Study on the compatibility effect and active constituents of Atractylodis Rhizoma in Ermiao Wan against Acute Gouty Arthritis

ETHNOPHARMACOLOGICAL RELEVANCE

Ermiao Wan (EMW), composed of Atractylodis Rhizoma (AR) and Phellodendri Chinensis Cortex (PC), is a classical traditional Chinese medicine prescription having been used to treat the disease named "Tong Feng", which is described as "ache in bones and joints" with the same symptom of modern disease named acute gouty arthritis for many years in TCM clinical practice. Besides, both PC and AR were considered to be effective in anti-inflammatory according to modern pharmacological research.

AIM OF THE STUDY

Present study was undertaken to probe the compatibility rationality between the two herbs PC and AR in EMW and the active constituents of AR against acute gouty arthritis (AGA).

MATERIALS AND METHODS

Rat model of AGA was induced by intra-articular injection of monosodium urate (MSU) crystal suspension, and PC combined with or without different AR extracts were used for AGA treatment. Ankle joint swelling, proinflammatory cytokines in serum and pathological changes of synovium were investigated. Using the developed UHPLC-QQQ-MS method, the plasma concentrations of the primary alkaloids in PC, such as berberine, phellodendrine, magnoflorine, jatrorrhizine, berberrubine, palmatine, and tetrahydropalmatine, in AGA rat were determined, and pharmacokinetics properties were compared following oral administration of PC, PC combined with or without different AR extracts.

RESULTS

PC, PC combined with AR volatile oil (VO) extract or PC combined with whole AR extract significantly attenuated the ankle joint swelling of AGA rats. Besides, the combination of PC and VO extract of AR showed superior efficacy than other groups in ameliorating ankle joint swelling, reducing the IL-6 expression in serum and improving tissue lesions of ankle joints. Furthermore, it turned out that the VO extract of AR increased the blood exposure level of PC related alkaloids than non-volatile oil (NVO) extract of AR, by comparing the pharmacokinetic results of each group.

CONCLUSIONS

The VO components of AR were the key compatible materials to combine with PC in EMW for AGA treatment. Moreover, the enhanced anti-AGA activity of PC after combining with VO extract of AR may attribute to the influence of VO on the pharmacokinetics of PC. This study may provide useful information for elucidating the compatibility effects of AR in EMW against AGA.

Effect of canakinumab on clinical and biochemical parameters in acute gouty arthritis: a meta-analysis

BACKGROUND

Targeted anti-IL-1β therapy may be a valuable option for the management of gouty arthritis. The present meta-analysis has evaluated the effect of canakinumab, an anti-IL-1β monoclonal antibody in gouty arthritis.

METHODS

A standard meta-analysis protocol was developed and after performing a comprehensive literature search in MEDLINE, Cochrane, and International Clinical Trial Registry Platform (ICTRP), reviewers assessed eligibility and extracted data from three relevant articles. A random-effects model was used to estimate the pooled effect size as the mean difference in Visual Analouge Scale (VAS) score, serum hsCRP, serum Amyloid A, and risk ratio for global assessment between the groups. Quality assessment was done using the risk of bias assessment tool and summary of findings was prepared using standard Cochrane methodology with GradePro GDT.

RESULTS

Treatment with canakinumab showed a mean reduction of VAS score by 14.59 mm [95% CI - 19.42 to - 9.77], serum hsCRP by 15.36 mg/L [95% CI 1.62-29.11], serum Amyloid A by 67.18 mg/L [95% CI 17.06-117.31], and improvement in patient global assessment (RR = 1.478; 95% CI 1.29-1.67) and physician global assessment (RR = 1.44; 95% CI 1.28-1.61). The probability that future studies may have a mean difference in VAS score less than zero has been calculated to be 27.3% using a cumulative distribution function (CDF) calculator.

CONCLUSION

This meta-analysis shows the beneficial effect of canakinumab over triamcinolone by reducing VAS score, serum hsCRP, serum amyloid A, and improvement in global assessments in acute gouty arthritis.

Characteristics of voltage-gated potassium currents in monosodium urate induced gouty arthritis in mice

OBJECTIVE

To evaluate the role of K⁺ channels in pain following gouty arthritis.

METHODS

The model of acute gouty arthritis was induced by monosodium urate (MSU) in mice. The swelling degree was determined by measuring the circumference of the ankle joint. Mechanical hyperalgesia was detected by von Frey filaments. Two types of K⁺ currents, A-type currents (I_A) and delayed rectifier currents (I_K), were recorded in dorsal root ganglion (DRG) neurons using patch-clamp techniques.

RESULTS

The swelling degree reached its maximum at 10 h and the minimum pain threshold was maintained between 8 and 48 h after MSU treatment in mice. The amplitudes of I_A and I_K in DRG neurons were moderately increased on day 1 after MSU treatment, and then, they were gradually decreased with times and reached their minimums on day 4 (for I_A) or 5 (for I_K). Compared with control group, the activation curve of I_A was significantly shifted to more positive potential and the recovery time of I_A from inactivation was markedly prolonged, but inactivation and frequency dependence of I_A appeared unaffected in MSU-treated group. Additionally, no change was observed in the activation curve of I_K after MSU treatment. The excitability was significantly higher in the MSU group than in the control group.

CONCLUSIONS

MSU-induced gout pain may be related to the hyperexcitability of DRG neurons elicited by decreasing K⁺ currents.

Better understanding of acute gouty attack using CT perfusion in a rabbit model

OBJECTIVE

To assess hemodynamic changes related to acute gouty knee arthritis in a rabbit with CT perfusion (CTP) METHODS: Forty-two rabbits were randomly separated into two groups: the treated group of 30 and the control group of 12. The right knee was injected with monosodium urate solution and polymyxin in the treated group and saline and polymyxin in the control group. At 2, 16, 32, 48, 60, and 72 h after injection, five rabbits from the treated group and two rabbits from the control group were selected for CTP. At each time point, blood flow (BF), blood volume (BV), and clearance rate (CL) were measured, and microvessel density (MVD) was evaluated with a microscope.

RESULTS

In the treated group, BF, BV, CL, and MVD were significantly higher than in the control group (p < 0.001). Differences within paired comparison of BV, BF, CL, and MVD were all significant (all p < 0.001). Peak time of BV, BF, and MVD was 32 h and 48 h for CL. After multivariate stepwise linear regression analysis, BV was linearly associated with MVD and vice versa, which also applied to BF with MVD and BF with CL, separately. The ascending rate of MVD was the highest among that of all parameters; so was the descending rate of CL.

CONCLUSION

CTP in this rabbit knee model accurately detected hemodynamic changes during a gouty attack.

KEY POINTS

• Acute gouty arthritis can be evaluated with CTP in a rabbit knee model. • Following injection of MSU crystals, producing an acute gouty attack, CTP successfully assessed hemodynamic changes. • The ascending rate of MVD was the highest among that of all parameters; so was the descending rate of CL.

Dysadipokinemia in patients with gout and its association with the disease activity

OBJECTIVE

Introduction: In recent years, the role of adipokines in the development of rheumatic diseases has been a pressing issue. The available data suggest the dysadipokinemia in patients with rheumatoid arthritis, osteoarthritis and psoriatic arthritis. However, there is no data on changes in the levels of adipokines in patients with gout and their association with the activity of inflammatory process. The aim was to study the levels of adipokines in gout patients and evaluate their association with the disease activity.

PATIENTS AND METHODS

Materials and methods: We examined 151 male patients with gout. The control group consisted of 31 practically healthy men, represented by age. We used the Gout Activity Score (GAS) to assess gout severity. The levels of leptin and adiponectin were determined using the ELISA kit. For comprehensive evaluation of dysadipokinemia, we used a logarithmic ratio of leptin to adiponectin (lg A/L). Primary processing of results was carried out using MS Excel and Statistica SPSS22 statistical software packages.

RESULTS

Results: The patients with gout demonstrated higher leptin levels, lower levels of adiponectin, and lower lg A/L compared to practically healthy individuals. Among patients with gout, the disturbance of adipokin status was most pronounced in patients with tophi. Patients with high GAS activity had maximum disturbance of adipokin profile by lg A/L, while the manifestations of dysadipokinemia were minimal in the group with low activity of the disease. It was established that GAS disease activity, BMI, and the number of joints under attack may be considered the most significant independent predictors of dysadipokinemia.

CONCLUSION

Conclusions: The patients with gout presented an increase in leptin level, a decrease in adiponectin level, and a decrease in the ratio lg A/L. Dysadipokinemia was associated with high disease activity and could serve as a prognostic factor for assessing the severity of the disease.

[Clinical observation of arthroscopic debridement for acute gouty arthritis of the ankle]

OBJECTIVE

To evaluate the effects of arthroscopic debridement for acute gouty arthritis of the ankle.

METHODS

Forty-one patients with acute gouty arthritis of the ankle were treated under arthroscopy from January 2010 to June 2012. All the patients were male, age in ranging from 28 to 69 years with an average of 43 years. Eighteen patients were in the left ankles and 23 in the right ankles; 12 cases were firstly attack and 29 cases were recurrent attack. Course of disease was from 2 weeks to 30 months. The American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale score was used to evaluate the clinical effects. Number of acute attacks of gouty arthritis were observed.

RESULTS

All the patients were followed up at least 12 months. The mean AOFAS Ankle-Hindfoot Scale score increased from 58.44 +/- 9.45 preoperatively to 86.15 +/- 7.36, 83.41 +/- 9.22, 84.10 +/- 8.22 postoperatively at 6, 12, months and the last follow-up respectively. Swelling of the ankle were improved significantly, pain was relieved and the mean number of acute attacks of gouty arthritis decreased significantly.

CONCLUSION

Arthroscopy is helpful for the diagnosis of acute gouty arthritis of the ankle and improvement of clinical symptoms and ankle function.

The effect of bariatric surgery on gout: a comparative study

BACKGROUND

Obesity is a risk factor for the development of gout. An increased incidence of early gouty attacks after bariatric surgery has been reported, but the data is sparse. The effect of weight loss surgery on the behavior of gout beyond the immediate postoperative phase remains unclear. The objective of this study was to evaluate the pre- and postoperative frequency and features of gouty attacks in bariatric surgery patients.

METHODS

Charts were reviewed to identify patients who had gout before bariatric surgery. Demographic and gout-related parameters were recorded. The comparison group consisted of obese individuals with gout who underwent nonbariatric upper abdominal procedures.

RESULTS

Ninety-nine morbidly obese patients who underwent bariatric surgery had gout. The comparison group consisted of 56 patients. The incidence of early gouty attack in the first month after surgery was significantly higher in the bariatric group than the nonbariatric group (17.5% versus 1.8%, P = .003). In the bariatric group, 23.8% of patients had at least one gouty attack during the 12-month period before surgery, which dropped to 8.0% during postoperative months 1-13 (P = .005). There was no significant difference in the number of gouty attacks in the comparison group before and after surgery (18.2% versus 11.1%, P = .33). There was a significant reduction in uric acid levels 13-months after bariatric surgery compared with baseline values (9.1±2.0 versus 5.6±2.5 mg/dL, P = .007).

CONCLUSION

The frequency of early postoperative gout attacks after bariatric surgery is significantly higher than that of patients undergoing other procedures. However, the incidence decreases significantly after the first postoperative month up to 1 year.

[The specific features of gout in the elderly]

AIM

To determine the specific feature of gout at its onset in the elderly.

SUBJECTS AND METHODS

The investigation included 100 patients (74 men and 26 women) with primary gout on the basis of the criteria proposed by S. Wallace et al. (1977). The patients were divided into 2 groups: 1) 51 patients aged over 60 years; 2) 49 patients aged less than 60 years. In Groups 1 and 2, the mean age at gout onset was 66.1 +/- 4.8 and 41.6 +/- 10.0 years, respectively. A comparative retrospective analysis was made to analyze the detection rate for the site of onset gout, the pattern of arthritis, the number of tophus forms, the use of diuretics, small-dose acetylsalicylic acid (ASA), comorbidities, such as hypertension, type 2 diabetes mellitus (T2DM), obesity, chronic renal failure, coronary heart disease, chronic heart failure, and prior myocardial infarction.

RESULTS

The disease duration in both groups averaged 8 years. In Groups 1 and 2, first metatarsophalangeal joint arthritis was diagnosed at its onset in 77 and 61%, respectively. In these groups, chronic arthritis was also diagnosed in 19 (37%) and 19 (39%). Examinations revealed tophi in 21 and 37% of cases in Groups 1 and 2, respectively. The administration of diuretics was recorded in 25 (49%) and 17 (35%) patients in these groups. Group 1 patients took low-dose ASA more frequently than Group 2 ones (19 (37%) and 7 (14%) patients, respectively; p = 0.013). Hypertension was identified in 23 (45%) examinees in Group 1 and 17 (40%) ones in Group 2. Both groups were matched for the number of patients with obesity (41 and 43%) and for that of patients with T2DM (15 and 10%, respectively). There were significant differences between the compared groups in the incidence of coronary heart disease, myocardial infarction, and chronic heart disease.

CONCLUSION

The patients' age of gout onset does not affect substantial differences in the clinical features of gout with its comparable duration in the young and elderly patients. The main clinical features of gout are unique to both young and elderly patients. Cardiovascular diseases are more common at gout onset in the elderly.

[Current opinions on gout, its diagnosis and treatment]

Gout is a heterogenous group of metabolic diseases characterized by formation and deposition of sodium urate crystals in various tissues. Gouty arthritis is a rheumatic syndrome occurring in individuals with hyperuricaemia; this is an inflammatory disease of the musculoskeletal system with a presence of sodium urate crystals. Hyperuricaemia, i.e. pathologically increased levels of uric acid in the serum, represents the most important risk factor for the development of gouty arthritis. The causes of hyperuricaemia may include an increased production of uric acid and/or its reduced elimination from the body. Acute gouty arthritis is an early manifestation of gouty arthritis. When deposition of sodium urate crystals in tissues leads to a destruction of musculoskeletal system structures, this is called chronic tophaceous gouty arthritis. To treat chronic tophaceous gout, the uric acid levels must be kept below 360 μmol/l, deposits of sodium urate in tissues dissolved and their further formation prevented. Pharmacological treatment of chronic hyperuricaemia involves administration of uric acid level lowering drugs, particularly xanthine oxidase inhibitors and uricosurics. Hyperuricaemia is an important risk factor not only for the development of chronic tophaceous gout and renal impairment but some data also suggests a risk associated with cardiovascular diseases.

Treatment of chronic gouty arthritis: it is not just about urate-lowering therapy

OBJECTIVES

The management of gouty arthritis is focused on treating pain and inflammation associated with acute flares and preventing further acute flares and urate crystal deposition. A challenge associated with the successful management of gouty arthritis is an increased risk of acute flares during the first months after initiation of urate-lowering therapy (ULT). This increase in flare frequency can occur regardless of the choice of ULT and is linked to suboptimal patient adherence to ULT. Current treatment recommendations for the use of prophylaxis are limited. There are no definitive recommendations as to which agents should be used or for how long therapy is beneficial after starting ULT. This article aims to improve awareness of the importance of gouty arthritis flare prophylaxis when initiating ULT and to summarize current recommendations and clinical findings related to the efficacy and safety of currently available and investigational new therapies.

METHODS

This review discusses the pathophysiology of acute gouty arthritis flares during initiation of ULT and examines the literature on the use of anti-inflammatory prophylaxis for reduction of these flares.

RESULTS

It has recently become clear that, even when the patient is asymptomatic, chronic inflammation is often present in patients with chronic gouty arthritis. Chronic anti-inflammatory therapy should therefore be added to chronic ULT. Prophylaxis with colchicine as well as with nonsteroidal anti-inflammatory drugs (NSAIDs) during ULT initiation can reduce the incidence and severity of gouty arthritis flares substantially; however, safety concerns associated with colchicine and NSAIDs may limit their use.

CONCLUSION

When colchicine and NSAIDs are contraindicated or poorly tolerated, rilonacept and canakinumab, interleukin-1 inhibitors in trials, may prove to be useful alternatives for flare prevention. (Of note, although both inhibit the IL-1β pathway, rilonacept also binds to IL-1α and IL-1RA, in contrast to canakinumab, which binds selectively to IL-1β.).

[Pathophysiology of gout]

Hyperuricemia is rather often metabolic disorder in general population. It is multifactorial disorder influenced by purine rich diet, alcohol consumption, diuretics use and renal deterioration. In the presence of local urate superasturation and lower solubility, monosodium crystals are deposited in joints, kidneys and soft tissue leading to clinical manifestations, such as gout, tophaceus deposits, nephrolithiasis and uric nephropathy. Major advances in understanding the pathogenesis of hyperuricemia and gout have been made recently, including genetic studies of urate transporters in kidneys as well as innate immune inflammatory responses and cytokine production which will be discussed thoroughly in this paper.

An update on the pathology and clinical management of gouty arthritis

Gouty arthritis is an inflammatory condition associated with debilitating clinical symptoms, functional impairments, and a substantial impact on quality of life. This condition is initially triggered by the deposition of monosodium urate crystals into the joint space. This causes an inflammatory cascade resulting in the secretion of several proinflammatory cytokines and neutrophil recruitment into the joint. While generally effective, currently available agents are associated with a number of adverse events and contraindications that complicate their use. Based on our increased understanding of the inflammatory pathogenesis of gouty arthritis, several new agents are under development that may provide increased efficacy and reduced toxicity.

Gouty arthritis: understanding the disease state and management options in primary care

Acute gouty arthritis is an inflammatory response triggered by the release of monosodium urate crystal deposits into the joint space. The disease is associated with debilitating clinical symptoms and functional impairments as well as adverse economic and quality-of-life burdens. Because gouty arthritis is typically diagnosed and managed in the primary care setting, clinicians require a thorough knowledge of the presenting clinical features, risk factors, differential diagnoses, and treatment options for appropriate management. Although generally effective, the use of currently available therapies to control gouty arthritis is challenging because many medications used to treat comorbidities can exacerbate gouty arthritis and because current agents are associated with a number of adverse events, contraindications, or both. Based on an understanding of the underlying inflammatory pathogenesis of gouty arthritis, several new agents are being developed that may provide improved efficacy.

[Syndromic approach to MR diagnosis of gouty arthritis]

The objective of the study was to improve radiodiagnosis of gouty arthritis. Thirty-six gout patients aged 39 to 58 years were examined. All the patients underwent X-ray of affected joints and magnetic resonance imaging (MRI). X-ray and MRI revealed tophus formation. The latter also showed articular syndrome and extraarticular manifestations of gout. Analysis of the findings indicated that MRI could enhance the informative value of clinicoradiographic examination of gout patients.

[A clinical research of Jiawei simiaosan oral administration combined with the external application of Sihuangshuimi in the treatment of acute gouty arthritis]

OBJECTIVE

To investigate the clinical curative effect in the treatment of acute gouty arthritis with Chinese traditional medicine.

METHODS

All the 65 patients of acute gouty arthritis were randomly divided into two groups. The treatment group was treated by jiawei simiaosan and combined with the external application of Sihuangshuimi. The control group was treated by gclchicine. Then an evaluation was made on the clinical effect just referring to clinical symptoms and physical sign after a week.

RESULTS

Two groups were therapeutic equivalence (P >0.05). The changes of the two groups in clinical symptoms physical signs and integral signs were so obviously after treatment (P <0.01), except for the UA of control group (P >0.05). Howerer, the level of UA of the treatment group had an advantage to the control group (P <0.05).

CONCLUSION

The effect of using sihuangshuimi combined with Jiawei simiaosan to cure acute gouty arthritis is not only to improve joint function and cut down UA level obviously, but also to decline the body temperature and decrease swelling to relieve pain.

Genetics and experimental models of crystal-induced arthritis. Lessons learned from mice and men: is it crystal clear?

PURPOSE OF REVIEW

We examine the major genes in mice and humans involved in the pathogenesis of monosodium urate, calcium pyrophosphate dihydrate and hydroxyapatite crystal-induced arthritis.

RECENT FINDINGS

Several genetic causes of renal disease associated with hyperuricemia and gout provide insight into genes involved in renal urate handling. Mutations or polymorphisms in exons 4 and 5 and intron 4 of urate transporter 1 may be independent genetic markers of hyperuricemia and gout. Genetic analysis supports the role of ANKH mutations in calcium pyrophosphate dihydrate-induced arthritis. ANKH gain-of-function mutations were confirmed by functional studies; however, the crystals formed in ATD5 cells were basic calcium phosphate, not calcium pyrophosphate dihydrate, underlying the significance of chondrocyte differentiation state and the factors regulating normal and pathological mineralization. Animal models have implicated a general model of crystal-induced inflammation involving innate immunity through the NALP3 (Natch domain, leucine-rich repeat, and PYD-containing protein 3) inflammasome signaling through the interleukin-1 receptor and its signaling protein myeloid differentiation primary response protein 88.

SUMMARY

Genetic analysis has elucidated genes responsible for crystal formation and animal models have unveiled mechanisms in the development of crystal-induced arthritis. Future studies will hasten understanding of the pathology of crystal-induced arthritis and provide new therapies.

Gout, have we met before? No, not like this

LEARNING OBJECTIVES

Extra-articular symptoms could be the first manifestation of gouty arthritis (GA); polyarticular GA can mimic an infectious arthritis; infection can complicate GA.

CASE

A 66-year-old male with a history of gout presented with high fever and excruciating bilateral calf pain for 1 day. Examination revealed chronic knee effusions; range of motion in both knees was limited by calf pain. Joint aspiration showed negatively birefringent intracellular crystals and normal gram stain.

HOSPITAL COURSE

While receiving empiric antibiotics fever continued and he developed bilateral knee, right ankle, and shoulder pain. After demonstration of urate crystals and exclusion of infection, antibiotics were discontinued and steroids initiated. Fever, calf pain, and polyarthritis quickly resolved.

DISCUSSION

Polyarticular gouty attack is an uncommon presentation of gout, and can mimic several other conditions. An exceptional presentation of this entity is excruciating calf pain, probably caused by tenosynovitis or referred pain preceding an acute polyarticular gouty attack.

Melanocortin 3 receptors control crystal‐induced inflammation

In this study we have characterized the anti-inflammatory profile of a selective melanocortin type 3 receptor (MC3-R) ligand [D-Trp8]-gamma-MSH, validating in vitro results with analyses in mice deficient for this receptor subtype. In wild-type (WT) macrophages, [D-Trp8]-gamma-MSH activated MC3-R (as tested by accumulation of cyclic AMP) and inhibited (approximately 50%) the release of interleukin (IL)-1 and the chemokine KC (CXCL1), but was ineffective in cells taken from MC3-R null mice. In vivo, administration of 3-30 microg [D-Trp8]-gamma-MSH significantly inhibited leukocyte influx and cytokine production in a model of crystal-induced peritonitis, and these effects were absent in MC3-R null mice or blocked by coadministration of an MC3-R antagonist. Finally, in a model of gouty arthritis, direct injection of urate crystals into the rat joint provoked a marked inflammatory reaction that was significantly inhibited (approximately 70%) by systemic or local administration of [D-Trp8]-gamma-MSH. In conclusion, using an integrated transgenic and pharmacological approach, we provide strong proof of concept for the development of selective MC3-R agonists as novel anti-inflammatory therapeutics.

[Pathogenesis, diagnostics and therapy of gout]

Gout refers to heterogeneous group of metabolic diseases characterized by production of deposits of sodium urate crystals in tissues. Gout manifests as acute gouty arthritis with classic clinical picture, or as chronic gouty arthropathy with periarticular and subcutaneous deposits of sodium urate crystals, i.e. tophi. As for kidney, gout is manifested as acute or chronic gouty nephropathy and urolithiasis. These manifestations occur separately or they are combined. Hyperuricemia of primary gout is caused rather by impaired renal secretion than overproduction of uric acid. Secondary hyperuricemia is associated with many pathological conditions; it is also connected with the use of various medicaments. Pathogenesis of gouty arthritis is critically influenced by sodium urate crystals and inflammatory processes they induce. Hyperuricemia is part of metabolic syndrome X which is associated with unanswered question of the relationship between uric acid and atherosclerosis. Although gouty arthritis is the most frequent inflammatory disease of joints in men over 50 years of age, it is often diagnosed and treated inadequately. On that account, the indication of long-term hypouricemic therapy should be always based on the following criteria: secondary causes of hyperuricemia have to be excluded first; frequency of gout attacks and the risk of their recurrence should be taken into consideration; then it is necessary to search for renal manifestations of gout; and last but not least, we should check whether there are any associated diseases classified in metabolic syndrome X.

[Gout and diabetes]

Gout is the most frequent cause of acute arthritis in men over 40 years of age. In the recent years, gout incidence has been increasing in developed countries probably due to dietary changes, alcohol consumption, ageing of population and also application of high-risk medications. Hyperuricemia is one of the symptoms of hyperinsulinism and metabolic syndrome. The level of uricemia correlates with the degree of insulin resistance. Correlation of uric acid levels and the risk of coronary and cerebral accidents were reported both in diabetic and non-diabetic population. It has not been explained satisfactorily whether this is the direct result of hyperuricemia or concurrently present symptom of metabolic syndrome. The study describes symptomatology of clinical signs of gout and discusses about appropriate therapeutic approach in each stage of the disease. New therapeutic possibilities that are still in the stage of clinical studies are mentioned. Also, we focus on alternative dietary recommendations for hyperuricemia and gout patients. The reason of changes in dietary regime is the effort to alleviate the signs of metabolic syndrome. The study emphasises the practical significance of screening of metabolic syndrome signs during examination of gout patients so that appropriate targeted therapeutic intervention could be performed. On the contrary, increased risk of gout-induced movement disorders should be taken into account in patients with diagnosed insulin resistance.

A concise history of gout and hyperuricemia and their treatment

First identified by the Egyptians in 2640 BC, podagra (acute gout occurring in the first metatarsophalangeal joint) was later recognized by Hippocrates in the fifth century BC, who referred to it as 'the unwalkable disease'. The term is derived from the Latin word gutta (or 'drop'), and referred to the prevailing medieval belief that an excess of one of the four 'humors'--which in equilibrium were thought to maintain health--would, under certain circumstances, 'drop' or flow into a joint, causing pain and inflammation. Throughout history, gout has been associated with rich foods and excessive alcohol consumption. Because it is clearly associated with a lifestyle that, at least in the past, could only be afforded by the affluent, gout has been referred to as the 'disease of kings'. Although there is evidence that colchicine, an alkaloid derived from the autumn crocus (Colchicum autumnale), was used as a powerful purgative in ancient Greece more than 2000 years ago, its first use as a selective and specific treatment for gout is attributed to the Byzantine Christian physician Alexander of Tralles in the sixth century AD. Uricosuric agents were first used at the end of the 19th century. In the modern era, nonsteroidal anti-inflammatory drugs are usually the drugs of choice for treating acute gout. Perhaps the most important historical advance in the treatment of hyperuricemia was the development of xanthine oxidase inhibitors, which are effective in reducing plasma and urinary urate levels and have been shown to reverse the development of tophaceous deposits.

The inflammatory process of gout and its treatment

Gouty arthritis is a characteristically intense acute inflammatory reaction that erupts in response to articular deposits of monosodium urate (MSU) crystals. Important recent molecular biologic advances in this field have given us a clear picture of the mechanistic basis of gouty inflammation. The innate immune inflammatory response is critically involved in the pathology of gout. Specifically, MSU crystals promote inflammation directly by stimulating cells via Toll-like receptor signaling and by providing a surface for cleavage of C5 and formation of complement membrane attack complex (C5b-9), culminating in secretion of cytokines, chemokines, and other inflammatory mediators with a dramatic influx of neutrophils into the joint. Despite the detailed mechanistic picture for gouty inflammation, there are no placebo-controlled, randomized clinical studies for any of the therapies commonly used, although comparative studies have demonstrated that many nonsteroidal anti-inflammatory drugs are equivalent to indomethacin with respect to controlling acute gouty attacks. In general, the first line of anti-inflammatory therapy for acute gout is nonsteroidal anti-inflammatory drugs, and the selective cyclo-oxygenase-2 inhibitor celecoxib can be used where appropriate. The second line of treatment is glucocorticosteroids, given systemically (oral, intravenous, or intramuscular) or intra-articularly. Alternatively, synthetic adrenocorticotropic hormone is effective, partly via induction of adrenal glucocorticosteroids and partly via rapid peripheral suppression of leukocyte activation by melatonin receptor 3 signaling. The third line of treatment is oral colchicine, which is highly effective when given early in an acute gouty attack, but it is poorly tolerated because of predictable gastrointestinal side effects.

Outcome measures for acute and chronic gout

Gout provides some unique challenges in classification and measurement of outcomes. Our aim was to evaluate criteria for classification and to develop and validate optimal instruments to measure outcomes for acute and chronic gout. A planning committee and interested attendees met to propose classification criteria and domains for outcomes. Seven of the current American Rheumatism Association preliminary criteria for classification were proposed as the best current criteria for acute gouty arthritis, pending further studies. The presence of gout is best established by crystal identification, although this technique has limitations. Five domains for acute gout outcomes and 9 for chronic gout were identified along with proposed instruments for testing and validation. The unique problems of gout evaluation can and will be addressed.

Renal function in minahasanese patients with chronic gout arthritis and tophi

AIM

Determine renal function and factors that influence reduction in renal function among Minahasanese with chronic gout arthritis and tophi.

METHODS

This is a descriptive cross-sectional study where study subjects are recruited using multi-stage sampling. The data are descriptively processed using T-test, Pearson correlates, and multiple regression analysis.

RESULTS

The proportion of mild, moderate, and severe reductions in renal function in Minahasanese with chronic gout arthritis and tophi were as follows: 25 patients (69.7%), 7 patients (19.5%), and 5 patients (11%). According to Pearson correlation, only urinary uric acid excretion (r=0.626, p=0.000). The same findings were found using multiple regression, only urinary uric acid excretion is significant (p=0.001).

CONCLUSION

Most Minahasanese with chronic gout arthritis and tophi suffer from a mild reduction in renal function associated with the amount of uric acid excreted in the urine, but not associated with age, serum uric acid level, duration of gout arthritis, or tophi. Correlation with duration of gout arthritis, or tophi. Correlation with hypertension and use of NSAID are not evident in this study.

Effects of Rebixiao granules on blood uric acid in patients with repeatedly attacking acute gouty arthritis

OBJECTIVE

To observe the clinical effect of Rebixiao granule (RBXG) in treating repeatedly attacking acute gouty arthritis and through experimental study on blood uric acid to explore RBXG's therapeutic mechanism.

METHODS

Ninety repeatedly attacking acute gouty arthritis patients were divided into the treated group (n = 60) and control group (n = 30). The treated group was treated with RBXG, and the control group was treated with Futalin tablets (diclofenac sodium). The baseline treatment including good rest, low purine diet, sufficient water drinking and urine alkalization, etc. was then given to both groups. Hypoxanthine 600 mg/kg and niacin 100 mg/kg was applied to hyperuricemic mice by gastrogavage to establish the animal models.

RESULTS

The clinical effective rate of the treated group was 95.0% and that of the control 90.0%. Good therapeutic effects were won, insignificant difference (P > 0.05)was shown between the two groups. However, the cure rate of the treated group was 26.7% while that of the control group was 10.0%, with significant difference (P < 0.01) shown between them. The treated group had its blood uric acid lowered, which was significantly different (P < 0.05) from that of the control group. The animal experiment indicated that all the three groups treated with different dosages of RBXG, as well as the Ash bark and Smilax glabra rhizome groups had their blood uric acid content reduced in the hyperuricemic mice.

CONCLUSION

RBXG has a quicker initiation and better treatment effects than sole anti-inflammatory and analgesic agents on the treatment of repeatedly attacking acute gouty arthritis, showing no obvious toxic or adverse reactions and therefore good for long-term administration and likely to be a safe TCM preparation to control the symptoms and reduce the onsets of repeatedly attacking of acute gouty arthritis. The animal experiment shows that both the compound preparation and part of the single ingredients in the recipe have the function of reducing blood uric acid. However, the compound recipe has better therapeutic effects, proving to be superior to single drugs.

Management of acute and chronic gouty arthritis: present state-of-the-art

There are three stages in the management of gout: (i) treating the acute attack; (ii) lowering excess stores of uric acid to prevent flares of gouty arthritis and to prevent tissue deposition of urate; and (iii) providing prophylaxis to prevent acute flares. It is important to distinguish between therapy to reduce acute inflammation in acute gout and therapy to manage hyperuricaemia in patients with chronic gouty arthritis. During the acute gouty attack nonpharmacological treatments such as topical ice and rest of the inflamed joint are useful. NSAIDs are the preferred treatment in acute gout. The most important determinant of therapeutic success is not which NSAID is chosen, but rather how soon NSAID therapy is initiated. Other treatments include oral and intravenous colchicine, intra-articular and systemic corticosteroids, and intramuscular corticotropin. Optimal treatment of chronic gout requires long-standing reduction in serum uric acid. The urate-lowering drugs used to treat chronic gout are the uricosuric drugs, the uricostatic drugs, which are xanthine oxidase inhibitors, and the uricolytic drugs. Xanthine oxidase inhibitors such as allopurinol, oxipurinol and febuxastat should be used as first-line treatment in patients with renal calculi, renal insufficiency, concomitant diuretic therapy and ciclosporin (cyclosporine) therapy, and urate overproduction. Uricosuric drugs include probenecid, benzbromarone, micronised fenofibrate and losartan. They are the urate-lowering drugs of choice in allopurinol-allergic patients and underexcretors with normal renal function and no history of urolithiasis. The use of recombinant urate oxidase in patients with chronic gout is limited by the need for parenteral administration, the potential antigenicity and production of anti-urate oxidase antibodies, and declining efficacy. The effectiveness of colchicine prophylaxis as an isolated therapy is still to be confirmed by placebo-controlled trials. Another issue is prophylaxis with NSAIDs. There are no comparative studies with colchicine.

Gout: a clinical and radiologic review

Gout is a group of diseases characterized by arthritis and results from a disturbance of urate metabolism with the deposition of monosodium urate crystals in the joints and soft tissues. Often, but not invariably, the serum urate levels are elevated as a result of overproduction or underexcretion of uric acid. Clinical manifestations include acute and chronic arthritis, tophaceous deposits, interstitial renal disease, and uric acid nephrolithiasis. The diagnosis is based on the identification of uric acid crystals in joints, tissues, or body fluids. Acute episodes are treated with colchicine, NSAIDs, or steroids. Long-term management includes treatment with uricosuric agents or xanthine oxidase inhibitors.

[The effectiveness and safety of nimesulide (nimesile) in patients with gouty arthritis]

Patients with gout are at a high risk for drug-induced complications associated with the use of nonsteroidal anti-inflammatory drugs due to the baseline renal and hepatic abnormalities, metabolic disturbances, and concomitant diseases, such as arterial hypertension or type 2 diabetes mellitus. In this connection, it is expedient to use safer selective cycloxygenase-2 (COG-2) inhibitors. However, there are only single reports dealing with studies of the effectiveness and safety of selective COG-2 inhibitors in gout. The study was undertaken to evaluate the effectiveness and safety of the selective COG-2 inhibitor nimesulide (nimesile) in acute gouty arthritis (GA). Twenty male patients (whose mean age was 51.1 +/- 8.4 years) with PA were examined. Seven patients were found to have monoarthritis of 1 metatarsophalangeal joint, oligoarthritis was present in 9 patients and 4 patients had polyarthritis. The history of arthritis was as long as 6 days in 16 patients and 21-30 days in 4. Nimesulide was given in a dose of 200 mg/day for at least 14 days. The time course of changes in the objective and subjective symptoms of arthritis was studied. The tolerability of the drug was evaluated by its effect on renal (the levels of creatinine and urea, creatinine clearance) and hepatic (alanine transferase (ALT), aspartate transferase (AST), gamma-glutamyltranspeptidase (gamma-GTP)) functions, and blood pressure (BP) [24-hour BP monitoring (24-h BPM) before and after treatment. There were clear positive changes in the major parameters of arthritis: the swelling index was 4.5 +/- 2.7 and 0.5 +/- 0.5 scores before and after treatment, respectively; hyperemia, 3.5 +/- 2.5 and 0.1 +/- 0. 1 scores; articular index, 3.6 +/- 2.0 and 0.7 +/- 0.6 scores; pain (visual analogue scale) when resting, 53.8 +/- 17.6 and 4.7 +/- 4.6 scores, and that when moving, 68.3 +/- 16.0 and 9.0 +/- 8.8 mm, respectively. Negative changes in the levels of creatinine and uric acid and a reduction in creatinine clearance were not observed. There were no increases in the levels of ACT, ALT, gamma-GTP. 24-h BPM did not reveal any significant changes in the mean 24-hour, mean diurnal and nocturnal variables of BP. The 24-hour BP profile became better in some patients. Thus, nimesulide is an effective and safe drug for the treatment of PA.

Rapid induction of peroxisome proliferator-activated receptor gamma expression in human monocytes by monosodium urate monohydrate crystals

OBJECTIVE

Peroxisome proliferator-activated receptor gamma (PPAR gamma) is a member of the nuclear hormone receptor superfamily and functions as a key regulator of lipid and glucose metabolism, atherosclerosis, and inflammatory responses. This study was undertaken to evaluate the biologic role of PPAR gamma in self-limiting episodes of acute gouty arthritis. To do this, we investigated PPAR gamma expression by monosodium urate monohydrate (MSU) crystal-stimulated monocytes, and we studied the effects of PPAR gamma ligands on crystal-induced acute inflammation.

METHODS

PPAR gamma expression by MSU crystal-stimulated human peripheral blood mononuclear cells was determined by reverse transcription-polymerase chain reaction and immunostaining. Expression of CD36 on monocytes was detected by flow cytometric analysis. The effects of PPAR gamma ligands on in vitro crystal-induced cytokine production and on in vivo cellular infiltration during crystal-induced acute inflammation were also investigated.

RESULTS

MSU crystals rapidly and selectively induced PPAR gamma expression by monocytes. Gene expression was detected as early as 2 hours, and maximum expression was observed at 4 hours after stimulation. The induced PPAR gamma was functional, since a PPAR gamma ligand was able to up-regulate CD36 expression on monocytes. A natural ligand of PPAR gamma, 15-deoxy-Delta(12,14)-prostaglandin J(2) (15deoxy-PGJ(2)), significantly reduced the crystal-induced production of cytokines by monocytes. Indomethacin inhibited cytokine production only at high concentrations, and an antidiabetic thiazolidinedione (troglitazone) failed to exert significant effects. Administration of troglitazone and 15deoxy-PGJ(2) significantly prevented cellular accumulation in a mouse air-pouch model of MSU crystal-induced acute inflammation.

CONCLUSION

Rapid induction of PPAR gamma expression on monocytes by MSU crystals may contribute, at least in part, to the spontaneous resolution of acute attacks of gout.

The inflammatory process in the mechanism of decreased serum uric acid concentrations during acute gouty arthritis

OBJECTIVE

To clarify the mechanism of decreased serum uric acid (SUA) concentrations during acute gouty arthritis.

METHODS

Data from patients with acute gouty arthritis during and after an attack were investigated retrospectively. Other investigations, including changes in urinary excretion and biochemical markers, were performed prospectively.

RESULTS

SUA was significantly lower in the acute phase (7.5 +/- 1.4 mg/dl) than in the intercritical phase (8.5 +/- 0.9 mg/dl) (p < 0.0001). During the acute gout phase, a normal SUA level was found in 20 of 41 patients (49%). C-reactive protein (CRP) during acute attacks was significantly correlated with plasma interleukin 6 (IL-6) and cortisol (r = 0.645, p < 0.005; r = 0.460, p < 0.05). Percentage change in SUA at onset of attack correlated with CRP and IL-6 (r = 0.762, p < 0.0001; r = 0.630, p < 0.005), as well as with increased urinary excretion of uric acid, estimated by percentage change in fractional excretion of uric acid (FEua) during attack (r = 0.447, p < 0.05). Further, change in FEua was correlated with plasma cortisol levels during the acute attack (r = 0.534, p < 0.05).

CONCLUSION

Decrease in SUA during acute gouty arthritis is associated with increased urinary excretion of uric acid; an inflammatory process may play a role in the mechanism.

Local ice therapy during bouts of acute gouty arthritis

OBJECTIVE

To evaluate the effect of local application of ice on duration and severity of acute gouty arthritis.

METHODS

Nineteen patients with acute gout were enrolled and randomized into 2 groups. Group A (n = 10) received topical ice therapy, oral prednisone 30 mg PO tapered to 0 over 6 days and colchicine 0.6 mg/day. Group B was the control group (n = 9), given the same regimen but without the ice therapy. The patients were followed for one week.

RESULTS

The mean reduction in pain for those patients treated with ice therapy was 7.75 cm (on 10 cm visual analog scale) with standard deviation +/- 2.58 compared with 4.42 cm (+/- SD 2.96) for the control group. Using a Wilcoxon rank-sum test there was a significant difference (p = 0.021 ) in pain reduction between the ice therapy and control groups. Joint circumference and synovial fluid volume also tended to be more effectively reduced after one week of therapy in the ice group compared with controls, but these did not achieve statistical significance.

CONCLUSION

The group treated with ice had a significantly greater reduction in pain compared with the control group. Although the clinical improvement was impressive, due to the small sample size we could not show statistically significant improvement in all the variables that tended to suggest that effect was more than simply analgesic. Cold applications may be a useful adjunct to treatment of acute gouty arthritis.

Gout: diagnosis, pathogenesis, and clinical manifestations

Gout is a common form of arthritis, in which many of the risk factors, pathogenetic mechanisms, and clinical features have been recognized for years. Nevertheless, new information has become available regarding the normal physiologic role of uric acid as an antioxidant, and greater insight has been obtained regarding the inflammatory process in acute gout. New studies have improved our understanding of the role of genetic and environmental factors responsible for hyperuricemia, and we know more about the significance of the association of hyperuricemia with other diseases. Clinically, rare complications and disease manifestations in new populations continue to be discussed, and diagnostic methods continue to be refined.

Evaluation of intraarticular opioid analgesia for the relief of articular pain in the domestic fowl

An experimental paradigm, based on the microcrystalline sodium urate-induced arthritis pain model, was used to investigate the potential peripheral analgesic properties of a variety of opioid agonists. The response criteria were changes in behavioral profiles and pain-related behaviors over 60 min commencing 1 h after intraarticular injection. The testing system was used to determine the potential optimum dose of intraarticular application of morphine sulphate (1-3 mg), fentanyl citrate (0.5-3 mg), and buprenorphine hydrochloride (0.05-1 mg). None of the opioid analgesics used had any effect on pain behavior, and it was concluded that opioids with a high affinity for the mu receptor when injected intraarticularly were unlikely to be of use in the treatment or diagnosis of inflammatory arthritic pain in the strain of domestic fowl chosen.

Gouty arthritis and uric acid metabolism

Important observations have continued to expand our understanding of gout. The increased risk of gout in black Americans has been linked more closely with the development of hypertension, and an increasing prevalence in African blacks and in England may have a similar association, possibly through the use of diuretics. The association of gout and insulin resistance appears to be related to fat distribution, and the link with hyperlipidemia may be related to genetic factors. The relationship between gout and renal disease and the frequency of gout in patients with renal failure continue to be areas of controversy. The mechanism and a possible therapeutic approach to the hyperuricemia associated with cyclosporine therapy are better understood. The potential for antibodies against urate crystals to potentiate further crystallization may explain some of the uncertainties about gouty attacks. Unusual manifestations of gout, including more cases of spinal involvement, were reported. The role of formalin in dissolving urate crystals in pathologic specimens was further clarified, and the use of atomic force microscopy to detect crystals was reported. Corticosteroids are increasingly accepted in treating acute gout, and the role of colchicine in acute and intercritical gout has come under increasing scrutiny. Urate-lowering drugs appear to be cost effective in patients with more than one or two attacks per year.

Clinics in diagnostic imaging (2). Juvenile gouty arthropathy with associated nephropathy

A 36-year-old Chinese man presented with clinical and biochemical features of renal failure. He has had recurrent attacks of acute gouty arthritis since the age of 15 years. Present radiographic features of extensive chronic tophaceous gout included soft tissue masses, calcification, and typical erosions in the hand and feet. The condition of familial juvenile gouty nephropathy is discussed. Awareness of juvenile-onset gouty arthropathy should lead to early investigation, diagnosis and appropriate management. The complication of associated nephropathy may potentially be prevented.

Renal function in gout patients

Patients with gouty arthritis were examined at Veterans General Hospital to evaluate whether their renal function is impaired and to define the factor(s), if any, of renal function deterioration. A total of 152 cases were included in the study, and the patients were divided into two groups. One group (n = 80) exhibited pure gout without any associated medical problems or preexisting renal disorders. The second group (n = 72) included patients with gout and hypertension. The group with pure gout was further stratified into patients with tophi (n = 21) and those without (n = 59). Seventy-two sex- and age-matched normal adults served as the control group. We found (1) that the renal function was impaired in the pure-gout group when compared with sex- and age-matched normal individuals (serum creatinine 1.56 +/- 0.64 vs. 0.90 +/- 0.16 mg/dl, p = 0.0001; creatinine clearance 59.91 +/- 30.90 vs. 97.10 +/- 27.19 ml/min, p = 0.0001); (2) that the renal function was significantly more aggravated in patients with clinically visible tophi than in those without (gout with tophi vs. gout without tophi: serum creatinine 1.89 +/- 0.90 vs. 1.44 +/- 0.48 mg/dl, p = 0.040; creatinine clearance 47.27 +/- 31.90 vs. 64.40 +/- 29.53 ml/min, p = 0.030), and (3) that a further significant decline of the renal function was noted in gouty patients with an associated medical illness, i.e., hypertension (gout with hypertension vs. pure gout: serum creatinine 2.10 +/- 0.97 vs. 1.56 +/- 0.64 mg/dl, p = 0.0001; creatinine clearance 45.06 +/- 24.69 vs. 59.91 +/- 30.90 ml/min, p = 0.0029).(ABSTRACT TRUNCATED AT 250 WORDS)

Calcium pyrophosphate dihydrate crystal deposition and other crystal deposition diseases

Calcium pyrophosphate dihydrate (CPPD) crystal deposition disease continues to be of intense clinical and basic science interest. Follow-up of studies of hereditary CPPD crystal deposition indicate differences from the common sporadic disease. The results of a prospective study of CPPD crystal deposition arthropathy confirm that clinical symptoms appear to be independent of radiologic progression. Novel clinical presentations include association with pregnancy and simulation of meningitis. CPPD crystal deposition pathology in synovium ultrastructurally resembles that in cartilage. Factors such as the presence of ATP can induce experimental calcifications in tissue culture that resemble CPPD crystal deposition. Interleukin-8 and tyrosine phosphorylation of neutrophil protons can mediate CPPD crystal deposition-associated inflammation. The control of crystal function and dissolution recently has been the subject of many general reviews. The theory outlined in these papers is important for understanding CPPD crystal deposition and basic phosphate crystal formation and dissolution.