Experience of arthroscopic surgery in tophaceous gout: indications, results and complications

Background Gout, lasting 5 years or more, and high uncontrollable levels of uric acid in blood lead to the formation of tophi – gouty stones containing the UA crystals surrounded with connective tissue. As the result of tophi formation in the joint area patients felt extreme discomfort and quite often completely lose ability to work. Objectives To define indications for tophaceous gout surgery in the Chengdu Rheumatism Hospital, evaluate surgical results and complications, as well as the effectiveness of a new surgery equipment. Materials and methods The indications and results of tophaceous gout surgery were investigated in 63 male gout patients of Chengdu Rheumatism hospital in 2019-2020. A retrospective analysis was carried out on the basis of medical records for all patients who were prescribed with urate lowering therapy and underwent arthroscopic intervention or complex surgical intervention combining arthroscopic shaving with open tophectomy procedure. Results The most common lesion site was foot joints: toes (49.41 %), ankle (39.68 %) and knee (34.92 %), with restricted mobility in the mentioned joints. Among common complaints were inability to perform daily routines due to enlarged joints (inability to wear shoes), joints’ dysfunction and pain. Younger patients (aged 20–44) had significantly higher levels of uric acid in serum before treatment. In most cases, indications for surgery for this group of patients were pain and discomfort in joints, inability to perform daily work. After accessing pain levels, 38.46 % of younger patients reported pain leveled 6 or higher on VAS score, which was more often, compared to patients aged 45–55 (26.92 %) and older than 55 (10.0 %). After surgery and following urate lowering therapy all patients noted functional improvement and reduction of pain. Decrease in serum urate levels were reported in 96.83 % of patients. Conclusion The results of surgical treatment for functional impairment of the joint (inability to perform daily work due to restricted range of motions) and massive joint transformation (inability to wear shoes/clothes) in gout patients are positive, with all patients reporting functional improvement and reduction of pain, and the risk of complications is low. In addition to urate lowering therapy we cautiously recommend performing arthroscopic shaving even in younger gout patients consistent with aforementioned indications.

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Controlling pain and hyperuricemia in patients with tophaceous gout after joints surgery

Laser Medicine ◽

10.37895/2071-8004-2020-24-2-3-85-89 ◽

2021 ◽

Vol 24 (2-3) ◽

pp. 85-89

Author(s):

Jianchun Chen ◽

Xiaofeng Zhong ◽

Yichuan Guo ◽

Wuyan Zheng ◽

Nataliia Oshmianska

Keyword(s):

Laser Therapy ◽

Functional Improvement ◽

Study Group ◽

Tophaceous Gout ◽

Low Intensity ◽

Lowering Therapy ◽

Reduction Of Pain ◽

Low Intensity Laser Therapy ◽

Urate Lowering Treatment ◽

Intensity Laser

The primary treatment of tophaceous gout is to control the disease by pharmacological therapy. Additional surgical intervention is used to correct cosmetic deformation in joints or disabling functional disorder; however, one of its reported complications is hyperuricemia and recurrent attacks of pain. Objectives: to access the effectiveness of Low Intensity Laser therapy as addition to urate lowering treatment in patients with tophaceous gout, who underwent joints surgery in the Chengdu Rheumatism Hospital, in comparison to those patients who received only nonsurgical treatment. Subjects and methods. The effectiveness of Low Intensity Laser therapy (LILT) and urate lowering treatment in patients with tophaceous gout was investigated in 63 male patients of Chengdu Rheumatism hospital with tophaceous gout who underwent joints surgery. Control group was formed of 63 gout patients comparable in age and pre-treatment uric acid, who received non-surgical treatment.Results. Patients underwent surgery in one or two sessions, the most common lesion site being foot joints: toes (49.41%), ankle (39.68%) and knee (34.92%), with restricted mobility in the mentioned joints. Levels of CRP before the treatment were elevated in almost all patients (median 3.74 (0.2, 48.75) mg/L), regardless of the other comorbidities. Urate lowering therapy notably reduced the levels of CRP to 2.44 (0, 33.27) mg/L in study group and to 1.3 (0.13, 31.72) mg/L in controls. After surgery and following urate lowering therapy all patients noted functional improvement and reduction of pain. Decrease in serum urate levels were reported in 96.83% of patients in study group and in 93.65% of controls. There was no significant difference in serum UA between patients who underwent joint surgery and who didn’t. Patients, who in addition to surgery received Low-Level Laser Therapy therapy, had a lowest mean serum UA after treatment (280.93 ± 97.05 μmol/L), but due to wide range of variation, difference to other groups wasn’t statistically significant. Addition of laser therapy also helped to reduce the pain almost twice (0.56±0.56 compared to 1.04 ± 0.91). However, we haven’t registered notable anti-inflammatory influence of LILT. There was a weak direct link established between levels of serum UA and CRP after treatment, but in patients receiving laser therapy, CRP was elevated more often, compared to those who weren’t prescribed with LILT or controls. Conclusion. Arthroscopic shaving and other surgical approaches focused on joints often doesn’t affect system hyperuricemia in any way and can’t be viewed as a substitute to urate lowering therapy. However, our experience confirms that timely performed surgery contribute to functional improvement and reduction of pain in gout patients. Low Intensity Laser therapy doesn’t affect hyperuricemia or guarantee long-term systemic anti-inflammatory effect, but help to additionally relieve pain in joints and thus enhance treatment effect and quality of patients’ life.

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Tophaceous Gout and Renal Insufficiency: A New Solution for an Old Therapeutic Dilemma

Case Reports in Medicine ◽

10.1155/2011/397646 ◽

2011 ◽

Vol 2011 ◽

pp. 1-3 ◽

Cited By ~ 5

Author(s):

Anne-Kathrin Tausche ◽

Carsten Wunderlich ◽

Martin Aringer

Keyword(s):

Renal Function ◽

Uric Acid ◽

Life Expectancy ◽

Renal Impairment ◽

Gouty Arthritis ◽

Serum Urate ◽

Oxidase Inhibitor ◽

The Novel ◽

Tophaceous Gout ◽

Rapid Control

The prevalence of gout is increasing with increased life expectancy. Approximately half of the patients with gout have some degree of renal impairment. If both conditions persistently coexist, and in severe tophaceous gout, in particular, treatment has been difficult. We here report on the case of an 87-year-old woman, who had been suffering from recurrent gouty arthritis over 4 years. Monthly polyarthritis attacks were accompanied by subcutaneous tophi. Serum uric acid levels were constantly above 600 μmol/L (10 mg/dL). Allopurinol was no option because of intolerance, while benzbromarone was ineffective because of renal impairment. Therefore, the novel xanthin oxidase inhibitor febuxostat was started, achieving rapid control of serum urate levels (<360 μmol/L). After initial worsening of inflammation in the first weeks, gouty attacks stopped and all tophi resolved within the following 10 months. Renal function remained stable.

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SUCCESSFUL CORRECTION OF HYPERURICEMIA AND FOLLOWING ARTHROSCOPIC INTERVENTION IN A YOUNG GOUT PATIENT: CASE STUDY

InterConf ◽

10.51582/interconf.21-22.05.2021.023 ◽

2021 ◽

pp. 201-205

Author(s):

Zhang Zheng ◽

Guo Yichuan ◽

Nataliia Oshmianska

Keyword(s):

Metacarpophalangeal Joint ◽

Serum Urate ◽

Functional Improvement ◽

Right Hand ◽

Fourth Finger ◽

Reduction Of Pain ◽

Urate Lowering Treatment ◽

The Right

Patient G., male, 32 years old was admitted to Chengdu Rheumatism hospital with the complains of pain and ulceration at the site of big tophaceous stone of fourth finger joint on the right hand as well as the pain and restricted movements in other right hand joints (elbow, wrist, fingers). Patient was first diagnosed with the gout approximately 10 years prior; by his own choice did not receive any urate-lowering treatment, only using oral analgesics during gout attacks. After surgery and following urate lowering therapy patient has noted functional improvement and reduction of pain. Decrease in serum urate levels from 586.7 to 469.3 μmol/L was reported. Wounds healing took from 1 to 1.5 weeks, with the wound on fourth metacarpophalangeal joint of the right hand being the last one to heal due to the wide ulceration defect. The longer follow-up period is needed to fully evaluate functional outcome (6-month follow-up examinations were scheduled).

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Febuxostat in Gout: Serum Urate Response in Uric Acid Overproducers and Underexcretors

The Journal of Rheumatology ◽

10.3899/jrheum.101156 ◽

2011 ◽

Vol 38 (7) ◽

pp. 1385-1389 ◽

Cited By ~ 20

Author(s):

DAVID S. GOLDFARB ◽

PATRICIA A. MacDONALD ◽

BARBARA HUNT ◽

LHANOO GUNAWARDHANA

Keyword(s):

Uric Acid ◽

Controlled Trial ◽

Serum Urate ◽

Oxidase Inhibitor ◽

Primary Efficacy ◽

Double Blind ◽

Xanthine Oxidase Inhibitor ◽

Lowering Therapy ◽

Post Hoc ◽

To Receive

Objective.Hyperuricemia of gout can arise due to either overproduction or underexcretion of uric acid. Not all available urate-lowering therapies are equally effective and safe for use in patients with renal disease. The objective of this post-hoc analysis was to determine the effectiveness of the xanthine oxidase inhibitor febuxostat in reducing serum urate (sUA) levels in gouty patients who were either overproducers or underexcretors.Methods.Gouty subjects 18 to 85 years of age with sUA ≥ 8.0 mg/dl at baseline were enrolled in a Phase 2, 28-day, multicenter, randomized, double-blind, placebo-controlled trial and randomized to receive febuxostat 40 mg, 80 mg, or 120 mg daily, or placebo. The primary efficacy endpoint was the proportion of subjects with sUA < 6.0 mg/dl at Day 28. Secondary efficacy endpoints included percentage reductions in sUA and urinary uric acid (uUA) from baseline to Day 28.Results.Of the 153 subjects, 118 (77%) were underexcretors (uUA ≤ 800 mg/24 h) and 32 (21%) were overproducers (uUA > 800 mg/24 h); baseline uUA data were missing for 3 subjects. Treatment with febuxostat led to the majority of subjects achieving sUA < 6.0 mg/dl at Day 28. Treatment with any dose of febuxostat led to significantly greater percentage reductions in uUA than that observed in the placebo group, for both underexcretors and overproducers.Conclusion.Febuxostat is a highly efficacious urate-lowering therapy in patients with gout regardless of overproduction or underexcretion status.

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Can Serum Uric Acid Lowering Therapy Contribute to the Prevention or Treatment of Nonalcoholic Fatty Liver Disease?

Current Vascular Pharmacology ◽

10.2174/1570161115666170621082237 ◽

2018 ◽

Vol 16 (3) ◽

pp. 269-275 ◽

Cited By ~ 1

Author(s):

Paschalis Paschos ◽

Vasilios G. Athyros ◽

Achilleas Tsimperidis ◽

Anastasia Katsoula ◽

Nikolaos Grammatikos ◽

...

Keyword(s):

Uric Acid ◽

Liver Disease ◽

Fatty Liver ◽

Nonalcoholic Fatty Liver Disease ◽

Serum Uric Acid ◽

Fatty Liver Disease ◽

Nonalcoholic Fatty Liver ◽

Lowering Therapy

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Uric Acid and Hypertension: Prognostic Role and Guide for Treatment

Journal of Clinical Medicine ◽

10.3390/jcm10030448 ◽

2021 ◽

Vol 10 (3) ◽

pp. 448

Author(s):

Federica Piani ◽

Arrigo F. G. Cicero ◽

Claudio Borghi

Keyword(s):

Clinical Trials ◽

Uric Acid ◽

Mendelian Randomization ◽

Strong Association ◽

Epidemiological Studies ◽

Hypertensive Disease ◽

Genetic Studies ◽

Lowering Therapy ◽

The Relationship

The relationship between serum uric acid (SUA) and hypertension has been a subject of increasing interest since the 1870 discovery by Frederick Akbar Mahomed. Several epidemiological studies have shown a strong association between high SUA levels and the presence or the development of hypertension. Genetic analyses have found that xanthine oxidoreductase (XOR) genetic polymorphisms are associated with hypertension. However, genetic studies on urate transporters and Mendelian randomization studies failed to demonstrate a causal relationship between SUA and hypertension. Results from clinical trials on the role of urate-lowering therapy in the management of patients with hypertension are not uniform. Our study sought to analyze the prognostic and therapeutic role of SUA in the hypertensive disease, from uric acid (UA) biology to clinical trials on urate-lowering therapies.

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POS0140 URATE-LOWERING THERAPY REDUCES NON-EPISODIC FOOT PAIN IN PATIENTS WHO FAIL TO MEET ACR/EULAR 2015 GOUT CLASSIFICATION CRITERIA: AN EFFECT PREDICTED BY ULTRASOUND

Annals of the Rheumatic Diseases ◽

10.1136/annrheumdis-2021-eular.1571 ◽

2021 ◽

Vol 80 (Suppl 1) ◽

pp. 282.1-282

Author(s):

R. Flood ◽

C. Kirby ◽

Y. Alammari ◽

D. Kane ◽

R. Mullan

Keyword(s):

Early Stage ◽

Serum Urate ◽

Classification Criteria ◽

Disease Classification ◽

Foot Pain ◽

Cross Sectional ◽

Baseline Serum ◽

First Metatarsophalangeal Joint ◽

Lowering Therapy ◽

Significant Difference

Background:Emerging evidence that the joints of asymptomatic hyperuricaemic individuals contain monosodium urate (MSU) deposits and that alternative presentations of foot pain occur in hyperuricaemia suggests that preclinical phases may occur prior to a first episodic gout attack. (1) This case–control study evaluates urate deposition in hyperuricaemic individuals not fulfilling the current gout classification criteria, as well as a potential therapeutic role for urate lowering therapy (ULT).Objectives:To investigate whether ULT reduces non-episodic foot pain in patients who fail to meet ACR/EULAR 2015 gout classification criteria.Methods:Following informed consent, hyperuricaemic individuals with persistent, non-episodic foot pain (n=53) not fulfilling ACR/EULAR 2015 gout classification criteria, were compared with asymptomatic hyperuricaemic controls (n=18). Ultrasound (US) of bilateral first metatarsophalangeal (MTP) joints and features of MSU deposition including double contour (DC) sign, tophus and juxta-articular erosion were recorded. Cases only were treated with febuxostat or allopurinol daily for 6 months. Serum urate, 24-hour and 7-day visual analogue score (VAS) 0–100 mm pain scales and the Manchester Foot Pain and Disability Index (MFPDI) were recorded before treatment and after 3 and 6 months. MTP Ultrasound was repeated after a minimum of 6 months on treatment.Results:53 hyperuricaemic individuals with persistent, non-episodic foot pain not meeting the ACR/EULAR 2015 gout classification criteria were recruited. At baseline MTP US DC sign, erosion and tophus occurred in 62.5%, 20.8% and 49% of cases, respectively. No US features of gout occurred in controls. No significant difference was seen in baseline serum urate between cases (481±14 mg/dL) versus controls (437±14; p=NS). Serum urate in cases fell at 3 months (325±25; p<0.01) and 6 months (248±19; p<0.01). For cases, baseline 24-hour pain VAS (46±3.9) reduced at 3 months (32±4.1; p<0.05) and 6 months (21±5.2; p<0.05) of ULT. The 7-day pain VAS (59±3.9) decreased at 3 months (35±4.5; p<0.05) and 6 months (30±5.3; P<0.05). MFPDI (17±1.4) decreased at 3 month (13±1.8; p=<0.05) and 6 months (11±2.2; p=<0.05). When cases were grouped according to the presence (N=33) or absence (N=18) of DC sign on baseline US, no differences were observed for baseline pain scores. Following ULT however, 24-hour pain VAS were significantly lower in DC positive patients at 3 months (22±4.48 DC positive vs 42±6.14 DC negative; p<0.05) and 6 months (12.±5.4 vs 33±8.4; p<0.05). The 7-day pain VAS were significantly lower in DC positive patients at 3 months (23±4.6 vs 47±6.6; p<0.05) and MFDPI were significantly lower in DC positive patients at 3 months (10±1.9 DC positive vs 19±2.9 DC negative; p<0.05).Conclusion:These findings indicate that persistent, non-episodic foot pain in hyperuricaemia is both associated with US features of MSU deposition and is responsive to ULT. Symptomatic hyperuricaemia occurring prior to episodic gout therefore represents an earlier or alternative disease presentation. Changes to the ACR/ EULAR classification criteria to include non-episodic foot pain in the presence of US features of gout may increase the sensitivity of disease classification at an early stage, leading to improved future treatment strategies and long-term outcomes.References:[1]Stewart S, Dalbeth N, Vandal AC, Rome K. Characteristics of the first metatarsophalangeal joint in gout and asymptomatic hyperuricaemia: A cross-sectional observational study. J Foot Ankle Res. 2015;8(1):1–8.Disclosure of Interests:None declared

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AB0932 FACTORS IN ACHIEVING TARGET SERUM URIC ACID LEVELS IN OUTPATIENT GOUT MANAGEMENT IN A MALAYSIAN TERTIARY RHEUMATOLOGY CENTRE

Annals of the Rheumatic Diseases ◽

10.1136/annrheumdis-2020-eular.5823 ◽

2020 ◽

Vol 79 (Suppl 1) ◽

pp. 1766.2-1766

Author(s):

M. H. Mustapha ◽

H. Baharuddin ◽

N. Zainudin ◽

S. S. Ch’ng ◽

H. Mohd Yusoof ◽

...

Keyword(s):

Uric Acid ◽

Serum Uric Acid ◽

Uric Acid Level ◽

Acid Level ◽

Cross Sectional Study ◽

British Society ◽

Treat To Target ◽

Tophaceous Gout ◽

Cross Sectional ◽

The Mean

Background:Gout is one of the most common inflammatory arthropathies. A target serum uric acid of less than 300µmol/l is recommended when tophi are present, and less than 360µmol/l for non-tophaceous gout. Urate-lowering therapy (ULT) should be titrated until the target is achieved and long-term maintenance of the target concentration is recommended. Although ULT has been proven to reduce the uric acid level, less than half of treated patients achieved the target serum uric acid (sUA) in real-world clinical practice.Objectives:To assess the mean treat-to-target achievement in outpatient management of gout by the tertiary rheumatology centre and to identify factors influencing the success rate.Methods:Retrospective cross-sectional study of all patients with gout attending out-patient clinics in a rheumatology referral centre from 1stJanuary 2018 until 31stDecember 2018. Electronic medical records were reviewed. The successful target achievement is defined as mean of all available sUA in 2018 which is ≤360 and ≤300µmol/l for non-tophaceous and tophaceous gout respectively. Chronic kidney disease (CKD) is defined as glomerular filtration rate of less than 60ml/min.Results:There were 251 patients analysed with mean age of 56.3±13.8 years and disease duration of 10.5±9.2 years. Majority were males (215, 85.7%) and 133 (53%) patients had tophaceous gout. The rate of success achieving the target SUA level of ≤360 and ≤300µmol/l were 33.9% (40) and 15.8% (21) in non-tophaceous and tophaceous gout respectively. However, in patients who are compliant, the target sUA achieved is 52.4% (33) and 31.7% (19) in non-tophaceous and tophaceous gout respectively. Characteristics of patients who achieved the targeted sUA were patients of more than 50 years old (48, 78.7%), without family history of gout (29, 65.9%), were prescribed colchicine prophylaxis upon initiating ULT (46, 76.7%), with absence of joint erosions (34, 73.9%) and those with normal creatinine clearance (40, 65.5%). There were 120 (48.4%) patients who were compliant to ULT. In 42 compliant patients who achieved target sUA, the mean allopurinol dose is 289.66mg±101.2 and 369.23mg±175 in non-tophaceous and tophaceous gout respectively. Sub-analysis in 31 compliant CKD patients, revealed no difference in allopurinol dose between those who achieved versus non-achieved target sUA (mean 243mg versus 263mg respectively). However, we noted that 11 (61%) CKD patients with tophi did not achieved target sUA at dose less than 300mg allopurinol. Lower achievement of target sUA was significantly associated with presence of tophi (p=0.001), poor compliance (p= 0.000) and presence of more than one comorbidity (p=0.041).Conclusion:There are several challenges in achieving target uric acid level contributed by both patient and clinician factors such as compliance, presence of comorbidity and ULT dose. Our study suggests that higher dosage of allopurinol is required in patients with tophaceous gout, with or without renal impairment. However, the limitation of this study is, the small number of subjects which therefore needsfurtherinvestigation.References:[1]Roddy, E., Packham, J., Obrenovic, K., Rivett, A., & Ledingham, J. M. (2018). Management of gout by UK rheumatologists: a British Society for Rheumatology national audit. Rheumatology, 57(5), 826–830.[2]Katayama A, Yokokawa H, Fukuda H, et al. Achievement of Target Serum Uric Acid Levels and Factors Associated with Therapeutic Failure among Japanese Men Treated for Hyperuricemia/Gout. Intern Med. 2019;58(9):1225–1231.Disclosure of Interests:Mariam Hamid Mustapha: None declared, Hazlyna Baharuddin Speakers bureau: Sanofi, J&J, Norliza Zainudin: None declared, Shereen Suyin Ch’ng Speakers bureau: Novartis, Pfizer, GSK, Habibah Mohd Yusoof: None declared, Ing Soo Lau: None declared, Mollyza Mohd Zain: None declared, Azmillah Rosman: None declared

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