Tophaceous gout

Control of gout and hyperuricemia The average dose is 200 to 300 mg/day for mild gout and 400 to 600 mg/day for moderately severe tophaceous gout. Divide doses in excess of 300 mg. The minimum effective dose is 100 to 200 mg/day the maximum recommended dose is 800 mg/day. 

Acute attacks with extensive build-up of uric acid as soft, nodular masses in the joints (tophaceous gout) are treated with colchicine to reduce inflammation. 

Richette P, Briere C, Hoenen-Clavert V, Loeuille D, Bardin T. Rasburicase for tophaceous gout not treatable with allopurinol an exploratory study. J Rheumatol 2007 34(10) 2093-8. 

Arthropathies associated with crystals deposition are acute gouty arthritis, chronic gout and chronic tophaceous gout due to monosodium urate crystals. Then there is acute pseudogout and chronic pyrophosphate arthropathy caused by calcium pyrophosphate dehydrate crystals. Acute calcific periarthritis, acute hydroxylapatite arthritis and chronic hydroxyapatite arthritis including Milwaukee-shoulder-knee syndrome are due to basic calcium-phosphate-hydroxyapatite crystals. 

Hyperuricemia-associated medical problems are clinical manifestations of gout by recurrent attacks of inflammatory arthritis, chronic tophaceous gout, uric acid urolithiasis, renal impairment, end stage renal disease and early mortality. These manifestations... 

Gouty arthritis, chronic gout, and chronic tophaceous gout is easily treatable and controllable compared with autoimmune arthritis or OA. Chronic tophaceous gout requires lifetime urate lowering drugs and to a lesser extent restriction of purine-rich food. 

Febuxostat is also an inhibitor of xanthine oxidase and seems to be most promising in difficult to treat chronic tophaceous gout. It can replace allopurinol when allopurinol is not tolerated and there is history of urolithiasis. 

Allopurinol (Zyloprim) is the drug of choice in the treatment of chronic tophaceous gout and is especially useful in patients whose treatment is complicated by renal insufficiency. 

Allopurinol is especially indicated in the treatment of chronic tophaceous gout, since patients receiving it show a pronounced decrease in their serum and urinary uric acid levels. Because it does not depend on renal mechanisms for its efficacy, allopurinol is particularly beneficial for patients who already have developed renal uric acid stones, patients with excessively high urate excretion (e.g., above 1,200 mg in 24 hours), patients with a variety of blood disorders (e.g., leukemia, polycythemia vera), patients with excessive tophus deposition, and patients who fail to respond well to the uricosuric drugs. 

The use of corticosteroids is often suggested for elderly patients with chronic tophaceous gout, since gout in the older individual often displays symptoms similar to those of rheumatoid arthritis. Patients can be given short-term administration of corticosteroids, especially for acute flare-ups. The concomitant use of alcohol, nonsteroidal antiinflammatory drugs, and most diuretics should be avoided. 

Probenecid and sulfinpyrazone are uricosuric drugs employed to decrease the body pool of urate in patients with tophaceous gout or in those with increasingly frequent gouty attacks. In a patient who excretes large amounts of uric acid, the uricosuric agents should not be used. 

Recurrent gout, tophaceous gout, and gout causing renal damage (gouty nephropathy)... 

Chronic tophaceous gout. Tophi can sometimes be reduced in size and even removed by the prolonged use of allopurinol and uricosuric agents. 

Allopurinol (e.g., Zyloprim) Decreases uric acid levels by inhibiting xanthine oxidase, the enzyme which converts hypoxanthine to xanthine and xanthine to uric acid. Tophaceous gout, recurrent calcium oxalate stones. May exacerbate gout attacks. GI upset, hepatotoxicity, rash, Stevens-Johnson syndrome. ... 

Sulfinpyrazone (Anturane) Inhibits renal reabsorption of uric acid. Tophaceous gout hyperuricemia. GI upset, hypersensitivity. ... 

Infection risk Serious infections in patients treated with anakinra for systemic juvenile idiopathic arthritis included one case each of an adenovirus infection, leading to chronic cough and clubbing, gastroenteritis with pre-renal failure, varicella pneumonitis, visceral leishmaniasis, and an acute Epstein-Barr virus infection [20 ]. A 32-year-old patient with severe juvenile-onset tophaceous gout developed HlNl influenza after taking anakinra [2T ]. 

The diagnosis was rapidly established when the patient later developed tophaceous gout, but it is important to note that immediately after discharge from hospital, the patient was not overproducing purines. From 1981 onwards, overproduction was clearly present, more than a mole of oxypurine being excreted per mole of creatinine whilst the patient was on a low purine diet. Hypoxanthine excretion has remain d bove xanthine excretion throughout, as would be expected. ... 

Rheumatoid factor (RF) appeared in a small but definite group of patients with gout confirming previous observations The mean duration of disease was lower in the RF positive patients than in the RF negative patients (5 06 3.19 and 8.35 — 8.33 years respectively). The mean serum urate concentration was also lower in the RF positive patients than in the RF negative patients (6.8O i I.60 and 9 37 2.5 mg/100 ml respectively). Ten of 62 patients (16.13 %) with chronic tophaceous gout were RF positive, compared with 5 H % (7 of 137) of those with acute arthritis only. 

Normal Volunteers Tophaceous Gout - severe Tophaceous gout Non-tophaceous gout Asymptomatic hyperuricemia Renal disease... 

Gutman, A. B. and Yu, T. F. 1957. Protracted uricosuric therapy in tophaceous gout. Lancet 1258-1260. 

Soft tissue masses of the subcutaneous tissue include a variety of lesions, such as calcifications, tophaceous gout or rheumatoid nodules, sebaceous cysts... 

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