estimated that at least 3% of the adult population of the world suffer from this ailment. What is true, then the truth: men suffer from gout at times more often: one woman receiving treatment for gout, there are 7 men with this disease. The disease begins in men much earlier: at the 40-year limit, while the peak incidence of gout among women falls to the age of over 60 years. It is believed that this is due to the natural level of hormones that promote the excretion of uric acid from the body, and protect the female body from a variety of different troubles.
The main cause of gout
It has long been determined that the main cause of gout is hyperuricemia - an increase in the level of uric acid in the serum. This happens if:
- the patient has an increased body weight. As is known, the causes of obesity (leading to an increase in the level of uric acid) - is a change in the composition of food and nutrition culture, with the ubiquitous "dominance" of simple carbohydrates, sweet drinks, the predominance of sedentary lifestyles;
- concomitant diagnosis - hypertensive disease;
- the patient suffers from a disease accompanied by hyperuricemia (eg, psoriasis);
- the patient often takes alcohol;
- there is a genetic predisposition to increased production of uric acid or a reduced rate of its excretion (such conditions are rare and usually occur at a young age - up to 30 years);
- the patient "abuses" products containing a large number of compounds and precursors of salts of uric acid. Traditionally, they include, besides "red" meat (beef, veal, lamb, rabbit), also by-products (liver, kidneys, heart, tongue) and broths from them. From fish products, tuna, anchovies, trout, squid, mussels and herring fall into the "risk zone", turkey and goose from poultry. Dangerous in terms of development of gout, all kinds of smoked meat, sausages, sausage, ham, eggs, especially fried. Not at all harmless are all legumes, whole grains, mushrooms, cauliflower, spinach, asparagus, coffee, chocolate, and even, according to some authors, ice cream and pastries. Old doctors called gout - "disease of kings", "disease of abundance";
- in connection with the concomitant diseases prescribed drugs that have the side effect of increasing the concentration of uric acid. Determine whether the drug increases the level of uric acid, it is quite simple: just look at the instructions for the use of the drug. More often than others, hyperuricemia is caused by anticancer drugs, diuretics (diuretics) and beta-blockers (a group of drugs used to treat hypertension). If the patient receives treatment from an oncologist, then drugs aimed at reducing uric acid are usually prescribed "automatically", and the development of gout in this group of patients can be avoided. With the rest of the drugs, things are much more complicated. One of the most "popular" among domestic therapists diuretics is furosemide. This drug acts quickly and powerfully, producing a diuretic effect, in connection with which its appointment for a long period is not recommended. Nevertheless, it is not uncommon for patients to take furosemide for several months or even years, as prescribed by the therapist or, more often, at their own will. Against the backdrop of this "treatment" gout develops with characteristic signs and possible rather serious complications.
A little more about uric acid
If the concentration of this substance in the blood exceeds the permissible limits (more than 320 μmol / l), a complex chemical reaction is triggered, and crystals begin to form from the acid, in the people they are also called "sand". It is these crystals, deposited in the joints, skin cells and other organs, and cause gout - "disease of kings".
What happens in the joint?
Pain in the joints arises not so much from the "mechanical trauma" of the crystals of the surrounding tissues as from the penetration into the joint and the production of a huge amount of "inflammatory substances" directly in it. That is, the cause of pain in gouty attacks is not mechanical (acute crystals), but chemical (irritants). Attracted by "inflammatory substances" (they are called mediators of inflammation), immune cells penetrate into the joint, which, on the one hand, produce even more mediators; on the other, they begin to destroy their own joint structures, accepting them for "attacking foreign agents." This is a brief description of the development of an autoimmune reaction in gouty arthritis.
Classification of gout
At present, it is common to distinguish acute gouty arthritis, interictal period and chronic gout.
1. Acute gouty arthritis
This is the main clinical, that is, visible to the eye, the manifestation of gout. It is believed that acute gouty arthritis, or gouty - one of the most painful conditions in rheumatology. Symptoms of a gouty attack are so vivid that they were at one time the inspirers of artists to create masterpieces that survived the centuries. Pain in gouty attacks occurs at night or in the early hours, and is so strong that the patient is not able not only to move his foot, but even a slight touch of the sheet causes unbearable anguish. Without treatment, acute gouty arthritis lasts no more than 10 days, but in almost 100% of cases, patients still seek medical help. Most often, patients get to see surgeons complaining of pain similar to drilling, raspryaniyu, burning in the first (large) toe, and the classic "folk" painkillers like analgin to the patient does not help. Trying to take a warm foot bath only intensifies the suffering.
In search of an effective analgesic, both patients and surgeons are often able to make a lot of mistakes, starting with the appointment of unimaginable combinations of analgesics in huge doses, ending with the use of antibiotics and local (cutaneous) agents (gels, ointments) - ineffective, but costly. True gout in everyday practice is not so common, but many doctors have the idea that allopurinol is treated with this ailment (we will talk about this a little later). But the fact that it is absolutely impossible to prescribe allopurinol in the acute period of the disease is usually forgotten. Moreover, allopurinol is able to aggravate the course of a gouty attack, and if the patient has already taken this drug at the time of exacerbation, it should be abolished as soon as possible for the entire "painful" period.
Another common mistake in the treatment of acute gouty attacks is the patient's refusal to eat. As is known, most often the "gouty attack" is provoked precisely by the error in the diet. In search of relief, the patient is ready to switch to "bread and water", or even starve, just to get rid of the pain. This is fundamentally wrong, and can adversely affect both the general condition of the patient, and the work of the kidneys, the heart.
Wishing to save the patient from suffering as soon as possible, physicians often prescribe physiotherapy (UHF, magnetotherapy, thermal procedures), not taking into account the almost total uselessness, and sometimes the harm of such tactics during an attack.
2. Interictal disease period
Gout leads to an attack on the body gradually. It is a mistake to believe that this problem is limited to joints. Urat crystals - the smallest needles - are deposited in many organs, primarily in the kidneys, forming stones, disrupting the work of these vital organs. The patient may be disturbed by renal colic, manifested by pain in the lower back, abdominal pain, vomiting, pain and rezi when urinating. Sometimes the severity of pain is such that it requires hospitalization, or surgery to remove the stones. With insufficient treatment and accumulation of uric acid and its salts, the disease goes so far that the heart is affected, with the development of heart failure.
3. Chronic tofusny gout
Tofusi are soft formations, tubercles, "bumps", filled with urate crystals. Most often, the tofus are located on the back (external) surface of the fingers, the auricle, elbows, knees. But tophi can be hidden, that is, located inside the body: in the region of the joints, for example. Such "depots" of crystals can not be seen without additional methods of examination - radiography and ultrasound.
Diagnosis of gout
The diagnosis of gout is based on three pillars: examining the patient and talking to him, laboratory and instrumental methods of research.
The classic picture of gouty attack is painful when palpating, red sometimes to blue, hot, swollen large (first) toe. The patient may notice an increase in body temperature, chills. Almost half the time, the first gouty attack becomes the last, but in the remaining 50% of cases the course of the disease becomes chronic. With such a long process and repeated attacks, there are problems from other joints: the thumb of the second leg, the ankle, knee joints, the joints of the brushes. The polyarthritis (inflammation of many joints) develops.
Interestingly, in recent years, there has been an increasing departure from this classic, so juicy described in the literature, pictures. Increasingly, gout occurs with an initially large number of affected joints. In addition, over the past 20 years, many patients have gout from the first days of a protracted nature, the aggravation of the disease again and again, and the pain is still intense, regardless of the number of seizures.
The blood test is general clinical (mainly an increase in the rate of erythrocyte sedimentation (ESR), a sign of inflammation, and an increase in the level of leukocytes) and biochemical (an increase in uric acid is detected, and signs of concomitant diseases - diabetes, liver diseases, kidney failure, etc.) . It should be remembered that the concentration of uric acid in the blood serum, which is determined by biochemical analysis, at the time of an attack can be normal!
Examination of the joint (synovial) fluid . This procedure can be quite unpleasant, but it is as a result of an articular puncture (puncture) that the doctor will be able to obtain with sufficient accuracy the answer to the question: "What exactly happened?" The joint puncture significantly alleviates the patient's condition, because, firstly, from the joint removes excess fluid, causing a sense of pressure from within and containing a large number of "inflammatory substances." Secondly, in the articular cavity, in the absence of contraindications, a medicinal preparation that rapidly removes signs of inflammation is introduced. The resulting liquid is collected in a test tube and sent to a laboratory for analysis and microscopy. If crystals of monoaurate of sodium of characteristic sizes and shapes are found, the diagnosis can be considered "in the pocket".
Analysis of the contents of tofus . If there are soft formations accessible for examination and taking material (like bubbles or warts), usually a rheumatologist tries to get their contents for analysis. When viewed with the naked eye, what stands out from tofus, resembles cottage cheese remotely, and with microscopy the same crystals are found as in the synovial fluid.
Radiography . The radiologist can answer the following questions: are we dealing with a gout? If so, how far did the disease go? Is there another pathology of the joints, against which gout was played?
Ultrasound examination of joints . In the case of gout, this is a much less informative way than radiography. Currently, new methods are being developed that could help determine the presence of deposits of uric acid crystals in the joints. In the meantime, the ultrasound doctor can only determine whether arthritis really does take place, how much fluid is in the joint, and whether we can take it for analysis, whether there are traumatic injuries of soft joint tissues that could "disguise" under a gouty attack.
What diseases can be taken for gout?
What other diseases occur according to a scenario similar to gout? Especially this information will be useful to those who are accustomed to making a diagnosis, using directories or information from the Internet.
- septic (purulent) arthritis . This condition can be preceded by any cutaneous or "general" infection, trauma or microtrauma of soft tissues around the joint. Almost always septic arthritis is accompanied by an increase in body temperature. The diagnosis is refined with the help of the same articular puncture, and already by the appearance of the received fluid the doctor will make a preliminary conclusion about the diagnosis.
- pyrophosphate arthropathy (it will be discussed below);
- reactive arthritis . This disease is a response to the presence of any pathogens in the body, and is treated, respectively, together - by a rheumatologist and infectious disease specialist.
- rheumatoid arthritis is a chronic autoimmune disease of an unknown nature, affecting mainly women, unlike gout;
- osteoarthritis (often combined with gout);
- psoriatic arthritis (inflammation of the joints in combination with skin disease - psoriasis).
Treatment of gout
It is accepted to share non-drug (non-drug) and drug treatment.
Non-drug treatment includes dietotherapy, the use of orthopedic drugs and joint relief, as well as lifestyle adjustments. Not every patient, accustomed to not limiting himself in nutrition, passive leisure, or traveling by private transport, is ready to change habits for his own health. And, nevertheless, it is extremely important to adjust the patient to the implementation of recommendations, which, in fact, are half the success.
Treatment of gout has two main directions: reducing pain during the gouty attack and reducing the risk or completely preventing new attacks by reducing the deposition of urate salts. To achieve this goal, anti-inflammatory and anti-hyperuricemic (that is, directed against increasing the concentration of uric acid in the blood) are used.
- Non-steroidal anti-inflammatory drugs
The undoubted advantages of this group of drugs are that they start to act quickly, and exactly where it is required - in the inflamed joint. It is very important to remember that increasing the dose does not necessarily lead to a greater effect. The anti-inflammatory effect will remain the same, but the harm from such "tactics" will be much greater, because with the increase in the dose the probability of development and the severity of side effects increase. The most effective and safe in this group, according to international studies, is etorikoksib, he is also arkoksia.
Another plus of non-steroidal anti-inflammatory drugs is the ability to penetrate the central nervous system. What is it for? The fact is that if a person experiences pain in remote areas of the body, then the signal about this immediately enters the brain and can enhance the subjective sensation of pain, and, therefore, multiply the sufferings of the patient. Further, the "cascade" reacts to pain: heart palpitations, vasoconstriction, release of stress hormones, elevation of blood pressure ... The use of non-steroid medications helps to reduce or prevent these effects.
This medicine is rarely used today, although its effectiveness in gout is unquestionable. In most patients, it causes stool disorder and nausea, a sense of metallic taste in the mouth. Nevertheless, his appointment is resorted to, if for any reason the reception of non-steroidal anti-inflammatory drugs becomes impossible. It is important that severe damage to the kidneys, heart, liver and mucous membrane of the gastrointestinal tract - strict contraindications to the appointment of colchicine.
The appointment of this group of drugs is a difficult and responsible decision. Preparations of steroid hormones, or steroids (prednisolone, metipred) are prescribed in cases when non-steroidal anti-inflammatory drugs do not help, and colchicine is either ineffective or unavailable. In the treatment of steroids, such careful monitoring of the patient's condition is required, that the doctor often thinks ten times what will assign these effective, but not very indifferent to the body means. Among the side effects (they are also called undesirable), the effects of such therapy are called increasing blood pressure, increasing blood glucose, a tendency to bleed, the risk of damage to small vessels of the eye, ulcers of the gastrointestinal tract ... and this is not a complete list. Recall that gout more often affects patients who are obese, who initially enter the risk group for many of the conditions listed above, multiply this by the side effects of steroids and get a pretty sad, in terms of prognosis, picture.
- Decreased uric acid levels
For this purpose, well-known allopurinol is used. Sometimes patients who "put" themselves a diagnosis with the help of neighbors or the Internet, independently start taking this drug. It should be noted that the dosage is selected individually, small doses are often ineffective, while the patient does not prescribe a large dose ... That is why the treatment with allopurinol should be carried out under medical supervision. So, allopurinol is prescribed:
- with frequent attacks (at least 1 time in 3 months);
- with an increase in the level of uric acid and concomitant damage to the joints;
- with serious deviations in the work of the kidneys;
- when there are kidney stones;
- when depositing uric acid crystals in soft tissues;
- when treating with antitumor drugs.
Diet for gout
Products that contribute to the occurrence of gout, have already been mentioned. What can you eat and drink to a patient with a gout or high uric acid in the interictal period?
From the first dishes you can recommend vegetarian soups, such as borsch or vegetable or potato. Meat, as already mentioned, is strictly limited - it's a chicken or a duck. Permissible "lean" varieties of fish (cod, pollock), not more than 3 times a week, in a moderate amount (maximum 200 g per reception). Whole milk is not recommended, you should give preference to lactic acid foods (kefir, cottage cheese, fermented baked milk, young cheeses). As a side dish, boldly choose any cereal or pasta, bread is not limited (within reason, remember the danger of excess weight!).
Vegetables and fruits, except raspberries, spinach and cauliflower, are allowed all, preferably in boiled or raw form, fried - not welcome. It is allowed to take in food any nuts and dried fruits, from sweets you can treat yourself to honey, molasses, pastille, nuts. It is useful to add enough olive oil to food.
From drinks are allowed a weak green tea, juices, fruit drinks, compotes. Ideally, such a diet should be followed not only during an attack of gout, but also throughout the illness, while there is an increase in the level of uric acid in the blood.
Lifestyle of the patient with gout
After eliminating the pain syndrome, the doctor must make sure that the level of uric acid remains safe for the patient, and the dosage of allopurinol is selected correctly. For this purpose, the level of uric acid is regularly determined using a biochemical blood test. At the beginning of treatment it is necessary to do this every 2-4 weeks, then every 6 months. If the optimal dose of medicine is selected, the patient follows a diet, returns to physical exercises, does not face gout attacks, does not need to take painkillers and anti-inflammatory drugs, the dose of allopurinol can be slowly reduced under the supervision of a doctor. Practice shows that it is possible to completely abolish it quite rarely. Unfortunately, in the overwhelming majority of cases, patients who have abolished allopurinol are forced to return to it after a second gouty attack.
Almost all patients with gout survive to advanced years, suffering more from concomitant diseases than from joint pain. But it is also known that almost half develop nephrolithiasis (kidney stones), and kidney failure.
As already mentioned, gout refers to a group of diseases caused by impaired calcium metabolism in the body. The same group includes the disease associated with deposits of calcium pyrophosphate salts, or pyrophosphate arthropathy. These two diseases are so similar that they are treated as one large section - crystalline arthropathies.
This disease is equally common in women and men of advanced age, and among patients older than 85 years, according to research, half have this pathology. The disease occurs under the guise of osteoarthritis, gout or rheumatoid arthritis.
Usually the development of pyrophosphate arthropathy is accompanied or preceded by any chronic disease (eg, diabetes, thyroid disease) or the patient has ever suffered a joint injury.
When an elderly patient appeals with pain complaints more often in large joints (most often knee joints), the doctor will firstly appoint a radiograph. If a "double line" of the joint space is found on the X-ray, the so-called phenomenon of chondrocalcinosis. In addition, the proof of the diagnosis of pyrophosphate arthropathy is the detection of special crystals when examining the joint fluid under a microscope. If the joint is inflamed, then this fluid, as in the case of gout, is obtained by puncturing the joint with a syringe. Further, it is only the laboratory. If the articular fluid for analysis can not be obtained, this can significantly complicate the diagnosis.
To treat or not to treat?
Pyrophosphate arthropathy, discovered by chance (for example, during radiography) is not treated, if there are no symptoms of inflammation of the joints. If there is arthritis (ie, swelling, redness, changes in skin temperature over the joint), and all other reasons for the appearance of these signs are excluded, excess fluid from the joint is removed with a syringe, then steroids are injected into the joint and cold applications (bandages) are applied. Further, course treatment with non-steroidal anti-inflammatory drugs is prescribed. Short courses of steroid hormones or colchicine are rarely prescribed. And of course, the main role is played by the treatment of concomitant diseases, which caused the deposition of crystals in the joints. Important also non-medicinal methods, such as physiotherapy exercises, physiotherapy, more often with the use of cold (in the absence of contraindications), wearing orthosis and others.