Gout - acute gouty arthritis and its treatment options

1.General information

For many people, the diagnosis of gout is associated primarily with joint disease. Less known is the fact that gout is almost always (more than 80% of cases) caused by an increased level of uric acid in the blood (hyperuricemia) and is accompanied by simultaneous kidney damage. Relative to the latter trend, estimates of occurrence vary widely (30–80%); some authors even estimate this connection as one hundred percent.

One way or another, gouty kidney, or urate nephropathy, which is a more precise and correct term, is a very common type of kidney pathology, given that up to 2% of the world's population suffers from gout.

It is known that gout affects men several times more often than women, and it usually begins at the age of 25-35 (in women, during menopause; in addition, occasionally a hereditary juvenile form occurs in men). And although the etiopathogenetic mechanisms of the development of gout, damage to the joints and internal organs in this serious illness remain the subject of intensive scientific research, the connection with urolithiasis, kidney dysfunction and, ultimately, with renal failure

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Gout - acute gouty arthritis and its treatment options

P

odagra is the most common and well-known disease from the group of microcrystalline arthritis, which is characterized by the loss of crystals into the synovial fluid, their impregnation of articular and periarticular tissues, and the development of synovitis.

Domestic and foreign literature provides data indicating an increase in the incidence of gout in the last 20 years and an unequal incidence of gout in the population - from 0.05% to 1%.
The ratio of men to women (fertile age) is 19:1. Gout is a chronic disease associated with impaired uric acid metabolism.

, clinically manifested by recurrent arthritis, the formation of gouty nodes (tophi) and damage to internal organs.

According to the ICD X revision, the heading “gout” (M10) includes:

• Idiopathic gout (M10.0)
• Lead gout (M10.1)
• Drug-induced gout (M10.2)
• Gout due to impaired renal function (M10.3)

Other crystalline arthropathy (M11) is divided into hereditary, idiopathic and arthropathy due to other diseases (Table 1).

The first classic description of gouty arthritis, “Treatise on Gout,” belongs to the largest English clinician of the 17th century, Th. Sydenham, who compared the pain of gout to the pain “from pinching a limb with a press.”

Later, Yarrod (1883), using a thread dipped into the blood of a gout patient, discovered the fact of an increase in the level of uric acid in the blood. In 1899, urate crystals were discovered in the joint fluid during an attack of gouty arthritis, but it was not until 1961 that MacCarty and Hollander established the role of urate crystals in the development of gouty inflammation.

It is customary to count the onset of gout from the first attack of arthritis, which marks the beginning of intermittent gout

. It is characterized by alternating acute attacks and remissions; During the latter, the person feels completely healthy. Several years may pass between the first and repeated attacks, but more often they recur 1-2 times a year. As the disease progresses, the “light intervals” between attacks become shorter.

In typical cases (50–65%), the first metatarsophalangeal joint is affected with the development of acute monoarthritis. The characteristic localization of gout may be due to the fact that it is in these joints that degenerative-dystrophic changes in cartilage occur earlier and most often, which predisposes to urate deposition. In 15–20%, gout debuts with damage to other joints of the legs: II–IV metatarsophalangeal, ankle, knee and, as an exception, joints of the hands (hence the name of the disease, which in Greek means “foot trap” - podos - foot, leg; argo – trap). In 5% of cases, a polyarticular onset of the disease is observed.

The clinical picture of an acute attack of gout has the following characteristic features:

• a joint attack can begin suddenly
  , at any time of the day, but
  more often at night or early in the morning
  (presumably, at rest, when tissue hydration and the rate of diffusion of urates from the synovial fluid into the plasma decrease, a supersaturation of the joint fluid with uric acid may occur);
• characterized by an extremely high intensity of pain
  (in the Treatise on Gout, the famous former researcher Sydenham, who himself suffered from this disease, described his sensations during an acute attack:
  “The pain seems to twist, then tear ligaments, then bite and gnaw bones, like dog..."
  ; the pain syndrome is so pronounced that the touch of a sheet to the affected joint is unbearable (the “sheet” symptom);
• rapid increase in local symptoms of inflammation
  , reaching a maximum after a few hours; swelling of the joint area and hyperemia of the skin over it can be so pronounced that they resemble phlegmon;
• significant restriction of movement
  in the affected joint;
• complete spontaneous reversal of symptoms
  after 3–7–10 days.

There are two classical approaches to treating an acute attack of gout. On the one hand, the early administration of large therapeutic doses of non-steroidal anti-inflammatory drugs, on the other hand, the use of colchicine (Table 2). It should be noted that there are a significant number of side effects when using colchicine, which sharply limits the frequency of its use.

It is difficult to find a disease that has so many artistic descriptions: “the disease of kings,” “the pirate disease,” “a drop of poison,” reflecting the unbearable suffering of the sick. This is precisely what requires the rapid and mandatory prescription of NSAIDs to relieve an acute attack. Numerous data have already been accumulated on the use of diclofenac sodium salt for gout.

We present the results of using the potassium salt of diclofenac for the relief of acute gouty arthritis.

For this purpose, Rapten Rapid

(pharmaceutical) in a dose of 50 mg 2 times a day for 7 days to patients with an acute attack of gout. 30 patients (men) were examined. The average age of the patients was 48±7.8 years. It should be noted that an acute attack of gout occurred as monoarthritis with localization in the ankle joint in 13 people, in the metatarsophalangeal joint in 9 people, in the knee in 5, in the elbow in 3 people, and all patients received allopurinol (minimum duration of use 3 months ) at an average dose of 200 mg per day. To assess the severity of pain and the index of functional deficiency, a visual analogue scale in mm was used, which was filled out by the patient before treatment, 24 hours and 7 days after the prescription of Rapten Rapid.

Figure 1 shows that all patients had severe pain syndrome and high values ​​of the functional impairment index. A significant regression of the pain syndrome was visible after the first day of treatment. By the end of the week of taking Rapten Rapid, 80% (24 people) of patients had mild pain, 16% (5 people) had no pain, and only 3% (1 person) had moderate pain.

Rice. 1. Dynamics of pain during an acute attack of gout during treatment with Rapten Rapid

Considering the data presented in Figure 2, it is clear that satisfactory indicators of the functional deficiency index were observed only at the end of the 7th day of treatment in 86% of patients (26 people).

Rice. 2. Dynamics of the functional deficiency index during an acute attack of gout during treatment with Rapten Rapid

In the process of monitoring the dynamics of the patients' condition, no side effects of the drug were identified, which indicates its good tolerability.

The data obtained indicate the high effectiveness and tolerability of therapeutic doses of Rapten Rapid

in the treatment of an acute attack of gout. The drug can be recommended as a drug of choice for the relief of acute gouty arthritis.

We should not forget that the main principle of treatment for gout is the patient’s adherence to a diet low in purines.

. Table No. 6 according to M.I. meets this principle. Pevzner. You should exclude liver, kidneys, lungs, brains, meat and mushroom broths, jelly, animal and poultry meat, sausages, fish, mushrooms (ceps, milk mushrooms, champignons), spicy snacks and seasonings, lentils, green peas, beans, beans, pickles; substances containing a lot of methylpurines and stimulating the nervous system: strong tea, coffee, cocoa, chocolate; alcoholic drinks, which impair the excretion of uric acid by the kidneys and provoke an attack of gout. Due to the fact that gout is almost always accompanied by oxalemia, sorrel, spinach, rhubarb, celery, pepper, rutabaga, and radishes should be limited in the diet of patients. For all forms of gout, drink plenty of fluids: milk, decoctions of rose hips, apples, juices from fresh raw berries, fruits, diuretic tea. The amount of proteins is reduced to 1 g/kg, fats - to 1 g/kg or less, the calorie requirement is satisfied mainly by carbohydrates.

Compliance with a dietary regimen in combination with NSAIDs, as components of the treatment of acute gouty arthritis, can increase the effectiveness of therapy and improve the quality of life of patients.

2. Reasons

Uric acid is one of the bioactive substances necessary for the body; in water it dissolves slightly and is broken down by special enzymes, and in the blood it is present in the form of salts (urates). Urate crystals, accumulating in the joints, lead to the development of gouty arthritis, the second most common joint disease after rheumatic arthritis. An increase in the concentration of uric acid compounds may be due to a congenital deficiency of the enzymes that break it down (for the production of which the “male” X chromosome is responsible, which explains gender differences in morbidity). Statistical correlations of gout with hypertension, alcoholism, congenital abnormalities of the structure and functioning of the renal tubules, certain types of cancer pathology, obesity and other factors have also been identified and confirmed.

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Symptoms of gouty arthritis

Symptoms of gouty arthritis depend on the latent, acute or chronic period of the disease:

• During the latent stage,
  the disease is practically invisible, no obvious manifestations are observed;
• Acute attacks are associated
  with severe pain, they occur irregularly, the interval can be up to a year. In this case, the tissues around the joint feel sore when pressed, especially severe pain bothers you at night;
• In a chronic disease,
  pain lasts for at least 3 months with periodic exacerbations and remission. The affected joints gradually become deformed.

The first symptom of gouty arthritis is usually tenderness around the joint.

Gradually, hyperemia of the skin appears, pain appears during movement and compactions from the subcutaneous tissue - tophi. A person's body temperature rises.

Most often, the disease begins with the big toe.

If there are symptoms of gouty arthritis, it is necessary to provide assistance to the patient as soon as possible, otherwise the pathology will progress. This means that deposits will begin to accumulate in other joints, causing inflammation, destruction of cartilage, and the formation of cavities that will eventually be filled with uric acid. Its crystals also accumulate under the skin, creating painful nodules. In the absence of proper treatment, severe deformation of the leg with subsequent disability is possible.

The development of acute gouty arthritis is accompanied by severe pain, especially on the first day.

The skin above the joint turns red, its temperature rises, it can be felt to the touch. The joint swells, asymmetrical edema forms. All this may be accompanied by skin swelling, general weakness, increased sweating and chills. Symptoms of gouty arthritis may include loss of appetite, bouts of nausea, increased blood pressure and gastrointestinal upset.

3. Symptoms and diagnosis

Hyperuricemia and hyperuricosuria themselves (abnormal levels of crystalline urates in the blood and urine, respectively) may be asymptomatic for a long time. Urate nephropathy manifests itself, as a rule, acutely, against the background of an attack of gouty arthritis. Renal colic, symptoms of pyelo- or glomerulonephritis, and a sharp reduction in the volume of urine excreted are noted. The color of the urine may change (to dark brown), and laboratory testing sometimes reveals the presence of protein and blood in the urine. Urate nephrolithiasis (presence of calculi, stones in the kidneys and/or urinary tract) is the second most common symptom found in gouty kidney. The acute form of urate nephropathy easily becomes chronic and results in pyelonephritis, glomerulonephritis, pyonephritis with varying degrees of renal failure.

Diagnosis of a gouty kidney can be very difficult if there is no pronounced joint damage specific to gout. A thorough examination of the medical history and, of course, “targeted” laboratory studies of the composition of blood and urine are necessary. According to indications, ultrasound, radiography and other imaging diagnostic methods are also prescribed.

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What is ankle arthritis?

Ankle arthritis is inflammation of the joint without previous injury. It occurs mainly against the background of other diseases or as a result of infection. The latter include dangerous types, such as purulent, the treatment of which may require surgical intervention.

Although the vast majority of arthritis sufferers are elderly, young people and even children are often affected. To prescribe the correct treatment, a thorough diagnosis and an established diagnosis according to ICD 10 are necessary.

4.Treatment

Therapy for urate nephropathy is always complex. It is necessary to control and relieve exacerbations of gout as the underlying disease, treatment and prevention of hypertension, and normalization of body weight. A diet is strictly required, which the doctor develops and explains on an individual basis (however, in any case, beer, certain types of fish and a number of other products that promote the production of uric acid are excluded). Sugar consumption is also sharply reduced, since there is a direct connection between the incidence of gout and diabetes. Diuretics (diuretics) and urostatics are prescribed - drugs that suppress the secretion of uric acid. Regular observation by a doctor of the appropriate profile and monitoring of laboratory tests are mandatory.

The prognosis is generally favorable, provided that all medical prescriptions are followed, especially those related to lifestyle and bad habits. In recent decades, significant advances have been made in understanding the etiopathogenesis and, accordingly, developing strategies for effective therapeutic control of renal (renal) functions in urate nephropathy.

How to treat ankle arthritis

To maintain confidentiality, as well as to standardize diagnoses, the ICD code was introduced - the international classification of diseases, 10th revision. The class includes all diseases of the connective tissue and musculoskeletal system. All species are assigned their own code. For example, purulent staphylococcal arthritis has the code M00.0.

With such a wide variety of diseases, classification is an invaluable aid in establishing an accurate diagnosis. ICD 10 systematizes statistical data and contains an expanded list of symptoms and signs, including a detailed description of the acceptable values ​​of indicators obtained as a result of biomaterials taken for analysis. It also contains examples of the correct formulation of the established diagnosis. Therefore, the diagnosis according to ICD 10 is accurate.

After establishing an accurate diagnosis and identifying the causes, the doctor prescribes a comprehensive treatment, and also decides whether the treatment will take place in a hospital or on an outpatient basis. In any form of the disease, first of all, it is necessary to eliminate or minimize the load on the foot: maintain bed rest, and when moving, use an elastic bandage and, possibly, a cane. If there are symptoms of an acute infection, then the following is prescribed:

• Antibacterial injections.
• Anti-inflammatory drugs.
• Preparations containing glucosamine.
• A diet excluding salt-containing foods.

The purulent type requires intravenous antibiotics (after the course they are prescribed orally). In difficult cases, surgical intervention by draining the joint will be required. Further treatment is carried out using analgesics and compresses. Sometimes the joint is blocked by a splint.

Ankle arthritis should be treated promptly to avoid irreversible changes leading to disability. A correctly classified diagnosis according to ICD 10 and timely treatment allow you to maintain physical activity for as long as possible.

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Neurologists leading the initial appointment
Titarchuk Andrey Borisovich Chief physician

Yurasov Pavel Aleksandrovich Neurologist

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