gout
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Fitango EducationHealth Topics
Gout
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Overview
Gout is a common, painful form of arthritis.
It causes swollen, red, hot and stiff joints. Gout occurs when uric acid builds
up in your blood. This happens if your body produces extra acid or does not
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Overview
eliminate enough, or if you eat too many foods with purines, such as liver and
dried beans. Pseudogout has similar symptoms and is sometimes confused with
gout. However, it is caused by calcium phosphate, not uric acid.
Often, gout first attacks your big toe. It
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Overview
can also attack ankles, heels, knees, wrists, fingers and elbows.
You are more likely to get gout if you:
Are a man
Have family
member with gout
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Overview
Drink
alcohol
At first, gout attacks usually get better in
days. Eventually, attacks last longer and occur more often. Uric acid buildup
can lead to kidney stones.
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Overview
Untreated gout can cause permanent joint and kidney damage. You can treat gout
with medicines.
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Symptoms
The most common symptom of gout is sudden and severe pain in
one or more joints; typically your big toe. Gout is extremely painful;
some people feel it's as painful as childbirth.
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Symptoms
Symptoms often develop at night, although they can occur at any time. Other symptoms include:
-- swelling (inflammation) in and around the affected joint
-- red, shiny skin over the affected joint
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Symptoms
-- peeling, itchy and flaky skin over the affected joint as the inflammation subsides
The intense pain that gout causes can make walking and getting around
difficult. Even the light pressure of a bed cover or blanket can be
painful.
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Symptoms
What joints are affected?
Seventy per cent of people with gout experience their first attack in
the big toe, and most people with gout will experience pain in this
joint at some point.
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Symptoms
However, while gout is most common in the big toe, it can affect any
peripheral limb joint and can occur in two or more joints at the same
time.
Affected joints may include:
-- midfoot
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Symptoms
-- ankles
-- knees
-- fingers
-- wrists
-- elbows
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Symptoms
If gout is left untreated, it is more likely to affect more than one joint as it progresses.
Pattern of symptoms
It is difficult to predict when an attack will occur. Symptoms can
develop rapidly over a few hours and usually last for 3-10 days. After
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Symptoms
this time, the joint will start to feel normal again and any pain or
discomfort should eventually disappear completely.
Just over half of all people with gout (62%) experience a repeat
attack within a year. You may experience symptoms every few weeks,
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Symptoms
months or years, but it is impossible to predict when the condition will
recur. Some only experience a few attacks in their lifetime.
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Diagnosis
The most accurate way to diagnosis gout is to check your
joints for the presence of crystals. However, this test is often not
practical to carry out at your local GP.
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Diagnosis
Instead, usually your GP will look at your symptoms and medical history to make a diagnosis.
Many conditions can cause joint pain, inflammation and swelling. Gout
is just one of over 200 different forms of arthritis (any condition
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Diagnosis
that causes pain and problems with the joints).
Therefore, your GP may be unable to make a firm diagnosis straight
away and you may be referred for further tests. These will either
confirm the diagnosis of gout or rule out other conditions.
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Diagnosis**Serum uric acid
A serum uric acid test is usually carried out four-to-six weeks after
an attack of gout, as the serum uric acid level is often not raised at
the time of the attack.
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Diagnosis**Serum uric acid
The test involves analysing a sample of blood taken from a vein in your arm to measure the amount of uric acid in your blood.
A raised uric acid level is often an indication you may have
developed gout. However, a serum uric acid test is not definitive. Some
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Diagnosis**Serum uric acid
healthy people without gout have high uric acid levels in their blood,
while others who experience an attack of gout have a normal level.
Synovial fluid
If there is any doubt about what is causing your joint pain, you may
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Diagnosis**Serum uric acid
have a sample of synovial fluid taken from the affected joint. Synovial
fluid helps to keep the joint lubricated and stops the bones and
cartilage from rubbing against each other.
The fluid sample is taken using a needle and syringe. It is then
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Diagnosis**Serum uric acid
examined under a microscope. If you have gout, there will nearly always
be crystals of sodium urate in the sample. This sort of test will also
help to rule out other crystals (calcium pyrophosphate) that can cause
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Diagnosis**Serum uric acid
similar attacks of inflammation, as well as an infection in the
joint such as septic arthritis (when a joint becomes infected with bacteria).
X-ray
An X-ray
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Diagnosis**Serum uric acid
is rarely used to diagnose gout because inflammation caused by gout is
not usually detectable using this method. However, an X-ray is sometimes
used to help rule out other conditions that affect the joints, such as
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Diagnosis**Serum uric acid
chondrocalcinosis (a build-up of calcium crystals in the joints).
Confirming the diagnosis
As checking the joints for crystals is not always practical in
general practice, a checklist is often used. This is based on the known
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Diagnosis**Serum uric acid
pattern of symptoms associated with the condition.
The checklist used is as follows:
-- You have had more than one attack with symptoms of pain, swelling and inflammation.
-- You have experienced high levels of inflammation within just one day of the onset of symptoms.
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Diagnosis**Serum uric acid
-- Symptoms only affect one joint at a time.
-- The joint in your big toe or other foot joints have been affected.
-- Results of the serum acid test show raised levels of uric acid in your blood.
-- Physical examination or X-rays have detected swelling within a joint.
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Diagnosis**Serum uric acid
-- There is no evidence that your joint has been infected by bacteria.
You will usually be diagnosed with gout if at least six of the statements above apply to you.
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Treatment
If you are diagnosed with gout, your treatment plan will have two goals:
-- relieving the symptoms of a gout attack
-- preventing further attacks
Relieving Symptoms: Self-care techniques
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Treatment
During a gout attack, it is important to rest, elevate (raise) your
limb and avoid accidentally knocking or damaging the affected joint.
Keeping the affected joint cool should also help. Remove surrounding
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Treatment
clothing and apply an ice pack to it, such as a bag of frozen peas or
some ice wrapped inside a towel.
Apply the ice pack to your joint for approximately 20 minutes. Do not
apply ice directly to your skin and do not apply it for more than 20
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Treatment
minutes at a time because this could damage the skin.
Medication
Non-steroidal anti-inflammatory drugs (NSAIDs)
are a type of painkiller usually recommended as an initial treatment
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Treatment
for gout. They work by reducing the levels of pain and inflammation.
NSAIDs often used to treat gout include:
-- diclofenac
-- indometacin
-- naproxen
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Treatment
If you have been prescribed NSAIDs for gout, it is best to keep them
near you at all times so you can use them at the first sign of a gout
attack. Continue to take your medication throughout the attack and for
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Treatment
48 hours after the attack has finished. NSAIDs should be prescribed
together with a medication called a proton pump inhibitor (PPI) that
reduces the risk of the NSAID causing indigestion, stomach ulcers and bleeding from the stomach.
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Treatment
People with reduced kidney function or those with conditions such as stomach ulcers or bleeding should avoid using NSAIDs.
Colchicine
If you are unable or do not want to take NSAIDs, or if NSAIDs are
ineffective, colchicine can be used instead. Colchicine is derived from
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Treatment
the Autumn crocus plant. It is not a painkiller, but works by reducing
the ability of the urate crystals to inflame the joint lining
(synovium), which reduces some of the inflammation and pain associated
with a gout attack.
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Treatment
Colchicine can be an effective treatment for gout. However, it should be used at low doses since it can cause upsets, including:
-- nausea
-- abdominal pain
-- diarrhoea
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Treatment
Colchicine can cause major gut problems if taken in too high a dose.
It is important to follow the recommended dose. For most people, this
means taking no more than two to four tablets a day.
Corticosteroids
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Treatment
Corticosteroids are a type of steroid sometimes used to treat severe cases of gout that do not respond to other treatment (above).
A short course of steroid tablets often provides relief, but can't be used long-term as they cause side effects including:
-- weight gain
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Treatment
-- thinning of the bones (osteoporosis)
-- bruising
-- muscle weakness
-- thinning of the skin
-- increased vulnerability to infection
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Treatment
Corticosteroids can also exacerbate diabetes and glaucoma (an eye condition which can cause blindness if untreated).
Corticosteroids may not be suitable for you if you have:
-- bone marrow disease
-- impaired kidney function
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Treatment
-- impaired liver function
-- heart failure
Corticosteroids can also be given by injection, either into muscle or
directly into the affected joint, which can provide rapid pain relief.
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Treatment
Lifestyle changes: Food
Some foods are high in purines. Avoiding eating the foods below
frequently or in large quantities can help reduce the risk of a gout
attack:
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Treatment
-- meat, particularly kidney, liver, veal, turkey and venison
-- seafood, particularly anchovies, herring, mackerel, sardines, fish roe, mussels and scallops
-- certain types of vegetables, such as asparagus, kidney beans, lima beans, lentils and spinach
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Treatment
-- foods or supplements that contain yeast extract, such as Marmite and Quorn
Weight
If you are overweight, the levels of uric acid in your blood often
rise. Losing weight will help reduce your uric acid levels
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Treatment
significantly.
If you need to lose weight, it is important to follow a balanced,
calorie-controlled diet. Do not crash diet. A high-protein,
low-carbohydrate diet should be avoided because high-protein foods often
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Treatment
contain high levels of purines.
Ensure you get plenty of regular exercise. Not only will this reduce
your urate levels and decrease your risk of developing gout, it will
also make you feel more energised and healthier.
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Treatment
If you have a gout attack, keep the joint rested and elevated
(raised). Avoid exercise that puts strain on the affected muscles or
joints. Swimming is a good way to stay fit without putting pressure on
your joints as the water supports your weight.
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Treatment
Read more about losing weight safely and getting fit with exercise.
Water
It is important to drink plenty of water. Aim to drink about 1.2
litres (six-to-eight glasses) a day, or more if you are exercising or
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Treatment
when it is hot. Keeping yourself well hydrated will reduce the risk of
crystals forming in your joints.
Alcohol
Some types of alcoholic drinks are associated with a greater risk of developing gout than others.
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Treatment
Beer and stout, which contain significant quantities of purines,
carry a greater risk for the development of gout than equivalent units
of spirits, such as vodka and whiskey.
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Treatment
A survey has shown that daily consumption of a small glass of wine is not associated with an increased risk of developing gout.
However, binge drinking of any kind of alcohol can bring on an attack
in people who have previously suffered with gout. Men should not drink
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Treatment
more than three-to-four units of alcohol a day and women no more than
two-to-three units a day.
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Causes
Gout is caused by a build-up of uric acid in the blood. Uric
acid is a waste product that forms when the body breaks down chemicals
in the cells known as purines.
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Causes
Most uric acid is removed from the body through the kidneys. A small amount is removed through the digestive system.
Uric acid
Uric acid usually remains dissolved in your blood and passes through
your kidneys into your urine so it can be passed out of your body.
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Causes
If you produce too much uric acid or excrete too little when you
urinate, the uric acid will build up and may cause microscopic crystals
to form, usually in a joint or surrounding tissue.
The crystals may spill over from the joint cartilage into the joint
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Causes
space where they trigger a reaction from the soft lining (synovium),
which produces the intense pain and inflammation associated with gout.
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Risks
Some things can increase the amount of uric acid in your blood,
making you more likely to develop gout. These risk factors fall into one
of two categories:
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Risks
-- medical conditions known to increase levels of uric acid, such
as obesity, high blood pressure (hypertension), high lipid levels and
long-standing impairment of kidney function
-- lifestyle factors, such as diet or certain types of medication that you may be taking
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Risks
These risk factors are discussed in more detail below.
Medication
Certain types of medication can increase your uric acid levels and your risk of developing gout. These include:
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Risks
-- diuretics, used to treat high blood pressure (hypertension) or an abnormal build-up of fluid in your body
-- niacin, used to treat high cholesterol
Sex
Men are more likely to develop gout than women because their uric
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Risks
acid levels rise during puberty. During the menopause, women experience a
similar, albeit smaller, rise in their uric acid levels. This explains
why symptoms start later in women than in men.
Diet
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Risks
Foods naturally high in purines include:
-- beef
-- pork
-- bacon
-- lamb
-- seafood
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Risks
-- liver
-- kidneys
Alcohol
Alcoholic drinks raise the level of uric acid in the blood by
increasing its production in the liver and by reducing how much is
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Risks
passed out in urine.
Beer and spirits do so more than wine, and beer also contains
significant quantities of purines. (Moderate consumption of wine – one
or two glasses a day – should not significantly increase your risk of
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Risks
gout).
Family history
Studies have shown that gout often runs in families.
Around one-in-five people with gout have a close family member who also
has the condition.
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Risks
Medical conditions
Medical conditions that can increase your risk of developing gout include:
-- high blood pressure (hypertension)
-- diabetes, both type 1 diabetes and type 2 diabetes
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Risks
-- kidney disease
-- having high levels of fat and cholesterol levels in your blood
Susceptibility
Gout attacks occur most frequently in the joints of the feet and
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Risks
hands, possibly because the temperature in these joints is often lower
than the rest of the body, which increases the likelihood of crystals
forming.
It is still uncertain why some people are more susceptible to crystal
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Risks
formation and gout than others with equally high blood levels of uric
acid. Many people with a high level of uric acid in their blood and
tissues never develop gout.
One theory is that certain genes you inherit from your parents may
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Risks
make you more likely to develop gout by causing your kidneys that are
otherwise healthy to be relatively inefficient at excreting uric
acid. Several genes have recently been identified that are associated
with high uric acid levels and gout and which influence uric acid
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Risks
elimination by the kidney.
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Prevention
Two methods used to try to prevent further attacks of gout are:
-- medication to reduce uric acid levels
-- making lifestyle changes to reduce uric acid levels
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Prevention**Medication
Usually recommended on a long-term basis for:
-- frequent attacks of gout and signs of tophi under the skin (tophi are small white lumps that can form under the skin)
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Prevention**Medication
-- evidence of joint damage; either in terms of associated symptoms or damage detected by X-ray
-- a history of kidney stones
The main treatment for gout is known as urate-lowering therapy or
ULT. The goal of ULT is to lower uric acid levels below the
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Prevention**Medication
levels required for crystals to form (the saturation point).
This should also help to dissolve existing crystals leading to an
effective cure for gout. But to maintain the "cure" you would need to
continue with ULT on a daily basis.
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Prevention**Medication
Many people with gout begin ULT as soon as they are diagnosed to
reduce the frequency of attacks and the risk of developing joint damage.
This has to be balanced against possible side effects that can occur
with ULT, although these are rare.
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Prevention**Medication
Discuss the potential benefits and disadvantages of ULT with your GP
or the doctor in charge of your care. If you agree to start ULT, usually
the ULT medication to try first is called allopurinol.
Allopurinol
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Prevention**Medication
Allopurinol helps to lower uric acid levels by inhibiting the enzyme
(xanthine oxidase) responsible for converting purines into uric acid,
thus reducing the production of uric acid. However, allopurinol is not a
painkiller and will have no effect during an attack of gout.
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Prevention**Medication
Allopurinol is a tablet taken once a day and usually for up to a year
or two before all crystals have dissolved and no further attacks can
occur. The medication will then usually be taken for the rest of your
life.
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Prevention**Medication
It can take a while to assess the most effective dose for your
circumstances. You may need to have several blood tests to find the most
effective dose.
When you first start taking allopurinol it can sometimes cause a gout
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Prevention**Medication
attack, because rapid reduction of uric acid levels to below the
saturation point causes existing crystals in joint cartilage to
partially dissolve and become smaller.
The smaller crystals can escape more easily or “shed” from the
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Prevention**Medication
cartilage into the joint cavity and then inflame the joint lining
(synovium).
The risk of this happening is reduced by slowly increasing the dose
of allopurinol from a low starting dose (e.g. 100mg daily) to the
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Prevention**Medication
recommended dose.
You may continue to have gout attacks until all the existing crystals have dissolved, which is perfectly normal.
So if this does happen, don't lose confidence in the effectiveness of
ULT. It's important to persevere with treatment to achieve the maximum
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Prevention**Medication
benefit. If you do develop a flare-up of gout while taking
allopurinol, continue the medication while your doctor prescribes
additional treatment to settle the attack.
Although allopurinol is taken without any side effects in most
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Prevention**Medication
patients, around 10% do experience problems. A skin rash is the most
common side effect. In most cases, it’s mild and soon goes away.
However, in a small number of cases, it can be a sign of an allergic
reaction. If you develop a skin rash while taking allopurinol, stop
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Prevention**Medication
taking the medication immediately and contact your GP for advice. It may
be necessary to stop taking allopurinol and try an alternative ULT (see
below).
Other side effects of allopurinol include:
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Prevention**Medication
-- indigestion
-- headache
-- diarrhoea
If you are currently being treating with immunosuppressant
medications (often used to prevent your body rejecting a donated organ)
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Prevention**Medication
or a type of medication called cyclophosphamide (used in the treatment
of some cancers) then you will probably not be able to take allopurinol
for safety reasons.
Allopurinol may also not be suitable if you have severe kidney disease.
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Prevention**Medication
Patients with kidney problems may be started on a lower dose (50mg
daily) and have lower monthly increases (50mg) of allopurinol.
Those with severe kidney disease may not even be started on allopurinol, but prescribed an alternative ULT such as febuxostat.
Febuxostat
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Prevention**Medication
Febuxostat acts in the same way as allopurinol by inhibiting the
enzyme (xanthine oxidase) that produces uric acid, thus reducing the
body’s production of uric acid.
However, unlike allopurinol, it is broken down by the liver and not
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Prevention**Medication
the kidney, so can be used in patients with kidney disease
without concerns over side effects.
Also unlike allopurinol, it only comes in two doses (80mg or 120 mg
daily). Because even 80 mg daily may quickly reduce uric acid levels
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Prevention**Medication
below the saturation point, initiation of even the lowest dose of
febuxostat often triggers acute attacks.
To try to reduce the frequency and severity of this side effect your
doctor may prescribe you regular daily oral NSAID or colchicine
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Prevention**Medication
(one-to-two tablets daily) for up to six months following the start of
febuxostat as “prophylaxis” (preventative treatment).
Common side effects of febuxostat include:
-- an increased number of acute gout attacks (discussed above)
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Prevention**Medication
-- diarrhoea
-- headache
-- feeling sick
-- skin rash
If you experience more serious symptoms such as breathing
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Prevention**Medication
difficulties or facial swelling, stop taking febuxostat and contact your
GP for advice.
Currently, febuxostat is not considered suitable for people with
heart problems (especially heart failure), or with serious kidney
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Prevention**Medication
disease.
Less commonly used ULT medications
Less commonly used ULT medications include:
-- benzbromarone
-- sulphinpyrazone
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Prevention**Medication
-- probenecid
They work by helping the kidneys to remove uric acid from the body.
Sulphinpyrazone and probenecid are now rarely used as they are not as
effective as other types of ULT medications and are not suitable for
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Prevention**Medication
people with kidney disease.
Benzbromarone is more effective in removing uric acid and can be used in people with kidney disease.
These types of medication tend only to be used if people are unable
to take allopurinol or febuxostat. They need to be prescribed under the
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Prevention**Medication
supervision of a specialist.
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