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Han L, Li R, Dalbeth N, Liu M, Yu Q, Jiang C, Ning C, Liu Z, He Y, Li M, Xue X, Jia F, Jia Z, Sun W, Zhang H, Lu J, Wang C, Li C. The value of musculoskeletal ultrasound in predicting gout flares in index joints: A prospective cohort study of people with gout starting urate-lowering therapy. Semin Arthritis Rheum 2024; 67:152418. [PMID: 38422901 DOI: 10.1016/j.semarthrit.2024.152418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 01/23/2024] [Accepted: 02/09/2024] [Indexed: 03/02/2024]
Abstract
OBJECTIVES To evaluate whether ultrasound findings of monosodium urate (MSU) crystal deposition predict frequent gout flares in index joints over 12 months. METHODS This single-center study enrolled people with at least one gout flare involving the MTP1, ankle or knee joint. The most painful or most frequently joint was identified as index joint for analysis. All participants were started on urate-lowering therapy and had an ultrasound scan of the index joints at the baseline visit. OMERACT scores (for tophus, double contour sign and aggregates) were used to analyze whether ultrasound scores predicted frequent (≥2) gout flares in the index joint over 12 months. RESULTS Frequent flares were significantly higher in those with ultrasound findings in all index joints (MTP1: tophus: 85.0% vs 46.0%, P < 0.001, aggregates: 78.8% vs 59.0%, P < 0.01; ankle: tophus: 54.6% vs 20.8%, P < 0.001; aggregates: 60.0% vs 35.9%, P < 0.05; knee: tophus: 68.4% vs 28.6%, P < 0.05). For the MTP1, for each 1-point increase in tophus score, the odds of frequent gout flares increased by 5.19 [(95%CI: 1.26-21.41), 7.91 [(95%CI: 2.23-28.14), and 13.79 [(95%CI: 3.79-50.20)] fold respectively. For the ankle, a tophus score of 3 markedly improved the prediction of the frequent flares [OR= 9.24 (95%CI=2.85-29.91)]. Semi-quantitative sum scores were associated with frequent flares with an OR (95%CI) of 13.66 (3.44-54.18), P < 0.001 at the MTP1, 7.05 (1.98-25.12), P < 0.001 at the ankle. CONCLUSION Ultrasound features of MSU crystal deposition at the MTP1 and knee predict subsequent risk of frequent gout flares in the same joints following initiation of urate-lowering therapy, with the highest risk in those with high tophus scores.
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Affiliation(s)
- Lin Han
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, PR China
| | - Runze Li
- Department of Medicine, Qingdao University, Qingdao, PR China
| | - Nicola Dalbeth
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Mingdi Liu
- Department of Rehabilitation, Qingdao Traditional Chinese Medicine Hospital (Qingdao Hiser Hospital), Qingdao, PR China
| | - Qing Yu
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, PR China
| | - Caiyun Jiang
- Department of Ultrasound, the Affiliated Hospital of Qingdao University, Qingdao, PR China
| | - Chunping Ning
- Department of Ultrasound, the Affiliated Hospital of Qingdao University, Qingdao, PR China
| | - Zhen Liu
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, PR China
| | - Yuwei He
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, PR China
| | - Maichao Li
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, PR China
| | - Xiaomei Xue
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, PR China
| | - Fenghao Jia
- Department of Psychiatry, Xi 'an Medical University, Xi 'an, PR China
| | - Zhaotong Jia
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, PR China
| | - Wenyan Sun
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, PR China
| | - Hui Zhang
- Institute of Metabolic Diseases, Qingdao University, Qingdao, PR China
| | - Jie Lu
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, PR China
| | - Can Wang
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, PR China
| | - Changgui Li
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, PR China; Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, PR China.
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Abhishek A, Fuller A, Nakafero G, Zhang W, Dumbleton J, Hawkey C, Coupland C, Terkeltaub R, Doherty M. Feasibility of conducting a randomized, placebo-controlled study assessing whether omega-3 fatty acids prevent gout flares when starting urate-lowering treatment. Rheumatol Adv Pract 2022; 6:rkac086. [DOI: 10.1093/rap/rkac086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 09/28/2022] [Indexed: 11/17/2022] Open
Abstract
Abstract
Objective
The aim was to test the feasibility of a randomized controlled trial exploring whether omega-3 fatty acid supplementation limits gout flares during treat-to-target urate-lowering treatment (T2T-ULT).
Methods
Adults with at least one gout flare in the past 12 months and serum urate (SU) ≥360 μmol/l were recruited from general practices (primary method) and randomly assigned 1:1 to receive omega-3 fatty acid supplementation (4 g/day) or placebo for 28 weeks. At week 5, participants began T2T-ULT. The primary outcome was drop-out rate. Secondary outcomes were recruitment rate, outcome data completeness, the number, severity and duration of gout flares between weeks 5 and 28, and study drug compliance.
Results
Ninety-five per cent of randomized participants (n = 60) completed all study visits. The primary method recruitment rate was 2.2%. Fifty and 42 participants achieved SU < 360 and 300 μmol/l (6 and 5 mg/dl), respectively. The number of gout flares [median (interquartile range): active 1 (0–2) and placebo 1 (0–2)], flare duration [mean (s.d.): active 7.00 (4.52) days and placebo 7.06 (8.14) days] and time to first flare [hazard ratio (95% CI) 0.97 (0.50, 1.86)] were comparable between both arms. Study drug compliance was high and comparable in both arms [median (interquartile range) returned capsule count: active 57 (26–100) and placebo 58 (27–154)]; red blood cell omega-3 fatty acid index increased twofold in the active arm and remained unchanged in the control arm.
Conclusion
The study demonstrated feasibility and provided useful metrics for conducting a community-based gout flare prophylaxis trial.
Study registration
ISRCTN; https://www.isrctn.com/; ISRCTN79392964.
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Affiliation(s)
- Abhishek Abhishek
- Academic Rheumatology, The University of Nottingham , Nottingham, UK
| | - Amy Fuller
- Academic Rheumatology, The University of Nottingham , Nottingham, UK
| | - Georgina Nakafero
- Academic Rheumatology, The University of Nottingham , Nottingham, UK
| | - Weiya Zhang
- Academic Rheumatology, The University of Nottingham , Nottingham, UK
| | - Jennifer Dumbleton
- Nottingham Digestive Diseases Centre, The University of Nottingham , Nottingham, UK
| | - Christopher Hawkey
- Nottingham Digestive Diseases Centre, The University of Nottingham , Nottingham, UK
| | - Carol Coupland
- Division of Primary Care, The University of Nottingham , Nottingham, UK
| | - Robert Terkeltaub
- Veterans Affairs San Diego Healthcare System , San Diego, CA, USA
- Department of Medicine, University of California , San Diego, CA, USA
| | - Michael Doherty
- Academic Rheumatology, The University of Nottingham , Nottingham, UK
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Weaver JS, Vina ER, Munk PL, Klauser AS, Elifritz JM, Taljanovic MS. Gouty Arthropathy: Review of Clinical Manifestations and Treatment, with Emphasis on Imaging. J Clin Med 2021; 11:jcm11010166. [PMID: 35011907 PMCID: PMC8745871 DOI: 10.3390/jcm11010166] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 12/16/2021] [Accepted: 12/26/2021] [Indexed: 12/22/2022] Open
Abstract
Gout, a crystalline arthropathy caused by the deposition of monosodium urate crystals in the articular and periarticular soft tissues, is a frequent cause of painful arthropathy. Imaging has an important role in the initial evaluation as well as the treatment and follow up of gouty arthropathy. The imaging findings of gouty arthropathy on radiography, ultrasonography, computed tomography, dual energy computed tomography, and magnetic resonance imaging are described to include findings of the early, acute and chronic phases of gout. These findings include early monosodium urate deposits, osseous erosions, and tophi, which may involve periarticular tissues, tendons, and bursae. Treatment of gout includes non-steroidal anti-inflammatories, colchicine, glucocorticoids, interleukin-1 inhibitors, xanthine oxidase inhibitors, uricosuric drugs, and recombinant uricase. Imaging is critical in monitoring response to therapy; clinical management can be modulated based on imaging findings. This review article describes the current standard of care in imaging and treatment of gouty arthropathy.
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Affiliation(s)
- Jennifer S. Weaver
- Department of Radiology, University of New Mexico, Albuquerque, NM 87131, USA;
- Correspondence:
| | - Ernest R. Vina
- Department of Medicine, University of Arizona Arthritis Center, Tucson, AZ 85724, USA;
| | - Peter L. Munk
- Department of Radiology, University of British Columbia, Vancouver, BC V6T 1Z4, Canada;
- Department of Radiology, Vancouver General Hospital, Vancouver, BC V5Z 1M9, Canada
| | - Andrea S. Klauser
- Radiology Department, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria;
| | - Jamie M. Elifritz
- Departments of Radiology and Pathology, University of New Mexico, Albuquerque, NM 87131, USA;
- New Mexico Office of the Medical Investigator, Albuquerque, NM 87131, USA
| | - Mihra S. Taljanovic
- Department of Radiology, University of New Mexico, Albuquerque, NM 87131, USA;
- Departments of Medical Imaging and Orthopaedic Surgery, University of Arizona, Tucson, AZ 85721, USA
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Dalbeth N, Doyle AJ, Billington K, Gamble GD, Tan P, Latto K, Parshu Ram T, Narang R, Murdoch R, Bursill D, Mihov B, Stamp LK, Horne A. Intensive serum urate lowering with oral urate-lowering therapy for erosive gout: A randomized double-blind controlled trial. Arthritis Rheumatol 2021; 74:1059-1069. [PMID: 34927391 DOI: 10.1002/art.42055] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 12/02/2021] [Accepted: 12/16/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To determine whether intensive serum urate lowering results in improved bone erosion scores in erosive gout. METHODS Two-year, double-blind, randomized, controlled trial of 104 participants with erosive gout on oral urate-lowering therapy (ULT) and serum urate ≥ 0.30mmol/L was undertaken. Participants were randomly assigned to serum urate target <0.20mmol/L (intensive target) or <0.30mmol/L (standard target, according to rheumatology guidelines). Oral ULT was titrated to target using a standardized protocol (using maximum approved doses of allopurinol, probenecid, febuxostat, and benzbromarone). The primary endpoint was total CT erosion score. OMERACT gout core outcome domains were secondary endpoints. RESULTS Although the serum urate was significantly lower in the intensive target group compared to the standard target group (P=0.002), fewer participants in the intensive group achieved the randomized serum urate target (at Year 2, 62% vs 83%, P<0.05). The intensive target group required higher allopurinol doses (mean (SD) 746 (210) mg/day vs 496 (185) mg/day, P<0.001), and used more combination therapy (P=0.0004). Small increases in CT erosion scores were observed in both groups over two years, with no between-group difference (P=0.20). OMERACT core outcome domains (gout flares, tophus, pain, patient global assessment, health-related quality of life, and activity limitation) improved in both groups, with no between-group differences. Adverse event and serious adverse event rates were similar between groups. CONCLUSION Compared with a serum urate target below 0.30mmol/L, more intensive serum urate-lowering is difficult to achieve with oral ULT, leads to high medication burden, and does not improve bone erosion scores in erosive gout.
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Affiliation(s)
- Nicola Dalbeth
- Bone and Joint Research Group, Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Anthony J Doyle
- Department of Radiology, Auckland District Health Board.,Department of Anatomy and Medical Imaging, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | | | - Greg D Gamble
- Bone and Joint Research Group, Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Paul Tan
- Bone and Joint Research Group, Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Kieran Latto
- Bone and Joint Research Group, Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Thrishila Parshu Ram
- Bone and Joint Research Group, Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Ravi Narang
- Bone and Joint Research Group, Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Rachel Murdoch
- Bone and Joint Research Group, Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - David Bursill
- Bone and Joint Research Group, Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Borislav Mihov
- Bone and Joint Research Group, Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Lisa K Stamp
- Department of Medicine, University of Otago, Christchurch, Christchurch, New Zealand
| | - Anne Horne
- Bone and Joint Research Group, Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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Anjum ZI, Bacha R, Manzoor I, Gilani SA. Reliability of knee joint sonography in the evaluation of gouty arthritis. J Ultrason 2021; 21:e300-e305. [PMID: 34970441 PMCID: PMC8678699 DOI: 10.15557/jou.2021.0051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 07/14/2021] [Indexed: 11/22/2022] Open
Abstract
Objective: To determine the reliability of knee joint sonography in the evaluation of gouty arthritis. Methodology: A search of Google Scholar, PubMed, NCBI, MEDLINE, and Medscape databases, from 1988 up to 2020. The key search terms used were knee joint; knee joint ultrasound; gout; gouty arthritis, knee joint pain; sensitivity; specificity. The reviewer independently screened the titles and abstracts of the relevant articles and full-text downloads to determine whether the inclusion or exclusion criteria were met. Results: In total, 103 articles were identified through the database search. In addition, 11 articles were identified through other sources. Then, screening was performed, and 9 articles were removed due to duplication. Further screening was done for 105 articles, and 27 articles were excluded due to insufficient information. Seventy-eight full-text articles were assessed for eligibility. A total of 13 full-text articles were excluded due to research performed on animals, as the study had been designed as a review of only human studies. Sixty-three studies were included that had a qualitative synthesis. Conclusion: The knee is a weight-bearing joint and may be affected by a myriad of different pathological conditions, therefore a proper diagnosis is of prime importance for a proper management plan. Ultrasound is a non-invasive, radiation-free, and readily available modality that has high sensitivity and specificity in the evaluation of gouty arthritis.
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Abstract
This review highlights outcomes for patients with calcium pyrophosphate deposition (CPPD) reported in prior studies and underscores challenges to assessing outcomes of this condition. Prior clinical studies of interventions for CPPD focused on joint damage and calcification on imaging tests, joint pain, swelling, and inflammatory biomarkers. Qualitative interviews with patients with CPPD and healthcare providers additionally identified flares, overall function, and use of analgesic medications as important outcomes. Imaging evidence of joint damage and calcification is likely to be outcomes in future clinical studies of CPPD, though reliability and sensitivity to change in CPPD require further testing for several imaging modalities. Challenges to outcome measurement in CPPD include questions of attribution of signs and symptoms to CPPD versus co-existing forms of arthritis, lack of therapies to prevent or dissolve calcium pyrophosphate crystal deposition, absence of validated patient- or physician-reported CPPD outcome measures, and scarcity of large cohorts in which to study outcomes of different clinical presentations of CPPD.
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Affiliation(s)
- Ken Cai
- Bone and Joint Research Group, Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Department of Rheumatology, Westmead Hospital, Westmead, Australia
| | - Sara K Tedeschi
- Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital, Boston, MA, USA.
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Filippucci E, Reginato AM, Thiele RG. Imaging of crystalline arthropathy in 2020. Best Pract Res Clin Rheumatol 2020; 34:101595. [PMID: 33012644 DOI: 10.1016/j.berh.2020.101595] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Crystal-related arthropathies are the result of crystal deposition in joint and periarticular soft tissues. Identification of urate crystals is mandatory to distinguish gout from other crystalline arthropathies, including calcium pyrophosphate dihydrate and basic calcium phosphate crystal deposition diseases. ACR/EULAR classification criteria for gout included dual-energy computed tomography and ultrasound with equal impact to the final score. Different diagnostic strengths of these imaging modalities depend on disease duration and scanned anatomic site. While ultrasound has been indicated as the first-choice imaging technique, especially in the early stages of the disease, dual-energy computed tomography has shown to be highly specific, allowing the detection of crystal deposits in anatomic sites not accessible by ultrasound, such as the spine. At the spinal level, MRI findings are usually nonspecific. Finally, there is preliminary evidence that at the knee, dual-energy computed tomography may discriminate calcium pyrophosphate dihydrate from basic calcium phosphate crystal deposits.
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Affiliation(s)
- Emilio Filippucci
- Rheumatology Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, "Carlo Urbani" Hospital, Jesi, Ancona, Italy.
| | - Anthony M Reginato
- Division of Rheumatology, Department of Dermatology, The Warren Alpert Medical School of Brown University, Providence, RI, USA.
| | - Ralf G Thiele
- Division of Allergy, Immunology and Rheumatology, Department of Medicine, University of Rochester, Rochester, NY, USA.
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Hammer HB, Karoliussen L, Terslev L, Haavardsholm EA, Kvien TK, Uhlig T. Ultrasound shows rapid reduction of crystal depositions during a treat-to-target approach in gout patients: 12-month results from the NOR-Gout study. Ann Rheum Dis 2020; 79:1500-1505. [PMID: 32669301 DOI: 10.1136/annrheumdis-2020-217392] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 06/06/2020] [Accepted: 06/24/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES As ultrasound is sensitive for detecting crystal depositions in patients with gout, our objectives were to explore the main locations for depositions and the extent of dissolution of depositions during a treat-to-target approach with urate lowering treatment (ULT) in patients with gout. METHODS Patients with a recent flare of gout were consecutively included in this single-centre study and managed by a treat-to-target approach with ULT. All patients were assessed at baseline, 3, 6 and 12 months including bilateral ultrasound examinations of joints/tendons/entheses of hands, elbows, knees, ankles and feet. A new semiquantitative scoring system of 0-3 of elementary lesions (double contour (DC), tophi and aggregates) was applied to quantify the amount of depositions during the follow-up. RESULTS 209 of the patients were evaluated with ultrasound at baseline (mean (SD) age 56.4 (13.8) years and disease duration 7.9 (7.7) years, 95.2% men). The serum urate levels decreased from baseline to 12 months (mean (SD) 500 (77) to 312 (49) µmol/L) (p<0.001)). The first metatarsophalangeal joint was the most frequent location for all the elementary lesions and erosions were associated with higher levels of crystal depositions. From baseline to 12 months, mean sum scores decreased for DC (4.3 to 1.3), tophi (6.5 to 3.8) and aggregates (9.3 to 6.7) (p<0.001 for all), with DC being most sensitive to change. CONCLUSIONS The ultrasound scoring system for crystal depositions was sensitive to change and showed that a treat-to-target approach with ULT resulted in significant reductions of all the depositions, most extensively for DC.
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Affiliation(s)
- Hilde Berner Hammer
- Department of Rheumatology, Diakonhjemmet Sykehus, Oslo, Norway .,University of Oslo, Faculty of Medicine, Oslo, Norway
| | | | - Lene Terslev
- Department of Rheumatology, Glostrup University Hospital, Copenhagen, Denmark
| | | | - Tore K Kvien
- Department of Rheumatology, Diakonhjemmet Sykehus, Oslo, Norway.,University of Oslo, Faculty of Medicine, Oslo, Norway
| | - Till Uhlig
- Department of Rheumatology, Diakonhjemmet Sykehus, Oslo, Norway.,University of Oslo, Faculty of Medicine, Oslo, Norway
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Lu B, Lu Q, Huang B, Li C, Zheng F, Wang P. Risk factors of ultrasound-detected tophi in patients with gout. Clin Rheumatol 2020; 39:1953-1960. [PMID: 32062769 DOI: 10.1007/s10067-020-04947-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 12/04/2019] [Accepted: 01/13/2020] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Tophus is a characteristic manifestation of advanced gout, the clinical significance of which is often underestimated. This study aimed to compare the difference of clinical and ultrasound features between gout patients with and without ultrasound-detected tophus and identify risk factors associated with the presence of ultrasonographic tophus in gout patients. MATERIALS AND METHODS A total of 85 gout patients were divided into tophaceous (n = 54) and non-tophaceous group (n = 31) according to the presence of ultrasound-detected tophus. All patients underwent ultrasound examination of the bilateral knee, ankle, and first metatarsophalangeal joint (MTP1). Clinical information and ultrasound findings were compared between the groups. A multivariate logistic regression analysis to determine possible risk factors is associated with the number of ultrasound-detected tophaceous joints. RESULTS Older age, longer gout duration, higher gout flare frequency, lower estimated glomerular filtration rate (eGFR), and higher prevalence of hypertension, hyperlipidemia, and ultrasound manifestations including double contour sign (DCS) and erosion were observed in tophaceous patients from the univariate analysis. Multivariable logistic regression analysis showed that eGFR and disease duration were independently associated with the number of tophaceous joints. Lower eGFR and longer course duration were associated with a higher risk of tophi (B = -0.020, 0.141; P = 0.009, 0.010, respectively). CONCLUSIONS The main factors that may influence the formation of tophi are disease duration and eGFR.Key Points• Lower eGFR and longer course duration are independent risk factors of tophi formation in gout patients.• The incidence of ultrasound manifestations including double contour sign (DCS) and erosion in patients with tophi were higher than those without tophi.
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Affiliation(s)
- Beilei Lu
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Qing Lu
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Beijian Huang
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, 200032, China. .,Shanghai Institute of Medical Imaging, Shanghai, 200032, China.
| | - Cuixian Li
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, 200032, China.,Shanghai Institute of Medical Imaging, Shanghai, 200032, China
| | - Fengyang Zheng
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, 200032, China.,Shanghai Institute of Medical Imaging, Shanghai, 200032, China
| | - Peilei Wang
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
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Impact of Dual-Energy CT Postprocessing Protocol for the Detection of Gouty Arthritis and Quantification of Tophi in Patients Presenting With Podagra: Comparison With Ultrasound. AJR Am J Roentgenol 2019; 213:1315-1323. [PMID: 31553656 DOI: 10.2214/ajr.19.21404] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE. The objective of our study was to compare ultrasound (US) tophus and monosodium urate (MSU) deposit detection and US tophus size in the metatarsophalangeal (MTP) 1 joint with dual-energy CT (DECT) using two DECT postprocessing protocols in patients presenting with podagra. SUBJECTS AND METHODS. Seventy-five consecutive patients with podagra (66 men and nine women; mean age, 65.6 years; age range, 33-88 years) and 75 control subjects with MTP 1 joint osteoarthritis (49 men and 26 women; mean age, 63.0 years; age range, 35-87 years) prospectively underwent US and DECT between 2016 and 2018 to assess the MTP 1 joint. Two Syngovia postprocessing DECT protocols with different minimum attenuation thresholds of 150 HU (DECT 150 protocol) versus 120 HU (DECT 120 protocol) and the same maximum attenuation threshold (500 HU) and constant kilovoltage setting of tubes A and B at 80 and 140 kVp were evaluated. Interobserver variability of the two DECT protocols was calculated and compared with that of US. RESULTS. The postprocessing DECT 150 protocol was positive for tophus detection in 55 of 75 patients (73.3%) with podagra, whereas the postprocessing DECT 120 protocol detected MSU deposits in all 75 patients (100%). Tophus size assessed using the DECT 120 protocol showed an improved correlation with tophus size detected on US (p < 0.01). Interobserver variability of DECT was improved when using the DECT 120 protocol (p < 0.01). CONCLUSION. The postprocessing DECT 120 protocol enables improved visualization of MSU deposits and provides more accurate information about tophus size that better correlates with tophus size on US compared with the standard postprocessing DECT 150 protocol.
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Davies J, Riede P, van Langevelde K, Teh J. Recent developments in advanced imaging in gout. Ther Adv Musculoskelet Dis 2019; 11:1759720X19844429. [PMID: 31019573 PMCID: PMC6469273 DOI: 10.1177/1759720x19844429] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 03/25/2019] [Indexed: 12/13/2022] Open
Abstract
The plain radiographic features of gout are well known; however, the sensitivity
of plain radiographs alone for the detection of signs of gout is poor in acute
disease. Radiographic abnormalities do not manifest until late in the disease
process, after significant joint and soft tissue damage has already occurred.
The advent of dual-energy computed tomography (DECT) has enabled the
non-invasive diagnosis and quantification of gout by accurately confirming the
presence and extent of urate crystals in joints and soft tissues, without the
need for painful and often unreliable soft tissue biopsy or joint aspiration.
Specific ultrasound findings have been identified and may also be used to aid
diagnosis. Both ultrasound and magnetic resonance imaging (MRI) may be used for
the measurement of disease extent, monitoring of disease activity or treatment
response, although MRI findings are nonspecific. In this article we summarize
the imaging findings and diagnostic utility of plain radiographs, ultrasound,
DECT, MRI and nuclear medicine studies in the assessment as well as the
implications and utility these tools have for measuring disease burden and
therapeutic response.
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Affiliation(s)
- Joseph Davies
- Radiology Department, Nuffield Orthopaedic Centre, Windmill Road, Oxford, OX3 7HE, UK
| | | | | | - James Teh
- Nuffield Orthopaedic Centre, Oxford, UK
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The popliteal groove region: A new target for the detection of monosodium urate crystal deposits in patients with gout. An ultrasound study. Joint Bone Spine 2018; 86:89-94. [PMID: 30025961 DOI: 10.1016/j.jbspin.2018.06.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 06/20/2018] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To determine the prevalence of the ultrasound findings indicating monosodium urate crystal deposits at the popliteal groove region in patients with gout; to evaluate the diagnostic accuracy of ultrasound in detecting monosodium urate crystal deposits at the popliteal groove region, patellar tendon and the knee hyaline cartilage; to investigate the correlation between the ultrasound findings at the popliteal groove region and the clinical features. METHODS Bilateral ultrasound assessment of the popliteal groove region, patellar tendon and femoral condyles' hyaline cartilage was performed on 47 consecutive patients with gout and 37 controls. The ultrasound findings indicating monosodium urate crystals (aggregates, tophi and "double-contour" sign) were identified according to the Outcome Measures in Rheumatology definitions. RESULTS One or more ultrasound abnormalities (aggregates and/or tophi) were found in at least one popliteal groove region in 23 out of 47 patients with gout (48.9%) and in 4 out of 37 controls (10.8%) (P < 0.001). Sensitivity, specificity and diagnostic odds ratio of the ultrasound findings at the popliteal groove region, patellar tendon and at the femoral condyles' hyaline cartilage were 0.49/0.89/7.9, 0.62/0.81/6.9 and 0.30/1.0/32.0, respectively. There was a significant correlation between the ultrasound findings at the popliteal groove region and history of knee inflammatory involvement (P < 0.001, V = 0.644) and number of gouty "attacks" in the previous year (P = 0.012, V = 0.434). CONCLUSIONS This study provides new insights into the ultrasound assessment of patients with gout, highlighting the clinical relevance of the popliteal groove region as an area of collection of otherwise undetectable monosodium urate crystals.
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Ramon A, Bohm-Sigrand A, Pottecher P, Richette P, Maillefert JF, Devilliers H, Ornetti P. Role of dual-energy CT in the diagnosis and follow-up of gout: systematic analysis of the literature. Clin Rheumatol 2018; 37:587-595. [PMID: 29350330 DOI: 10.1007/s10067-017-3976-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 12/28/2017] [Accepted: 12/29/2017] [Indexed: 12/27/2022]
Abstract
The aim of this systematic review was to determine the potential role of dual-energy CT in the diagnosis and follow-up of gout with regard to the Outcome Measures in Rheumatology (OMERACT) filter. A systematic analysis of the literature was conducted using the MEDLINE and Cochrane databases and published abstracts of international congresses, according to the criteria of the OMERACT filter: feasibility, reproducibility, validity versus laboratory (serum urate, MSU synovial fluid aspirate) and other imaging modalities for gout, and its sensitivity to change in patients on urate lowering therapy (ULT). Thirty-two articles were found representing a total of 1502 patients. The data on feasibility showed that the examination took little time and involved low levels of radiation but had current limited availability. Intra- and inter-observer reproducibility was excellent, with intra-class correlation coefficients > 0.9. Validity in comparison with polarized-light microscopy showed good sensitivity and specificity (> 80%). The diagnostic performance was better than that of radiography and conventional CT-scan and at least equivalent to that of ultrasonography. The sensitivity to change varied with effect sizes from 0.05 (low) to 1.24 (high) for decrease in the tophus volume following different ULT in gout patients. Dual-energy CT-scan is a reproducible and accurate imaging modality for the diagnosis of gout, particularly for tophaceous gout (intra- or extra-articular). It can become a second-line imaging modality of choice in cases of diagnostic doubt, such as ultrasonography. Its role remains uncertain in the follow-up of gout patients treated with ULT and needs further clarification.
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Affiliation(s)
- André Ramon
- Department of Rheumatology, Dijon University Hospital, 14 rue Gaffarel, 21000, Dijon, France
| | - Amélie Bohm-Sigrand
- Department of Rheumatology, Dijon University Hospital, 14 rue Gaffarel, 21000, Dijon, France
| | - Pierre Pottecher
- Department of Radiology, Section of Musculoskeletal Imaging and Intervention, Dijon University Hospital, Dijon, France
- LE2I UMR CNRS 6306, Arts et Métiers, University of Burgundy, Dijon, France
| | - Pascal Richette
- INSERM U1132 and University Paris-Diderot, Paris, France
- Department of Rheumatology, Hopital Lariboisiere, Paris, France
| | - Jean-Francis Maillefert
- Department of Rheumatology, Dijon University Hospital, 14 rue Gaffarel, 21000, Dijon, France
- INSERM UMR1093-CAPS, Bourgogne Franche-Comté University, Dijon, France
| | - Herve Devilliers
- Department of Internal Medicine, Dijon University Hospital, Dijon, France
- CIC INSERM 1432, Centre Hospitalier Universitaire de Dijon, F-21000, Dijon, France
| | - Paul Ornetti
- Department of Rheumatology, Dijon University Hospital, 14 rue Gaffarel, 21000, Dijon, France.
- INSERM UMR1093-CAPS, Bourgogne Franche-Comté University, Dijon, France.
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Nguyen USDT, Zhang Y, Louie-Gao Q, Niu J, Felson DT, LaValley MP, Choi HK. Obesity Paradox in Recurrent Attacks of Gout in Observational Studies: Clarification and Remedy. Arthritis Care Res (Hoboken) 2017; 69:561-566. [PMID: 27331767 DOI: 10.1002/acr.22954] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 05/10/2016] [Accepted: 06/07/2016] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Obesity is strongly associated with incident gout risk, but its association with the risk of recurrent gout attacks has been null or weak, constituting an obesity paradox. We sought to demonstrate and overcome the methodologic issues associated with the obesity paradox for risk of recurrent gout attacks. METHODS Using the Multiple Risk Factor Intervention Trial database, we decomposed the total effect of obesity into its direct and indirect (i.e., mediated) effects using marginal structural models. We also estimated the total effect of body mass index (BMI) change from baseline among incident gout patients. RESULTS Of 11,816 gout-free subjects at baseline, we documented 408 incident gout cases, with 132 developing recurrent gout attacks over a 7-year followup period. The adjusted odds ratio (OR) for incident gout among obese individuals was 2.6, whereas that for recurrent gout attacks among gout patients was 0.98 (i.e., the obesity paradox). These ORs correlated well with the ORs for the indirect and direct effects of obesity on the risk of recurrent gout attacks (2.83 and 0.98, respectively). Compared with no BMI change, the OR of increasing versus decreasing >5% of baseline BMI was 0.61 and 1.60 for recurrent gout attacks, respectively (P for trend < 0.01), suggesting a dose-response association. CONCLUSION The obesity paradox for the risk of recurrent gout attacks is explained by the absence of the direct effect, which is often measured in conventional analyses and misinterpreted as the intended total effect of interest. In contrast, the BMI change analysis correctly estimated the intended total effect of BMI, and revealed a dose-response relationship.
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Affiliation(s)
- Uyen-Sa D T Nguyen
- University of Massachusetts Medical School, Worcester, and Boston University School of Medicine, Boston, Massachusetts
| | - Yuqing Zhang
- Boston University School of Medicine, Boston, Massachusetts
| | | | - Jingbo Niu
- Boston University School of Medicine, Boston, Massachusetts
| | - David T Felson
- Boston University School of Medicine, Boston, Massachusetts
| | | | - Hyon K Choi
- Boston University School of Medicine, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts
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Comparison of dual-energy CT, ultrasound and surface measurement for assessing tophus dissolution during rapid urate debulking. Clin Rheumatol 2017. [PMID: 28623421 DOI: 10.1007/s10067-017-3729-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Tophaceous gout is painful and impairs quality of life. The optimal modality for assessing tophus resolution in response to urate-lowering treatment remains poorly defined. Using pegloticase as a model system for resolving tophi, we compared multiple imaging and physical diagnostic strategies for assessing tophus resolution. A 32-year-old subject with chronic refractory tophaceous gout was enrolled and received 6 months of pegloticase treatment. Measurements of tophi using vernier calipers (monthly), photographs and musculoskeletal ultrasound (MSK-US; every 3 months), and dual-energy CT (DECT) were compared. Pegloticase persistently lowered the patient's sUA to <0.5 mg/dl. After 6 months, caliper measurements revealed 73, 60, and 61% reductions of three index tophi, while MSK-US revealed 47, 65, and 48% reductions. In contrast, DECT revealed 100% resolution of monosodium urate deposition in all three index tophi, and resolution or improvement of all other tophi identified. On caliper and MSK-US measurement, index tophus size fluctuated, with some lesions enlarging before ultimately contracting. Correlation between assessment modalities during tophus resolution may be poor. DECT identifies urate deposits invisible to physical exam and reveals that some urate deposits completely resolve even as their physically/sonographically measurable lesions persist. Recognition of urate resorption during the urate-lowering process may be confounded by fluctuating lesion volumes during initial tophus breakdown. While DECT was superior for identifying total (including occult) urate deposition, and assessing volume of deposits, other modalities may permit better assessment of non-urate tophus components.
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Fernandes EDA, Bergamaschi SB, Rodrigues TC, Dias GC, Malmann R, Ramos GM, Monteiro SS. Aspectos relevantes do diagnóstico e seguimento por imagem na gota. REVISTA BRASILEIRA DE REUMATOLOGIA 2017. [DOI: 10.1016/j.rbr.2016.03.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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Bardin T, Keenan RT, Khanna PP, Kopicko J, Fung M, Bhakta N, Adler S, Storgard C, Baumgartner S, So A. Lesinurad in combination with allopurinol: a randomised, double-blind, placebo-controlled study in patients with gout with inadequate response to standard of care (the multinational CLEAR 2 study). Ann Rheum Dis 2016; 76:811-820. [PMID: 27821644 PMCID: PMC5530336 DOI: 10.1136/annrheumdis-2016-209213] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Revised: 08/25/2016] [Accepted: 10/05/2016] [Indexed: 01/19/2023]
Abstract
Objectives Determine the efficacy and safety of daily lesinurad (200 or 400 mg orally) added to allopurinol in patients with serum uric acid (sUA) above target in a 12-month, randomised, phase III trial. Methods Patients on allopurinol ≥300 mg (≥200 mg in moderate renal impairment) had sUA level of ≥6.5 mg/dL (≥387 µmol/L) at screening and two or more gout flares in the prior year. Primary end point was the proportion of patients achieving sUA level of <6.0 mg/dL (<357 µmol/L) (month 6). Key secondary end points were mean gout flare rate requiring treatment (months 7 through 12) and proportions of patients with complete resolution of one or more target tophi (month 12). Safety assessments included adverse events and laboratory data. Results Patients (n=610) were predominantly male, with mean (±SD) age 51.2±10.90 years, gout duration 11.5±9.26 years and baseline sUA of 6.9±1.2 mg/dL (410±71 µmol/L). Lesinurad at 200 and 400 mg doses, added to allopurinol, significantly increased proportions of patients achieving sUA target versus allopurinol-alone therapy by month 6 (55.4%, 66.5% and 23.3%, respectively, p<0.0001 both lesinurad+allopurinol groups). In key secondary end points, there were no statistically significant treatment-group differences favouring lesinurad. Lesinurad was generally well tolerated; the 200 mg dose had a safety profile comparable with allopurinol-alone therapy. Renal-related adverse events occurred in 5.9% of lesinurad 200 mg+allopurinol, 15.0% of lesinurad 400 mg+allopurinol and 4.9% of allopurinol-alone groups, with serum creatinine elevation of ≥1.5× baseline in 5.9%, 15.0% and 3.4%, respectively. Serious treatment-emergent adverse events occurred in 4.4% of lesinurad 200 mg+allopurinol, in 9.5% of lesinurad 400 mg+allopurinol and in 3.9% of allopurinol-alone groups, respectively. Conclusion Lesinurad added to allopurinol demonstrated superior sUA lowering versus allopurinol-alone therapy and lesinurad 200 mg was generally well tolerated in patients with gout warranting additional therapy. Trial registration number NCT01493531.
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Affiliation(s)
- Thomas Bardin
- Rhumatologie, Lariboisière Hospital, and Université Paris Diderot Sorbonne Cité, Paris, France
| | - Robert T Keenan
- Division of Rheumatology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Puja P Khanna
- Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Jeff Kopicko
- Biometrics, Ardea Biosciences, Inc., San Diego, California, USA
| | - Maple Fung
- Research & Development, Ardea Biosciences, Inc., San Diego, California, USA
| | - Nihar Bhakta
- Research & Development, Ardea Biosciences, Inc., San Diego, California, USA
| | - Scott Adler
- Research & Development, AstraZeneca Pharmaceuticals, Gaithersburg, Maryland, USA
| | - Chris Storgard
- Research & Development, Ardea Biosciences, Inc., San Diego, California, USA
| | - Scott Baumgartner
- Medical Affairs, Ardea Biosciences, Inc., San Diego, California, USA
| | - Alexander So
- Service de rhumatologie, Université de Lausanne, Lausanne, Switzerland
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Scirè CA, Carrara G, Viroli C, Cimmino MA, Taylor WJ, Manara M, Govoni M, Salaffi F, Punzi L, Montecucco C, Matucci-Cerinic M, Minisola G. Development and First Validation of a Disease Activity Score for Gout. Arthritis Care Res (Hoboken) 2016; 68:1530-7. [PMID: 26815286 PMCID: PMC5129490 DOI: 10.1002/acr.22844] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 12/06/2015] [Accepted: 01/12/2016] [Indexed: 01/24/2023]
Abstract
Objective To develop a new composite disease activity score for gout and provide its first validation. Methods Disease activity has been defined as the ongoing presence of urate deposits that lead to acute arthritis and joint damage. Every measure for each Outcome Measures in Rheumatology core domain was considered. A 3‐step approach (factor analysis, linear discriminant analysis, and linear regression) was applied to derive the Gout Activity Score (GAS). Decision to change treatment or 6‐month flare count were used as the surrogate criteria of high disease activity. Baseline and 12‐month followup data of 446 patients included in the Kick‐Off of the Italian Network for Gout cohort were used. Construct‐ and criterion‐related validity were tested. External validation on an independent sample is reported. Results Factor analysis identified 5 factors: patient‐reported outcomes, joint examination, flares, tophi, and serum uric acid (sUA). Discriminant function analysis resulted in a correct classification of 79%. Linear regression analysis identified a first candidate GAS including 12‐month flare count, sUA, visual analog scale (VAS) of pain, VAS global activity assessment, swollen and tender joint counts, and a cumulative measure of tophi. Alternative scores were also developed. The developed GAS demonstrated a good correlation with functional disability (criterion validity) and discrimination between patient‐ and physician‐reported measures of active disease (construct validity). The results were reproduced in the external sample. Conclusion This study developed and validated a composite measure of disease activity in gout. Further testing is required to confirm its generalizability, responsiveness, and usefulness in assisting with clinical decisions.
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Das S, Ghosh A, Ghosh P, Lahiri D, Sinhamahapatra P, Basu K. Sensitivity and specificity of ultrasonographic features of gout in intercritical and chronic phase. Int J Rheum Dis 2016; 20:887-893. [PMID: 27529533 DOI: 10.1111/1756-185x.12928] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Shyamashis Das
- Department of Rheumatology; Institute of Postgraduate Medical Education and Research; Kolkata West Bengal India
| | - Alakendu Ghosh
- Department of Rheumatology; Institute of Postgraduate Medical Education and Research; Kolkata West Bengal India
| | - Parasar Ghosh
- Department of Rheumatology; Institute of Postgraduate Medical Education and Research; Kolkata West Bengal India
| | - Debasish Lahiri
- Department of Rheumatology; Institute of Postgraduate Medical Education and Research; Kolkata West Bengal India
| | - Pradyot Sinhamahapatra
- Department of Rheumatology; Institute of Postgraduate Medical Education and Research; Kolkata West Bengal India
| | - Kaushik Basu
- Department of Rheumatology; Institute of Postgraduate Medical Education and Research; Kolkata West Bengal India
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Suh YS, Cheon YH, Kim JE, Kim JM, Kim SH, Lee WS, Yoo WH, Lee SI, Kim HO. Usefulness of plain radiography for assessing hypouricemic treatment response in patients with tophaceous gout. Int J Rheum Dis 2016; 19:1183-1188. [PMID: 27514938 DOI: 10.1111/1756-185x.12921] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM To investigate whether plain radiography is useful for assessing the changes in gouty tophi size following hypouricemic therapy. METHODS Gout was diagnosed according to the American College of Rheumatology criteria. Before and after hypouricemic treatment, serum uric acid level was measured, and plain radiography was performed to measure gouty tophi size. The tophi were graded by measuring the maximum vertical and horizontal diameters, and they were scored by adding up the scores of the grades. The vertical diameter was measured on both sides of the proximal phalanges (PPs). The horizontal diameter was measured on the lateral side of the PPs. The maximum vertical diameter measurement was graded 0-4. The maximum horizontal diameter measurement was graded 0-3. RESULTS Seven hundred first metatarsal phalangeal joints (MTPJ) of 350 patients with gout were assessed for gouty tophi. Tophi were observed using plain radiography in 174 MTPJs (24.9%) of 109 patients (31.1%). Follow-up plain radiography was performed in 60 of these patients. Before the treatment, the average serum uric acid level of these patients was 8.3 ± 1.9 mg/dL, and the average tophi score was 3.7 ± 2.5. After hypouricemic treatment, the uric acid level decreased to 5.9 ± 1.6 mg/dL (P < 0.05), and the average tophi score decreased to 1.5 ± 1.8 (P < 0.05). CONCLUSIONS This new method for measuring gouty tophi using plain radiography may be useful for evaluating changes in gouty tophi size following hypouricemic treatment.
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Affiliation(s)
- Young Sun Suh
- Department of Internal Medicine and Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Yun-Hong Cheon
- Department of Internal Medicine and Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Ji Eun Kim
- Department of Radiology, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Ji-Min Kim
- Department of Internal Medicine, School of Medicine, Keimyung University, Daegu, Korea
| | - Sang-Hyon Kim
- Department of Internal Medicine, School of Medicine, Keimyung University, Daegu, Korea
| | - Won-Seok Lee
- Department of Internal Medicine, Chonbuk National University Medical School, Jeonju, Korea
| | - Wan-Hee Yoo
- Department of Internal Medicine, Chonbuk National University Medical School, Jeonju, Korea
| | - Sang-Il Lee
- Department of Internal Medicine and Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Hyun-Ok Kim
- Department of Internal Medicine and Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Korea
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De Avila Fernandes E, Bergamaschi SB, Rodrigues TC, Dias GC, Malmann R, Ramos GM, Monteiro SS. Relevant aspects of imaging in the diagnosis and management of gout. REVISTA BRASILEIRA DE REUMATOLOGIA 2016; 57:64-72. [PMID: 28137404 DOI: 10.1016/j.rbre.2016.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 03/31/2016] [Indexed: 12/27/2022] Open
Abstract
Gout is an inflammatory arthritis characterized by the deposition of monosodium urate crystals in the synovial membrane, articular cartilage and periarticular tissues leading to inflammation. Men are more commonly affected, mainly after the 5th decade of life. Its incidence has been growing with the population aging. In the majority of the cases, the diagnosis is made by clinical criteria and synovial fluid analysis, in search for monosodium urate crystals. Nonetheless, gout may sometimes have atypical presentations, complicating the diagnosis. In these situations, imaging methods have a fundamental role, aiding in the diagnostic confirmation or excluding other possible differential diagnosis. Conventional radiographs are still the most commonly used method in gout patients' evaluation; nevertheless, this is not a sensitive method, since it detect only late alterations. In the last years, there have been several advances in imaging methods for gout patients. Ultrasound has shown a great accuracy in the diagnosis of gout, identifying monosodium urate deposits in the synovial membrane and articular cartilage, in detecting and characterizing tophi and in identifying tophaceous tendinopathy and enthesopathy. Ultrasound has also been able to show crystal deposition in patients with articular pain in the absence of a classical gout crisis. Computed tomography is an excellent method for detecting bone erosions, being useful in spine involvement. Dual-energy CT is a new method able to provide information about the chemical composition of tissues, with high accuracy in the identification of monosodium urate deposits, even in the early stages of the disease and in cases of difficult characterization. Magnetic resonance imaging is useful in the evaluation of deep tissues not accessible by ultrasound. Besides the diagnosis, with the emergence of new drugs that aim to reduce tophaceous burden, imaging methods have become useful tools in monitoring the treatment of patients with gout.
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Affiliation(s)
- Eloy De Avila Fernandes
- Hospital do Servidor Público Estadual (Iamspe), São Paulo, SP, Brazil; Universidade Federal de São Paulo (Unifesp), Departamento de Diagnóstico por Imagem, São Paulo, SP, Brazil
| | | | | | | | - Ralff Malmann
- Hospital Estadual Vila Alpina, São Paulo, SP, Brazil
| | | | - Soraya Silveira Monteiro
- Hospital do Servidor Público Estadual (Iamspe), São Paulo, SP, Brazil; Universidade Federal de São Paulo (Unifesp), Departamento de Diagnóstico por Imagem, São Paulo, SP, Brazil
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Petsch C, Araujo EG, Englbrecht M, Bayat S, Cavallaro A, Hueber AJ, Lell M, Schett G, Manger B, Rech J. Prevalence of monosodium urate deposits in a population of rheumatoid arthritis patients with hyperuricemia. Semin Arthritis Rheum 2015; 45:663-8. [PMID: 26743072 DOI: 10.1016/j.semarthrit.2015.11.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 11/18/2015] [Accepted: 11/25/2015] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To investigate the prevalence of monosodium urate (MSU) crystal deposits, indicative for gout, in a population of rheumatoid arthritis (RA) patients with concomitant hyperuricemia and to analyze the clinical and disease-specific characteristics of RA patients who exhibit MSU crystal deposits. METHODS Overall, 100 consecutive patients with the diagnosis of RA and a serum urate level above 6mg/dl underwent dual energy computed tomography (DECT) of both feet and hands to search for MSU crystals in a prospective study between October 2011 and July 2013. Presence and extent of MSU crystal deposits on DECT was assessed by automated volume measurement. Demographic and disease-specific characteristics were recorded and included into two logistic regression models to test for the factors associated with MSU crystal deposits in RA. RESULTS Hyperuricemic RA patients were mostly male (55%), over 60 years of age (63 ± 11 years), had established disease (8.7 ± 10.5 years) and a mean disease activity score 28 (DAS 28) of 3.2. In total, 20 out of 100 patients displayed MSU crystal deposits in DECT. Interestingly, the majority (70%) of the RA patients positive for MSU crystal deposits were seronegative RA patients. Hence, every third seronegative RA patient had MSU crystal deposits. According to logistic regression model analysis, seronegative status correlated positively with presence of urate deposits (p = 0.019). CONCLUSIONS These data show that a considerable number of RA patients display periarticular MSU crystal deposits. Seronegative patients were shown to be predominantly affected with every third patient being positive for urate deposits.
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Affiliation(s)
- Christina Petsch
- Department of Internal Medicine 3, Rheumatology and Immunology, University of Erlangen-Nuremberg, Ulmenweg 18, 91054 Erlangen, Germany
| | - Elizabeth G Araujo
- Department of Internal Medicine 3, Rheumatology and Immunology, University of Erlangen-Nuremberg, Ulmenweg 18, 91054 Erlangen, Germany
| | - Matthias Englbrecht
- Department of Internal Medicine 3, Rheumatology and Immunology, University of Erlangen-Nuremberg, Ulmenweg 18, 91054 Erlangen, Germany
| | - Sara Bayat
- Department of Internal Medicine 3, Rheumatology and Immunology, University of Erlangen-Nuremberg, Ulmenweg 18, 91054 Erlangen, Germany
| | - Alexander Cavallaro
- Department of Radiology, University of Erlangen-Nuremberg, Ulmenweg 18, 91054 Erlangen, Germany
| | - Axel J Hueber
- Department of Internal Medicine 3, Rheumatology and Immunology, University of Erlangen-Nuremberg, Ulmenweg 18, 91054 Erlangen, Germany
| | - Michael Lell
- Department of Radiology, University of Erlangen-Nuremberg, Ulmenweg 18, 91054 Erlangen, Germany
| | - Georg Schett
- Department of Internal Medicine 3, Rheumatology and Immunology, University of Erlangen-Nuremberg, Ulmenweg 18, 91054 Erlangen, Germany
| | - Bernhard Manger
- Department of Internal Medicine 3, Rheumatology and Immunology, University of Erlangen-Nuremberg, Ulmenweg 18, 91054 Erlangen, Germany
| | - Juergen Rech
- Department of Internal Medicine 3, Rheumatology and Immunology, University of Erlangen-Nuremberg, Ulmenweg 18, 91054 Erlangen, Germany.
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Abstract
The tophus is the cardinal feature of advanced gout. This review summarises recent research into the biology, impact and treatment of tophaceous gout. Microscopically, tophi are chronic foreign body granuloma-like structures containing collections of monosodium urate (MSU) crystals surrounded by inflammatory cells and connective tissue. Extracellular trap formation mediated by neutrophil interactions with MSU crystals may be a central checkpoint in tophus formation. Gouty tophi impact on many aspects of health-related quality of life. Tophi are also implicated in the development of structural joint damage and increased mortality risk in people with gout. Effective treatment of tophaceous gout requires long-term urate-lowering therapy, ideally to achieve a serum urate concentration of <5 mg/dL (300 μmol/L). Recent advances in gout therapeutics have expanded urate-lowering therapy options for patients with severe tophaceous disease to allow faster regression of tophi, improved health-related quality of life and, potentially, improved structural outcomes.
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Affiliation(s)
- Ashika Chhana
- Bone and Joint Research Group, Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Rd. Grafton, Auckland, New Zealand,
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Diekhoff T, Ziegeler K, Feist E, Kiefer T, Mews J, Hamm B, Hermann KGA. First experience with single-source dual-energy computed tomography in six patients with acute arthralgia: a feasibility experiment using joint aspiration as a reference. Skeletal Radiol 2015; 44:1573-7. [PMID: 26142537 DOI: 10.1007/s00256-015-2204-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 05/29/2015] [Accepted: 06/15/2015] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Dual-energy computed tomography (DECT) is an emerging imaging technique for examining patients with suspected gout. Single-source dual-energy CT (S-DECT) is a new way of obtaining DECT information on conventional CT scanners rather than using special dual-source CT systems. METHODS We tested the feasibility of S-DECT (320-row CT; Aquilion ONE, Toshiba Medical Systems, Otawara, Japan) in 6 patients (5 men, 1 woman; mean age 61.3, range 48 to 69 years) with acute arthralgia and suspected gout, and compared the S-DECT findings with the results of joint aspiration. RESULTS Three patients had a diagnosis of gouty arthritis with negatively birefringent crystals in synovial fluid, in addition to gouty tophi in S-DECT. Three patients had no detectable crystals by polarization microscopy and no tophi on DECT. Their final diagnoses were rheumatoid arthritis, activated osteoarthritis, and septic arthritis in one case each. CONCLUSION This initial experience suggests that S-DECT might be a valuable alternative to dual-source CT. Hence, more patients may benefit from its additional diagnostic abilities in the future.
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Affiliation(s)
- Torsten Diekhoff
- Department of Radiology, Charité-Universitätsmedizin Berlin Campus Mitte, Humboldt-Universität zu Berlin, Freie Universität Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Katharina Ziegeler
- Department of Rheumatology and Clinical Immunology, Charité-Universitätsmedizin Berlin Campus Mitte, Humboldt-Universität zu Berlin, Freie Universität Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Eugen Feist
- Department of Rheumatology and Clinical Immunology, Charité-Universitätsmedizin Berlin Campus Mitte, Humboldt-Universität zu Berlin, Freie Universität Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Tobias Kiefer
- Department of Radiology, Charité-Universitätsmedizin Berlin Campus Mitte, Humboldt-Universität zu Berlin, Freie Universität Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Jürgen Mews
- Toshiba Medical Systems Europe, BV, Zilverstraat 1, 2701 RP, Zoetermeer, Netherlands
| | - Bernd Hamm
- Department of Radiology, Charité-Universitätsmedizin Berlin Campus Mitte, Humboldt-Universität zu Berlin, Freie Universität Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Kay-Geert A Hermann
- Department of Radiology, Charité-Universitätsmedizin Berlin Campus Mitte, Humboldt-Universität zu Berlin, Freie Universität Berlin, Charitéplatz 1, 10117, Berlin, Germany
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Outcome Measures for Gout Clinical Trials: a Summary of Progress. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2015. [DOI: 10.1007/s40674-015-0014-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Pineda C, Fuentes-Gómez AJ, Hernández-Díaz C, Zamudio-Cuevas Y, Fernández-Torres J, López-Macay A, Alba-Sánchez I, Camacho-Galindo J, Ventura L, Gómez-Quiróz LE, Gutiérrez-Ruíz MC, García-Vázquez F, Reginato AM, Gutiérrez M, López-Reyes A. Animal model of acute gout reproduces the inflammatory and ultrasonographic joint changes of human gout. Arthritis Res Ther 2015; 17:37. [PMID: 25889158 PMCID: PMC4363186 DOI: 10.1186/s13075-015-0550-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 02/05/2015] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Gout is an inflammatory condition induced by the deposition of monosodium urate (MSU) crystals in the joints and soft tissues that can produce acute or chronic arthritis. Several animal models of crystal-induced inflammation have been proposed that involve direct injection of MSU-crystals into different anatomical structures; however, only a few of these models reflect a true diarthrodial joint microenvironment in which an acute gouty attack takes place. The aim of this study was to assess the inflammatory and structural joint changes in a rabbit model of acute gout attack by ultrasound (US), synovial fluid (SF) and histopathological analyses. METHODS Under US guidance, 42 rabbit knees were randomly injected with a suspension of 50 mg/ml of either MSU or allopurinol synthetic crystals. The control group received intra-articular vehicle of phosphate-buffered saline (PBS). US evaluation, SF and histopathological analyses were performed at days 1, 3, and 7. RESULTS A total of 21 rabbit knees were assigned to the control group, 12 to the MSU-crystals group, and 9 to the allopurinol crystals group. By US, the MSU crystals group displayed the double contour sign and bright stippled aggregates in 67% and 75% of joints, respectively. Neither control knees nor allopurinol crystals group displayed these US signs. Power Doppler (PD) signal was moderate to intense in the MSU-crystals group and greater than both the allopurinol crystal and control groups at day 1 (P<0.001) and 3 (P<0.05), with its practical disappearance by day 7. SF leukocyte count was 40,312±6,369 cells/mm3 in the MSU-crystals group, higher than in controls (P=0.004) and allopurinol crystal group (P=0.006). At day 7, SF leukocyte count decreased in both MSU and allopurinol crystal groups reaching the non-inflammatory range. Histologically, at day 3 intense synovial polymorphonuclear cells infiltration and MSU aggregates were identified. CONCLUSION The rabbit model of MSU crystal-induced acute arthritis efficiently reproduces the inflammatory, US, SF and histopathological changes of the human acute gouty attack.
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Affiliation(s)
- Carlos Pineda
- Molecular Synovioanalysis Laboratory, Musculoskeletal Ultrasound Laboratory, Hip-Knee Joint Reconstruction Department, Instituto Nacional de Rehabilitación, Calzada Mexico-Xochimilco 289, Tlalpan, 14389, Mexico City, Mexico.
- Biological and health sciences PhD program, Universidad Autónoma Metropolitana, Avenida San Rafael Atlixco 186, Iztapalapa, 09340, Mexico City, Mexico.
| | - Arturo J Fuentes-Gómez
- Molecular Synovioanalysis Laboratory, Musculoskeletal Ultrasound Laboratory, Hip-Knee Joint Reconstruction Department, Instituto Nacional de Rehabilitación, Calzada Mexico-Xochimilco 289, Tlalpan, 14389, Mexico City, Mexico.
| | - Cristina Hernández-Díaz
- Molecular Synovioanalysis Laboratory, Musculoskeletal Ultrasound Laboratory, Hip-Knee Joint Reconstruction Department, Instituto Nacional de Rehabilitación, Calzada Mexico-Xochimilco 289, Tlalpan, 14389, Mexico City, Mexico.
| | - Yessica Zamudio-Cuevas
- Molecular Synovioanalysis Laboratory, Musculoskeletal Ultrasound Laboratory, Hip-Knee Joint Reconstruction Department, Instituto Nacional de Rehabilitación, Calzada Mexico-Xochimilco 289, Tlalpan, 14389, Mexico City, Mexico.
- Molecular Microbiology Laboratory, Department of Microbiology, Escuela Nacional de Ciencias Biológicas (ENCB), Instituto Politécnico Nacional (IPN), Prolongación de Carpio y Plan de Ayala S/N, Col. Casco de Santo Tomás, Miguel Hidalgo, 11340, Mexico City, Mexico.
| | - Javier Fernández-Torres
- Molecular Synovioanalysis Laboratory, Musculoskeletal Ultrasound Laboratory, Hip-Knee Joint Reconstruction Department, Instituto Nacional de Rehabilitación, Calzada Mexico-Xochimilco 289, Tlalpan, 14389, Mexico City, Mexico.
| | - Ambar López-Macay
- Molecular Synovioanalysis Laboratory, Musculoskeletal Ultrasound Laboratory, Hip-Knee Joint Reconstruction Department, Instituto Nacional de Rehabilitación, Calzada Mexico-Xochimilco 289, Tlalpan, 14389, Mexico City, Mexico.
| | - Ismael Alba-Sánchez
- Molecular Synovioanalysis Laboratory, Musculoskeletal Ultrasound Laboratory, Hip-Knee Joint Reconstruction Department, Instituto Nacional de Rehabilitación, Calzada Mexico-Xochimilco 289, Tlalpan, 14389, Mexico City, Mexico.
| | - Javier Camacho-Galindo
- Molecular Synovioanalysis Laboratory, Musculoskeletal Ultrasound Laboratory, Hip-Knee Joint Reconstruction Department, Instituto Nacional de Rehabilitación, Calzada Mexico-Xochimilco 289, Tlalpan, 14389, Mexico City, Mexico.
| | - Lucio Ventura
- Molecular Synovioanalysis Laboratory, Musculoskeletal Ultrasound Laboratory, Hip-Knee Joint Reconstruction Department, Instituto Nacional de Rehabilitación, Calzada Mexico-Xochimilco 289, Tlalpan, 14389, Mexico City, Mexico.
| | - Luis E Gómez-Quiróz
- Departamento de Ciencias de la Salud, Universidad Autónoma Metropolitana, Avenida San Rafael Atlixco 186, Iztapalapa, 09340, Mexico City, Mexico.
| | - María Concepción Gutiérrez-Ruíz
- Departamento de Ciencias de la Salud, Universidad Autónoma Metropolitana, Avenida San Rafael Atlixco 186, Iztapalapa, 09340, Mexico City, Mexico.
| | - Francisco García-Vázquez
- Pathology Department, National Institute of Pediatrics, Av. Insurgentes Sur 3700-C, Coyoacán, 04530, Mexico City, Mexico.
| | - Anthony M Reginato
- Rheumatology Division, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, 02903, RI, USA.
| | - Marwin Gutiérrez
- Clinica Reumatologica, Università Politecnica delle Marche, Via dei Colli 52-60035, Jesi, Ancona, Italy.
| | - Alberto López-Reyes
- Molecular Synovioanalysis Laboratory, Musculoskeletal Ultrasound Laboratory, Hip-Knee Joint Reconstruction Department, Instituto Nacional de Rehabilitación, Calzada Mexico-Xochimilco 289, Tlalpan, 14389, Mexico City, Mexico.
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Abstract
BACKGROUND Uricosuric agents have long been used in the treatment of gout but there is little evidence regarding their benefit and safety in this condition. OBJECTIVES To assess the benefits and harms of uricosuric medications in the treatment of chronic gout. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 4, 2013), Ovid MEDLINE and Ovid EMBASE for studies to the 13 May 2013. We also searched the World Health Organization Clinical Trials Registry, ClinicalTrials.gov and the 2011 to 2012 American College of Rheumatology and European League against Rheumatism abstracts. WE considered black box warnings and searched drug safety databases to identify and describe rare adverse events. SELECTION CRITERIA We considered all randomised controlled trials (RCTs) or quasi-randomised controlled trials (controlled clinical trials (CCTs)) that compared uricosuric medications (benzbromarone, probenecid or sulphinpyrazone) alone or in combination with another therapy (placebo or other active uric acid-lowering medication, or non-pharmacological treatment) in adults with chronic gout for inclusion. DATA COLLECTION AND ANALYSIS Two review authors independently selected the studies for inclusion, extracted data and performed a risk of bias assessment. Main outcomes were frequency of acute gout attacks, serum urate normalisation, study participant withdrawal due to adverse events, total adverse events, pain reduction, function and tophus regression. MAIN RESULTS The search identified four RCTs and one CCT that evaluated the benefit and safety of uricosurics for gout. One study (65 participants) compared benzbromarone with allopurinol for a duration of four months; one compared benzbromarone with allopurinol (36 participants) for a duration of nine to 24 months; one study (62 participants) compared benzbromarone with probenecid for two months and one study (74 participants) compared benzbromarone with probenecid. One study (37 participants) compared allopurinol with probenecid. No study was completely free from bias.Low-quality evidence from one study (55 participants) comparing benzbromarone with allopurinol indicated uncertain effects in terms of frequency of acute gout attacks (4% with benzbromarone versus 0% with allopurinol; risk ratio (RR) 3.58, 95% confidence interval (CI) 0.15 to 84.13), while moderate-quality evidence from two studies (101 participants; treated for four to nine months) indicated similar proportions of participants achieving serum urate normalisation (73.9% with benzbromarone versus 60% with allopurinol; pooled RR 1.27, 95% CI 0.90 to 1.79). Low-quality evidence indicated uncertain differences in withdrawals due to adverse events (7.1% with benzbromarone versus 6.1% with allopurinol; pooled RR 1.25, 95% CI 0.28 to 5.62), and total adverse events (20% with benzbromarone versus 6.7% with allopurinol; RR 3.00, 95% CI 0.64 to 14.16). The study did not measure pain reduction, function and tophus regression.When comparing benzbromarone with probenecid, there was moderate-quality evidence based on one study (62 participants) that participants taking benzbromarone were more likely to achieve serum urate normalisation after two months (81.5% with benzbromarone versus 57.1% with probenecid; RR 1.43, 95% CI 1.02 to 2.00). This indicated that when compared with probenecid, five participants needed to be treated with benzbromarone in order to have one additional person achieve serum urate normalisation (number needed to treat for an additional beneficial outcome (NNTB) 5). However, the second study reported no difference in the absolute decrease in serum urate between these groups after 12 weeks. Low-quality evidence from two studies (129 participants) indicated uncertain differences between treatments in the frequency of acute gout attacks (6.3% with benzbromarone versus 10.6% with probenecid; pooled RR 0.73, 95% CI 0.09 to 5.83); fewer withdrawals due to adverse events with benzbromarone (2% with benzbromarone versus 17% with probenecid; pooled RR 0.15, 95% CI 0.03 to 0.79, NNTB 7) and fewer total adverse events (21% with benzbromarone versus 47% with probenecid; pooled RR 0.43, 95% CI 0.25 to 0.74; NNTB 4). The studies did not measure pain reduction, function and tophus regression.Low-quality evidence based on one small CCT (37 participants) indicated uncertainty around the difference in the incidence of acute gout attacks between probenecid and allopurinol after 18 to 20 months' treatment (53% with probenecid versus 55% with allopurinol; RR 0.96, 95% CI 0.53 to 1.75). The study did not measure or report the proportion achieving serum urate normalisation, pain reduction, function, tophus regression, withdrawal due to adverse events and total adverse events. AUTHORS' CONCLUSIONS There was moderate-quality evidence that there is probably no important difference between benzbromarone and allopurinol at achieving serum urate normalisation, but that benzbromarone is probably more successful than probenecid at achieving serum urate normalisation in people with gout. There is some uncertainty around the effect estimates, based on low-quality evidence from only one or two trials, on the number of acute gout attacks, the number of withdrawals due to adverse events or the total number of participants experiencing adverse events when comparing benzbromarone with allopurinol. However, when compared with probenecid, benzbromarone resulted in fewer withdrawals due to adverse events and fewer participants experiencing adverse events. Low-quality evidence from one small study indicated uncertain effects in the incidence of acute gout attacks when comparing probenecid with allopurinol therapy. We downgraded the evidence because of a possible risk of performance and other biases and imprecision.
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Affiliation(s)
- Alison S R Kydd
- Division of Rheumatology, University of British Columbia, 1650 Terminal Ave, Suite 206, Nanaimo, BC, Canada, V9S 0A3
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Abstract
BACKGROUND Allopurinol, a xanthine oxidase inhibitor, is considered one of the most effective urate-lowering drugs and is frequently used in the treatment of chronic gout. OBJECTIVES To assess the efficacy and safety of allopurinol compared with placebo and other urate-lowering therapies for treating chronic gout. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE on 14 January 2014. We also handsearched the 2011 to 2012 American College of Rheumatology (ACR) and European League against Rheumatism (EULAR) abstracts, trial registers and regulatory agency drug safety databases. SELECTION CRITERIA All randomised controlled trials (RCTs) or quasi-randomised controlled clinical trials (CCTs) that compared allopurinol with a placebo or an active therapy in adults with chronic gout. DATA COLLECTION AND ANALYSIS We extracted and analysed data using standard methods for Cochrane reviews. The major outcomes of interest were frequency of acute gout attacks, serum urate normalisation, pain, function, tophus regression, study participant withdrawal due to adverse events (AE) and serious adverse events (SAE). We assessed the quality of the body of evidence for these outcomes using the GRADE approach. MAIN RESULTS We included 11 trials (4531 participants) that compared allopurinol (various doses) with placebo (two trials); febuxostat (four trials); benzbromarone (two trials); colchicine (one trial); probenecid (one trial); continuous versus intermittent allopurinol (one trial) and different doses of allopurinol (one trial). Only one trial was at low risk of bias in all domains. We deemed allopurinol versus placebo the main comparison, and allopurinol versus febuxostat and versus benzbromarone as the most clinically relevant active comparisons and restricted reporting to these comparisons here.Moderate-quality evidence from one trial (57 participants) indicated allopurinol 300 mg daily probably does not reduce the rate of gout attacks (2/26 with allopurinol versus 3/25 with placebo; risk ratio (RR) 0.64, 95% confidence interval (CI) 0.12 to 3.52) but increases the proportion of participants achieving a target serum urate over 30 days (25/26 with allopurinol versus 0/25 with placebo, RR 49.11, 95% CI 3.15 to 765.58; number needed to treat for an additional beneficial outcome (NNTB) 1). In two studies (453 participants), there was no significant increase in withdrawals due to AE (6% with allopurinol versus 4% with placebo, RR 1.36, 95% CI 0.61 to 3.08) or SAE (2% with allopurinol versus 1% with placebo, RR 1.93, 95% CI 0.48 to 7.80). One trial reported no difference in pain reduction or tophus regression, but did not report outcome data or measures of variance sufficiently and we could not calculate the differences between groups. Neither trial reported function.Low-quality evidence from three trials (1136 participants) indicated there may be no difference in the incidence of acute gout attacks with allopurinol up to 300 mg daily versus febuxostat 80 mg daily over eight to 24 weeks (21% with allopurinol versus 23% with febuxostat, RR 0.89, 95% CI 0.71 to 1.1); however more participants may achieve target serum urate level (four trials; 2618 participants) with febuxostat 80 mg daily versus allopurinol 300 mg daily (38% with allopurinol versus 70% with febuxostat, RR 0.56, 95% CI 0.48 to 0.65, NNTB with febuxostat 4). Two trials reported no difference in tophus regression between allopurinol and febuxostat over a 28- to 52-week period; but as the trialists did not provide variance, we could not calculate the mean difference between groups. The trials did not report pain reduction or function. Moderate-quality evidence from pooled data from three trials (2555 participants) comparing allopurinol up to 300 mg daily versus febuxostat 80 mg daily indicated no difference in the number of withdrawals due to AE (7% with allopurinol versus 8% with febuxostat, RR 0.89, 95% CI 0.62 to 1.26) or SAE (4% with allopurinol versus 4% with febuxostat, RR 1.13, 95% CI 0.71 to 1.82) over a 24- to 52-week period.Low-quality evidence from one trial (65 participants) indicated there may be no difference in the incidence of acute gout attacks with allopurinol up to 600 mg daily compared with benzbromarone up to 200 mg daily over a four-month period (0/30 with allopurinol versus 1/25 with benzbromarone, RR 0.28, 95% CI 0.01 to 6.58). Based on the pooled results of two trials (102 participants), there was moderate-quality evidence of no probable difference in the proportion of participants achieving a target serum urate level with allopurinol versus benzbromarone (58% with allopurinol versus 74% with benzbromarone, RR 0.79, 95% CI 0.56 to 1.11). Low-quality evidence from two studies indicated there may be no difference in the number of participants who withdrew due to AE with allopurinol versus benzbromarone over a four- to nine-month period (6% with allopurinol versus 7% with benzbromarone, pooled RR 0.80, 95% CI 0.18 to 3.58). There were no SAEs. They did not report tophi regression, pain and function.All other comparisons were supported by small, single studies only, limiting conclusions. AUTHORS' CONCLUSIONS Our review found low- to moderate-quality evidence indicating similar effects on withdrawals due to AEs and SAEs and incidence of acute gout attacks when allopurinol (100 to 600 mg daily) was compared with placebo, benzbromarone (100 to 200 mg daily) or febuxostat (80 mg daily). There was moderate-quality evidence of little or no difference in the proportion of participants achieving target serum urate when allopurinol was compared with benzbromarone. However, allopurinol seemed more successful than placebo and may be less successful than febuxostat (80 mg daily) in achieving a target serum urate level (6 mg/dL or less; 0.36 mmol/L or less) based on moderate- to low-quality evidence. Single studies reported no difference in pain reduction when allopurinol (300 mg daily) was compared with placebo over 10 days, and no difference in tophus regression when allopurinol (200 to 300 mg daily) was compared with febuxostat (80 mg daily). None of the trials reported on function, health-related quality of life or participant global assessment of treatment success, where further research would be useful.
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Affiliation(s)
- Rakhi Seth
- University Hospital Southampton NHS Foundation TrustDepartment of RheumatologySouthamptonUK
| | - Alison SR Kydd
- University of British ColumbiaDivision of Rheumatology1650 Terminal Ave, Suite 206NanaimoBCCanadaV9S 0A3
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash UniversityMonash Department of Clinical Epidemiology, Cabrini HospitalSuite 41, Cabrini Medical Centre183 Wattletree RoadMalvernVictoriaAustralia3144
| | - Claire Bombardier
- Institute for Work & Health481 University Avenue, Suite 800TorontoONCanadaM5G 2E9
| | - Christopher J Edwards
- University Hospital Southampton NHS Foundation TrustDepartment of RheumatologySouthamptonUK
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Faruque LI, Ehteshami-Afshar A, Wiebe N, Tjosvold L, Homik J, Tonelli M. A systematic review and meta-analysis on the safety and efficacy of febuxostat versus allopurinol in chronic gout. Semin Arthritis Rheum 2014; 43:367-75. [PMID: 24326033 DOI: 10.1016/j.semarthrit.2013.05.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 05/16/2013] [Accepted: 05/21/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To evaluate the safety and efficacy of febuxostat compared to allopurinol for the treatment of chronic gout. METHODS We did a systematic review and meta-analysis of randomized and non-randomized controlled trials that compared oral febuxostat to oral allopurinol for treatment of chronic gout. Two reviewers independently selected studies, assessed study quality, and extracted data. Risk ratios (RR) were calculated with random effects and were reported with corresponding 95% confidence intervals (CI). RESULTS From 1076 potentially relevant citations, 7 studies and 25 associated publications met inclusion criteria; 5 studies were ultimately included in the analysis. Febuxostat did not reduce the risk of gout flares compared with allopurinol (RR = 1.16, 95% CI = 1.03-1.30, I(2) = 44%). Overall, the risk of any adverse event was lower in febuxostat recipients compared to allopurinol (RR = 0.94, 95% CI = 0.90-0.99, I(2) = 13%). Patients receiving febuxostat were more likely to achieve a serum uric acid of <6 mg/dl than allopurinol recipients (RR = 1.56, 95% CI = 1.22-2.00, I(2) = 92%). Subgroup analysis did not indicate any significant difference between high- and low-dose febuxostat on the risk of gout flares. CONCLUSION Although febuxostat was associated with higher likelihood of achieving a target serum uric acid level of <6 mg/dl, there was significant heterogeneity in the pooled results. There was no evidence that febuxostat is superior to allopurinol for clinically relevant outcomes. Given its higher cost, febuxostat should not be routinely used for chronic gout.
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Affiliation(s)
- Labib I Faruque
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Aati O, Taylor WJ, Siegert RJ, Horne A, House ME, Tan P, Drake J, Stamp LK, Dalbeth N. Development of a patient-reported outcome measure of tophus burden: the Tophus Impact Questionnaire (TIQ-20). Ann Rheum Dis 2014; 74:2144-50. [DOI: 10.1136/annrheumdis-2014-205671] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 07/20/2014] [Indexed: 11/03/2022]
Abstract
BackgroundTophus burden is currently measured using physical examination and imaging methods. The aim of this study was to develop a patient-reported outcome (PRO) tool to assess tophus burden in people with gout.MethodsThe responses from interviews with 25 people with tophaceous gout were used to generate items for a preliminary PRO tool. Following cognitive testing of each item, a preliminary 34-item questionnaire was administered to 103 people with tophaceous gout. Rasch analysis generated a 20-item Tophus Impact Questionnaire (TIQ-20). Test-retest reproducibility and construct validity of the TIQ-20 were assessed.ResultsThe TIQ-20 responses fit the Rasch model and demonstrated unidimensionality, adequate precision, absence of differential item functioning and adequate person separation index. The TIQ-20 included items related to pain, activity limitation, footwear modification, participation, psychological impact and healthcare use due to tophi. In the 103 patients with tophaceous gout, floor effects were observed in 4.9% and ceiling effects in 1%. The TIQ-20 test-retest intraclass correlation coefficient was 0.76 (95% CI 0.61 to 0.85). All predicted correlations for construct validity testing were observed, including weak correlation with serum urate concentrations (r<0.30), moderate correlation with subcutaneous tophus count and dual energy CT urate volume (r=0.30–0.50), and stronger correlation with Health Assessment Questionnaire scores (r>0.50).ConclusionsWe have developed a tophus-specific PRO in patients with tophaceous gout. The TIQ-20 demonstrates acceptable psychometric properties. Initial results show internal, face and construct validity, reproducibility and feasibility. Further research is required to determine responsiveness to change.
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Shi D, Xu JX, Wu HX, Wang Y, Zhou QJ, Yu RS. Methods of assessment of tophus and bone erosions in gout using dual-energy CT: reproducibility analysis. Clin Rheumatol 2014; 34:755-65. [PMID: 24935412 DOI: 10.1007/s10067-014-2725-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 04/18/2014] [Accepted: 06/08/2014] [Indexed: 02/04/2023]
Abstract
This study aims to evaluate the intraobserver and interobserver reproducibility of the tophus urate volume, erosion volume, and the erosion score measurements in patients with gout by using dual-energy CT (DECT) scans comparing their bone erosion volumes against bone erosion scores and also to determine a valid measure of joint destruction in chronic gout. Sixty-six subjects underwent DECT scans of the hands or feet. Two independent observers measured the tophus urate volumes and bone erosion volumes using automated volume assessment software and the erosion scores based on the rheumatoid arthritis magnetic resonance imaging score (RAMRIS). The intraobserver and interobserver reproducibility were analyzed by intraclass correlation coefficient (ICC) and limits of agreements analysis. The relationship between erosion volumes and erosion scores was analyzed. The intraobserver and interobserver ICC for tophus urate volume measurements (n = 636) were 1.000 (95 % confidence interval (95 % CI) 1.000 to 1.000) and 1.000 (95 % CI 1.000 to 1.000), 0.999 (0.999, 0.999) and 0.999 (0.999, 0.999) for bone erosion volumes (n = 350), 0.937 (0.928, 0.946) and 0.899 (0.883, 0.912) for erosion scores (n = 350). Strong positive correlations were demonstrated between individual erosion volumes and scores (r s = 0.914, p < 0.001) as well as total erosion volume and score per patient (r = 0.838-0.867, p < 0.001). This study demonstrated a high reproducibility of tophus urate volumes, erosion volumes, and erosion score measurements using DECT. Erosion volumes show to be a more direct and accurate method to evaluate bone erosion compared with erosion score, strongly supporting it as a superior and standard measure of structural joint damage in gout.
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Affiliation(s)
- Dan Shi
- Department of Radiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Jiefang Road 88#, Hangzhou, 310009, China
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Huppertz A, Hermann KGA, Diekhoff T, Wagner M, Hamm B, Schmidt WA. Systemic staging for urate crystal deposits with dual-energy CT and ultrasound in patients with suspected gout. Rheumatol Int 2014; 34:763-71. [PMID: 24619560 DOI: 10.1007/s00296-014-2979-1] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 02/28/2014] [Indexed: 12/22/2022]
Abstract
Objective of the study is to compare the diagnostic accuracy for detecting monosodium urate crystal deposits between dual-energy CT (DECT) and ultrasound (US). Sixty consecutive patients (49 men, mean age 62 years) with clinically suspected gout were included in this case-control study. DECT and US of feet, knees, hands and elbows were performed in all patients. Polarisation microscopy of synovial fluid or a score incorporating serum uric acid level, first MTP joint involvement, gender, previous patient-reported arthritis attack, cardiovascular diseases, joint redness and onset within 1 day was used as standard of reference. Standard of reference classified 39 patients as gout positive. Sixteen patients had gout and a concomitant rheumatic disease. Sensitivities for diagnosis of gout disease were 84.6 % (33/39) for DECT and 100 % (39/39) for US. Specificities were 85.7 % (18/21) for DECT and 76.2 % (16/21) for US. Positive and negative predictive values were 91.7 % (33/36) and 75.0 % (18/24) for DECT, 88.6 % (39/44) and 100 % (16/16) for US, respectively. Urate crystals were detected most frequently in MTP1 joints (DECT 20/78, US 58/78), any other toe joints (DECT 25/78, US 62/78) and knees (DECT 41/78, US 31/78). The volumetry of DECT computed a mean urate crystal deposit load of 2.1 cm(3) (SD 9.6 cm(3)). A mean effective dose of ≤0.5 mSv was estimated. DECT is more specific for the diagnosis of gout than US. However, it fails to detect small urate crystal deposits. It might be particularly useful for patients with ambivalent findings, concomitant rheumatic diseases and with non-conclusive joint aspiration.
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Affiliation(s)
- Alexander Huppertz
- Department of Radiology, Charité - University Hospitals, Charitéplatz 1, 10117, Berlin, Germany,
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Perez-Ruiz F, Castillo E, Chinchilla SP, Herrero-Beites AM. Clinical manifestations and diagnosis of gout. Rheum Dis Clin North Am 2014; 40:193-206. [PMID: 24703343 DOI: 10.1016/j.rdc.2014.01.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Gout has been academically considered to be a step-up disease consisting of different stages: acute gout, intercritical gout, and chronic gout. This simple approach may lead to misinterpretation and misdiagnosis. In clinical practice, we should consider gout as a single disease with either or both acute (most commonly, episodes of acute inflammation) and persistent clinical manifestations, but not restricted to chronic synovitis. In this article, an innovative, practical, and rational approach to the clinical manifestations and diagnosis of gout is presented, which may be supportive for clinicians involved in everyday care and management of patients with gout.
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Affiliation(s)
- Fernando Perez-Ruiz
- Division of Rheumatology, BioCruces Health Institute, Hospital Universitario Cruces, Pza Cruces sn, Baracaldo 48903, Spain.
| | - Edwin Castillo
- Division of Rheumatology, Hospital Universitario Cruces, Pza Cruces sn, Baracaldo 48903, Spain
| | - Sandra P Chinchilla
- Division of Rheumatology, Hospital Universitario Cruces, Pza Cruces sn, Baracaldo 48903, Spain
| | - Ana M Herrero-Beites
- Division of Physical Medicine, Hospital de Górliz, Astondo Ibiltoki, km. 2, Górliz 48630, Spain
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Abstract
OBJECTIVE The purpose of this article is to describe the role of advanced imaging using ultrasound, CT, and MRI in the assessment and diagnosis of gout. CONCLUSION Dual-energy CT can quantitatively identify monosodium urate crystal deposits with high sensitivity and specificity within joints, tendons, and periarticular soft tissues. There are several characteristic ultrasound imaging findings, which include visualization of echogenic monosodium urate crystal deposition, tophus, and adjacent erosions. MRI is sensitive in showing soft-tissue and osseous abnormalities of gout, although the imaging findings are not specific. Gout commonly involves specific joints and anatomic structures, and knowledge of these sites and imaging appearances are clues to the correct diagnosis.
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Rajan A, Aati O, Kalluru R, Gamble GD, Horne A, Doyle AJ, McQueen FM, Dalbeth N. Lack of change in urate deposition by dual-energy computed tomography among clinically stable patients with long-standing tophaceous gout: a prospective longitudinal study. Arthritis Res Ther 2013; 15:R160. [PMID: 24286500 PMCID: PMC3978645 DOI: 10.1186/ar4343] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Accepted: 10/07/2013] [Indexed: 12/02/2022] Open
Abstract
Introduction Dual-energy computed tomography (DECT) has potential for monitoring urate deposition in patients with gout. The aim of this prospective longitudinal study was to analyse measurement error of DECT urate volume measurement in clinically stable patients with tophaceous gout. Methods Seventy-three patients with tophaceous gout on stable therapy attended study visits at baseline and twelve months. All patients had a comprehensive clinical assessment including serum urate testing and DECT scanning of both feet. Two readers analysed the DECT scans for the total urate volume in both feet. Analysis included inter-reader intraclass correlation coefficients (ICCs) and limits of agreement, and calculation of the smallest detectable change. Results Mean (standard deviation) serum urate concentration over the study period was 0.38 (0.09) mmol/L. Urate-lowering therapy was prescribed in 70 (96%) patients. The median (interquartile range) baseline DECT urate volume was 0.49 (0.16, 2.18) cm3, and change in DECT urate volume was -0.01 (-0.40, 0.28) cm3. Inter-reader ICCs were 1.00 for baseline DECT volumes and 0.93 for change values. Inter-reader bias (standard deviation) for baseline volumes was -0.18 (0.63) cm3 and for change was -0.10 (0.93) cm3. The smallest detectable change was 0.91 cm3. There were 47 (64%) patients with baseline DECT urate volumes <0.91 cm3. Higher serum urate concentrations were observed in patients with increased DECT urate volumes above the smallest detectable change (P = 0.006). However, a relationship between changes in DECT urate volumes and serum urate concentrations was not observed in the entire group. Conclusions In patients with tophaceous gout on stable conventional urate-lowering therapy the measurement error for DECT urate volume assessment is substantially greater than the median baseline DECT volume. Analysis of patients commencing or intensifying urate-lowering therapy should clarify the optimal use of DECT as a potential outcome measure in studies of chronic gout.
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Gruber M, Bodner G, Rath E, Supp G, Weber M, Schueller-Weidekamm C. Dual-energy computed tomography compared with ultrasound in the diagnosis of gout. Rheumatology (Oxford) 2013; 53:173-9. [PMID: 24136065 DOI: 10.1093/rheumatology/ket341] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The aim of our study was to compare dual-energy CT (DECT) with US for the diagnosis of gouty arthritis and to correlate the imaging findings with results from synovial fluid aspiration whenever possible. METHODS We recruited 21 patients (17 male and 4 female) who presented with a clinical suspicion of acute or chronic gout in 37 joints. DECT scans of the hands, wrists, feet, ankles, knees and elbows were performed. For post-processing, a colour-coding gout software protocol was used. US examinations of the same joints were performed. In addition, joint fluid aspiration was performed in a total of 14 joints. RESULTS DECT images were positive for urate crystal deposits in 25 of 37 joints. US findings were positive in 24 of 37 examined joints. In 12 of 14 joints the synovial fluid aspiration was positive. CT and US findings correlated in 32 of 37 joints (86.5%; κ = 0.698, P < 0.001). CT and synovial fluid results correlated in 12 of 14 joints (85.7%; κ = 0.417, P = 0.119). US and cytology findings correlated in 14 of 14 joints (100%; κ = 1, P < 0.001). CONCLUSION DECT and US have comparable sensitivity for the detection of gouty arthritis in a clinical setting. However, DECT results should be interpreted carefully, as there could be some false-negative findings.
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Affiliation(s)
- Michael Gruber
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Radiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
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Baraf HSB, Becker MA, Gutierrez-Urena SR, Treadwell EL, Vazquez-Mellado J, Rehrig CD, Ottery FD, Sundy JS, Yood RA. Tophus burden reduction with pegloticase: results from phase 3 randomized trials and open-label extension in patients with chronic gout refractory to conventional therapy. Arthritis Res Ther 2013; 15:R137. [PMID: 24286509 PMCID: PMC3979037 DOI: 10.1186/ar4318] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 09/04/2013] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Two replicate randomized, placebo-controlled six-month trials (RCTs) and an open-label treatment extension (OLE) comprised the pegloticase development program in patients with gout refractory to conventional therapy. In the RCTs, approximately 40% of patients treated with the approved dose saw complete response (CR) of at least one tophus. Here we describe the temporal course of tophus resolution, total tophus burden in patients with multiple tophi, tophus size at baseline, and the relationship between tophus response and urate-lowering efficacy. METHODS Baseline subcutaneous tophi were analyzed quantitatively using computer-assisted digital images in patients receiving pegloticase (8 mg biweekly or monthly) or placebo in the RCTs, and pegloticase in the OLE. Tophus response, a secondary endpoint in the trials, was evaluated two ways. Overall tophus CR was the proportion of patients achieving a best response of CR (without any new/enlarging tophi) and target tophus complete response (TT-CR) was the proportion of all tophi with CR. RESULTS Among 212 patients randomized in the RCTs, 155 (73%) had ≥ 1 tophus and 547 visible tophi were recorded at baseline. Overall tophus CR was recorded in 45% of patients in the biweekly group (P = 0.002 versus placebo), 26% in the monthly group, and 8% in the placebo group after six months of RCT therapy. TT-CR rates at six months were 28%, 19%, and 2% of tophi, respectively. Patients meeting the primary endpoint of sustained urate-lowering response to therapy (responders) were more likely than nonresponders to have an overall tophus CR at six months (54% vs 20%, respectively and 8% with placebo). CONCLUSIONS Pegloticase reduced tophus burden in patients with refractory tophaceous gout, especially those achieving sustained urate-lowering. Complete resolution of tophi occurred in some patients by 13 weeks and in others with longer-term therapy. TRIAL REGISTRATIONS NCT00325195, NCT01356498.
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As compared to allopurinol, urate-lowering therapy with febuxostat has superior effects on oxidative stress and pulse wave velocity in patients with severe chronic tophaceous gout. Rheumatol Int 2013; 34:101-9. [PMID: 24026528 DOI: 10.1007/s00296-013-2857-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Accepted: 08/30/2013] [Indexed: 01/19/2023]
Abstract
We prospectively evaluated whether an effective 12-month uric acid-lowering therapy (ULT) with the available xanthine oxidase (XO) inhibitors allopurinol and febuxostat in patients with chronic tophaceous gout has an impact on oxidative stress and/or vascular function. Patients with chronic tophaceous gout who did not receive active ULT were included. After clinical evaluation, serum uric acid levels (SUA) and markers of oxidative stress were measured, and carotid-femoral pulse wave velocity (cfPWV) was assessed. Patients were then treated with allopurinol (n = 9) or with febuxostat (n = 8) to target a SUA level ≤ 360 μmol/L. After 1 year treatment, the SUA levels, markers of oxidative stress and the cfPWV were measured again. Baseline characteristics of both groups showed no significant differences except a higher prevalence of moderate impairment of renal function (estimated glomerular filtration rate <60 ml/min) in the febuxostat group. Uric acid lowering with either inhibitors of XO resulted in almost equally effective reduction in SUA levels. The both treatment groups did not differ in their baseline cfPWV (allopurinol group: 14.1 ± 3.4 m/s, febuxostat group: 13.7 ± 2.7 m/s, p = 0.80). However, after 1 year of therapy, we observed a significant cfPWV increase in the allopurinol group (16.8 ± 4.3 m/s, p = 0.001 as compared to baseline), but not in the febuxostat patients (13.3 ± 2.3 m/s, p = 0.55). Both febuxostat and allopurinol effectively lower SUA levels in patients with severe gout. However, we observed that febuxostat also appeared to be beneficial in preventing further arterial stiffening. Since cardiovascular events are an important issue in treating patients with gout, this unexpected finding may have important implications and should be further investigated in randomized controlled trials.
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Naredo E, Uson J, Jiménez-Palop M, Martínez A, Vicente E, Brito E, Rodríguez A, Cornejo FJ, Castañeda S, Martínez MJ, Sanz J, Möller I, Batlle-Gualda E, Garrido J, Pascual E. Ultrasound-detected musculoskeletal urate crystal deposition: which joints and what findings should be assessed for diagnosing gout? Ann Rheum Dis 2013; 73:1522-8. [PMID: 23709244 DOI: 10.1136/annrheumdis-2013-203487] [Citation(s) in RCA: 118] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The primary objective of this prospective case-control study was to assess the diagnostic value of several intra-articular and periarticular ultrasound (US)-detected abnormalities in the upper and lower limbs in gout. The secondary objective was to test the concurrent validity of US abnormalities using as gold standard the microscopic demonstration of monosodium urate (MSU) crystals. METHODS Ninety-one men with gout and 42 age-matched controls were prospectively recruited. All patients with gout and controls underwent US assessment of several US abnormalities in 26 joints, six bursae, eight tendons, 20 tendon compartments, four ligaments, and 18 articular cartilages by experts in US blinded to the patients' group. Patients with gout and controls with US abnormalities were asked to undergo US-guided aspiration for microscopic identification of MSU crystals. Interobserver and intraobserver reliability of the US assessment was evaluated in a web-based exercise. RESULTS The assessment of one joint (ie, radiocarpal joint) for hyperechoic aggregates (HAGs), two tendons (ie, patellar tendon and triceps tendon) for HAGs and three articular cartilages (ie, first metatarsal, talar and second metacarpal/femoral) for double contour sign showed the best balance between sensitivity and specificity (84.6% and 83.3%, respectively). Intraobserver reliability was good (mean κ 0.75) and interobserver reliability was moderate (κ 0.52). The aspirated material from HAGs was positive for MSU crystals in 77.6% of patients with gout and negative in all controls. CONCLUSIONS Our results suggest that US bilateral assessment of one joint, three articular cartilages and two tendons may be valid for diagnosing gout with acceptable sensitivity and specificity.
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Affiliation(s)
- Esperanza Naredo
- Department of Rheumatology, Hospital General Universitario Gregorio Marañón, Complutense University, Madrid, Spain Department of Rheumatology, Hospìtal Universitario Severo Ochoa, Madrid, Spain
| | - Jacqueline Uson
- Department of Rheumatology, Hospital Universitario de Móstoles, Madrid, Spain
| | | | - Agustín Martínez
- Department of Rheumatology, Hospital Universitario de Alicante, Alicante, Spain
| | - Esther Vicente
- Department of Rheumatology, Hospital de la Princesa, IIS-Princesa, Madrid, Spain
| | - Elia Brito
- Department of Rheumatology, Hospital Ramón y Cajal, Madrid, Spain
| | - Ana Rodríguez
- Department of Rheumatology, Hospital Ramón y Cajal, Madrid, Spain
| | | | - Santos Castañeda
- Department of Rheumatology, Hospital de la Princesa, IIS-Princesa, Madrid, Spain
| | | | - Jesús Sanz
- Department of Rheumatology, Hospital Puerta de Hierro, Madrid, Spain
| | - Ingrid Möller
- Department of Rheumatology, Instituto Poal, Barcelona, Spain
| | | | - Jesús Garrido
- Department of Social Psychology and Methodology, Faculty of Psychology, Autonoma University, Madrid, Spain
| | - Eliseo Pascual
- Department of Rheumatology, Hospital Universitario de Alicante, Alicante, Spain
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Dalbeth N, Doyle AJ. Imaging of gout: an overview. Best Pract Res Clin Rheumatol 2013; 26:823-38. [PMID: 23273794 DOI: 10.1016/j.berh.2012.09.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 09/13/2012] [Indexed: 01/30/2023]
Abstract
The diverse clinical states and sites of pathology in gout provide challenges when considering the features apparent on imaging. Ideally, an imaging modality should capture all aspects of disease including monosodium urate crystal deposition, acute inflammation, tophus, tissue remodelling and complications of disease. The modalities used in gout include conventional radiography, ultrasonography, magnetic resonance imaging, computed tomography and dual-energy computed tomography. This review discusses the role of each of these imaging modalities in gout, focussing on the imaging characteristics, role in gout diagnosis and role for disease monitoring. Ultrasonography and dual-energy computed tomography are particularly promising methods for both non-invasive diagnosis and monitoring of disease. The observation that ultrasonographic appearances of monosodium urate crystal deposition can be observed in patients with hyperuricaemia but no other clinical features of gout raises important questions about disease definitions.
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Affiliation(s)
- Nicola Dalbeth
- Department of Medicine, University of Auckland, Grafton, Auckland, New Zealand.
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Khanna D, Fitzgerald JD, Khanna PP, Bae S, Singh MK, Neogi T, Pillinger MH, Merill J, Lee S, Prakash S, Kaldas M, Gogia M, Perez-Ruiz F, Taylor W, Lioté F, Choi H, Singh JA, Dalbeth N, Kaplan S, Niyyar V, Jones D, Yarows SA, Roessler B, Kerr G, King C, Levy G, Furst DE, Edwards NL, Mandell B, Schumacher HR, Robbins M, Wenger N, Terkeltaub R. 2012 American College of Rheumatology guidelines for management of gout. Part 1: systematic nonpharmacologic and pharmacologic therapeutic approaches to hyperuricemia. Arthritis Care Res (Hoboken) 2013. [PMID: 23024028 DOI: 10.1002/acr.21772;10.1002/acr.21772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Dalbeth N, Choi HK. Dual-Energy Computed Tomography for Gout Diagnosis and Management. Curr Rheumatol Rep 2012; 15:301. [DOI: 10.1007/s11926-012-0301-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Perez-Ruiz F, Herrero-Beites AM. Evaluation and treatment of gout as a chronic disease. Adv Ther 2012; 29:935-46. [PMID: 23104464 DOI: 10.1007/s12325-012-0059-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Indexed: 12/22/2022]
Abstract
Gout is a disease caused by deposition of monosodium urate crystals in tissues. One of the limitations for successful treatment of gout is to consider it as an intermittent disease rather than a chronic inflammatory disease which, if improperly treated, leads to chronic clinical manifestations. In addition, gout is linked to increased cardiovascular morbidity and mortality.Urate-lowering therapy comprises both nonpharmacologic and pharmacologic interventions, but most patients will need urate-lowering drugs to achieve target therapeutic serum urate levels. Reaching target serum urate levels is associated with improvement in clinical outcomes, including a reduction of acute inflammation episodes, resolution of tophi, and improvement in health-related quality of life perception.A number of urate-lowering drugs are available but a number of patients fail to achieve or maintain therapeutic serum urate levels and go on to develop refractory chronic gout. For such patients, efforts have been made to develop new treatments (e.g., febuxostat or pegloticase).This review intends to increase the awareness of gout as a chronic deposition disease, and show that efforts should be made to properly control serum urate levels in order to achieve complete disappearance of urate crystal deposition.
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Khanna D, FitzGerald JD, Khanna PP, Bae S, Singh M, Neogi T, Pillinger MH, Merill J, Lee S, Prakash S, Kaldas M, Gogia M, Perez-Ruiz F, Taylor W, Lioté F, Choi H, Singh JA, Dalbeth N, Kaplan S, Niyyar V, Jones D, Yarows SA, Roessler B, Kerr G, King C, Levy G, Furst DE, Edwards NL, Mandell B, Schumacher HR, Robbins M, Wenger N, Terkeltaub R. 2012 American College of Rheumatology guidelines for management of gout. Part 1: systematic nonpharmacologic and pharmacologic therapeutic approaches to hyperuricemia. Arthritis Care Res (Hoboken) 2012; 64:1431-46. [PMID: 23024028 PMCID: PMC3683400 DOI: 10.1002/acr.21772] [Citation(s) in RCA: 1049] [Impact Index Per Article: 87.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
| | | | | | - Sangmee Bae
- University of California Los Angeles, Los Angeles, CA
| | | | | | | | - Joan Merill
- Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Susan Lee
- VA Healthcare System and University of California San Diego, San Diego, CA
| | | | - Marian Kaldas
- University of California Los Angeles, Los Angeles, CA
| | - Maneesh Gogia
- University of California Los Angeles, Los Angeles, CA
| | | | - Will Taylor
- University of Otago, Wellington, New Zealand
| | - Frédéric Lioté
- Université Paris Diderot, Sorbonne Paris Cité, and Hôpital Lariboisière, Paris, France
| | - Hyon Choi
- Boston University Medical Center, Boston, MA
| | - Jasvinder A. Singh
- VA Medical Center. Birmingham, Alabama and University of Alabama, Birmingham, AL
| | | | - Sanford Kaplan
- Private Practice, Oral and Maxillofacial Surgery, Beverly Hills, CA
| | | | | | | | | | - Gail Kerr
- Veterans Affairs Medical Center, Washington, DC
| | | | - Gerald Levy
- Southern California Permanente Medical Group, Downey, CA
| | | | | | | | | | - Mark Robbins
- Harvard Vanguard Medical Associates/Atrius Health, Somerville, MA
| | - Neil Wenger
- University of California Los Angeles, Los Angeles, CA
| | - Robert Terkeltaub
- VA Healthcare System and University of California San Diego, San Diego, CA
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Taylor WJ. Gout measures: Gout Assessment Questionnaire (GAQ, GAQ2.0), and physical measurement of tophi. Arthritis Care Res (Hoboken) 2012; 63 Suppl 11:S59-63. [PMID: 22588771 DOI: 10.1002/acr.20622] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- William J Taylor
- University of Otago, Wellington, and Hutt Valley District Health Board, Lower Hutt, New Zealand.
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Abstract
PURPOSE OF REVIEW Imaging has the potential to assess various pathological manifestations of gout, including monosodium urate (MSU) crystal deposition, tophus formation and cartilage, soft tissue, and bone pathology. This review discusses recent research examining the role of imaging to assess the manifestations of disease. RECENT FINDINGS Various imaging techniques are used in the assessment of gout, including plain radiography, ultrasonography, conventional computed tomography (CT), dual energy computed tomography (DECT), and MRI. Potential roles for ultrasonography are MSU crystal detection, measurement of tophi, and assessment of disease complications. Ultrasonography may allow detection of MSU crystals in patients with hyperuricaemia, prior to development of clinically apparent gout. Conventional CT allows excellent visualization of tophi and bone erosion. DECT is a promising method of noninvasive MSU crystal detection. MRI allows assessment of tophi, synovial and soft tissue disease, and bone pathology. The relative absence of MRI bone marrow oedema in gout suggests that the mechanisms of bone erosion in gout are quite different from those in other erosive arthropathies. SUMMARY Imaging modalities have provided important insights into the pathology of gout. The role of various imaging techniques in gout diagnosis, monitoring, and prediction of outcome is rapidly developing.
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Schiavenato M, Thiele RG. Thermography detects subclinical inflammation in chronic tophaceous gout. J Rheumatol 2012; 39:182-3. [PMID: 22210677 DOI: 10.3899/jrheum.110581] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Martin Schiavenato
- University of Miami, School of Nursing and Health Studies, 5030 Brunson Drive, Coral Gables, FL 33146, USA.
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The broad spectrum of urate crystal deposition: unusual presentations of gouty tophi. Semin Arthritis Rheum 2012; 42:146-54. [PMID: 22522111 DOI: 10.1016/j.semarthrit.2012.03.007] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Revised: 03/07/2012] [Accepted: 03/18/2012] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Gout is typically described as an inflammatory arthropathy that affects the peripheral joints. Our aim was to describe atypical and rare clinical presentations of gouty tophi to help increase physician awareness and aid in patient care. METHODS The relevant English literature of unusual gout manifestations was searched using the keywords gout, toph*, monosodium urate, uric acid, unusual, and rare. Well-described case reports, case series, and review articles were evaluated and included, if relevant, in the literature review. RESULTS Review of the literature revealed many unusual manifestations of gouty tophi involving the head and neck, skin, viscera, bones, tendons, ligaments, nerves, and axial skeleton. Transplant recipients, women, and elderly people are particularly susceptible to developing tophi. Furthermore, gout can cause diagnostic dilemmas, as it can be a great mimicker of and can coexist with infection, malignancy, and other connective tissue diseases. Imaging modalities can help detect tophi in atypical locations. CONCLUSIONS Tophi can present in unexpected locations, even as the first sign of gout, and vigilance is required when unusual symptoms or signs occur in a patient with gout.
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Current World Literature. Curr Opin Rheumatol 2012; 24:237-44. [DOI: 10.1097/bor.0b013e3283513e33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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