Gout

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Gout is a common, painful form of arthritis.
It causes swollen, red, hot and stiff joints. Gout occurs when uric acid builds
up in your blood. This happens if your body produces extra acid or does not
eliminate enough, or if you eat too many foods with purines, such as liver and
dried beans. Pseudogout has similar symptoms and is sometimes confused with
gout. However, it is caused by calcium phosphate, not uric acid.

Often, gout first attacks your big toe. It
can also attack ankles, heels, knees, wrists, fingers and elbows.
You are more likely to get gout if you:

Are a man
Have family
member with gout
Drink
alcohol
At first, gout attacks usually get better in
days. Eventually, attacks last longer and occur more often. Uric acid buildup
can lead to kidney stones.
Untreated gout can cause permanent joint and kidney damage. You can treat gout
with medicines.

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Gout

  1. 1. Fitango Education Health Topics Gouthttp://www.fitango.com/categories.php?id=87
  2. 2. Overview Gout is a common, painful form of arthritis. It causes swollen, red, hot and stiff joints. Gout occurs when uric acid builds up in your blood. This happens if your body produces extra acid or does nothttp://www.fitango.com/categories.php?id=87 1
  3. 3. Overview eliminate enough, or if you eat too many foods with purines, such as liver and dried beans. Pseudogout has similar symptoms and is sometimes confused with gout. However, it is caused by calcium phosphate, not uric acid. Often, gout first attacks your big toe. Ithttp://www.fitango.com/categories.php?id=87 2
  4. 4. Overview can also attack ankles, heels, knees, wrists, fingers and elbows. You are more likely to get gout if you: Are a man Have family member with gouthttp://www.fitango.com/categories.php?id=87 3
  5. 5. Overview Drink alcohol At first, gout attacks usually get better in days. Eventually, attacks last longer and occur more often. Uric acid buildup can lead to kidney stones.http://www.fitango.com/categories.php?id=87 4
  6. 6. Overview Untreated gout can cause permanent joint and kidney damage. You can treat gout with medicines.http://www.fitango.com/categories.php?id=87 5
  7. 7. Symptoms The most common symptom of gout is sudden and severe pain in one or more joints; typically your big toe. Gout is extremely painful; some people feel its as painful as childbirth.http://www.fitango.com/categories.php?id=87 6
  8. 8. Symptoms Symptoms often develop at night, although they can occur at any time. Other symptoms include: -- swelling (inflammation) in and around the affected joint -- red, shiny skin over the affected jointhttp://www.fitango.com/categories.php?id=87 7
  9. 9. Symptoms -- peeling, itchy and flaky skin over the affected joint as the inflammation subsides The intense pain that gout causes can make walking and getting around difficult. Even the light pressure of a bed cover or blanket can be painful.http://www.fitango.com/categories.php?id=87 8
  10. 10. Symptoms What joints are affected? Seventy per cent of people with gout experience their first attack in the big toe, and most people with gout will experience pain in this joint at some point.http://www.fitango.com/categories.php?id=87 9
  11. 11. Symptoms However, while gout is most common in the big toe, it can affect any peripheral limb joint and can occur in two or more joints at the same time. Affected joints may include: -- midfoothttp://www.fitango.com/categories.php?id=87 10
  12. 12. Symptoms -- ankles -- knees -- fingers -- wrists -- elbowshttp://www.fitango.com/categories.php?id=87 11
  13. 13. Symptoms If gout is left untreated, it is more likely to affect more than one joint as it progresses. Pattern of symptoms It is difficult to predict when an attack will occur. Symptoms can develop rapidly over a few hours and usually last for 3-10 days. Afterhttp://www.fitango.com/categories.php?id=87 12
  14. 14. Symptoms this time, the joint will start to feel normal again and any pain or discomfort should eventually disappear completely. Just over half of all people with gout (62%) experience a repeat attack within a year. You may experience symptoms every few weeks,http://www.fitango.com/categories.php?id=87 13
  15. 15. Symptoms months or years, but it is impossible to predict when the condition will recur. Some only experience a few attacks in their lifetime.http://www.fitango.com/categories.php?id=87 14
  16. 16. Diagnosis The most accurate way to diagnosis gout is to check your joints for the presence of crystals. However, this test is often not practical to carry out at your local GP.http://www.fitango.com/categories.php?id=87 15
  17. 17. Diagnosis Instead, usually your GP will look at your symptoms and medical history to make a diagnosis. Many conditions can cause joint pain, inflammation and swelling. Gout is just one of over 200 different forms of arthritis (any conditionhttp://www.fitango.com/categories.php?id=87 16
  18. 18. Diagnosis that causes pain and problems with the joints). Therefore, your GP may be unable to make a firm diagnosis straight away and you may be referred for further tests. These will either confirm the diagnosis of gout or rule out other conditions.http://www.fitango.com/categories.php?id=87 17
  19. 19. Diagnosis **Serum uric acid A serum uric acid test is usually carried out four-to- six weeks after an attack of gout, as the serum uric acid level is often not raised at the time of the attack.http://www.fitango.com/categories.php?id=87 18
  20. 20. Diagnosis **Serum uric acid The test involves analysing a sample of blood taken from a vein in your arm to measure the amount of uric acid in your blood. A raised uric acid level is often an indication you may have developed gout. However, a serum uric acid test is not definitive. Somehttp://www.fitango.com/categories.php?id=87 19
  21. 21. Diagnosis **Serum uric acid healthy people without gout have high uric acid levels in their blood, while others who experience an attack of gout have a normal level. Synovial fluid If there is any doubt about what is causing your joint pain, you mayhttp://www.fitango.com/categories.php?id=87 20
  22. 22. Diagnosis **Serum uric acid have a sample of synovial fluid taken from the affected joint. Synovial fluid helps to keep the joint lubricated and stops the bones and cartilage from rubbing against each other. The fluid sample is taken using a needle and syringe. It is thenhttp://www.fitango.com/categories.php?id=87 21
  23. 23. Diagnosis **Serum uric acid examined under a microscope. If you have gout, there will nearly always be crystals of sodium urate in the sample. This sort of test will also help to rule out other crystals (calcium pyrophosphate) that can causehttp://www.fitango.com/categories.php?id=87 22
  24. 24. Diagnosis **Serum uric acid similar attacks of inflammation, as well as an infection in the joint such as septic arthritis (when a joint becomes infected with bacteria). X-ray An X-rayhttp://www.fitango.com/categories.php?id=87 23
  25. 25. Diagnosis **Serum uric acid is rarely used to diagnose gout because inflammation caused by gout is not usually detectable using this method. However, an X-ray is sometimes used to help rule out other conditions that affect the joints, such ashttp://www.fitango.com/categories.php?id=87 24
  26. 26. Diagnosis **Serum uric acid chondrocalcinosis (a build-up of calcium crystals in the joints). Confirming the diagnosis As checking the joints for crystals is not always practical in general practice, a checklist is often used. This is based on the knownhttp://www.fitango.com/categories.php?id=87 25
  27. 27. Diagnosis **Serum uric acid pattern of symptoms associated with the condition. The checklist used is as follows: -- You have had more than one attack with symptoms of pain, swelling and inflammation. -- You have experienced high levels of inflammation within just one day of the onset of symptoms.http://www.fitango.com/categories.php?id=87 26
  28. 28. Diagnosis **Serum uric acid -- Symptoms only affect one joint at a time. -- The joint in your big toe or other foot joints have been affected. -- Results of the serum acid test show raised levels of uric acid in your blood. -- Physical examination or X-rays have detected swelling within a joint.http://www.fitango.com/categories.php?id=87 27
  29. 29. Diagnosis **Serum uric acid -- There is no evidence that your joint has been infected by bacteria. You will usually be diagnosed with gout if at least six of the statements above apply to you.http://www.fitango.com/categories.php?id=87 28
  30. 30. Treatment If you are diagnosed with gout, your treatment plan will have two goals: -- relieving the symptoms of a gout attack -- preventing further attacks Relieving Symptoms: Self-care techniqueshttp://www.fitango.com/categories.php?id=87 29
  31. 31. Treatment During a gout attack, it is important to rest, elevate (raise) your limb and avoid accidentally knocking or damaging the affected joint. Keeping the affected joint cool should also help. Remove surroundinghttp://www.fitango.com/categories.php?id=87 30
  32. 32. Treatment clothing and apply an ice pack to it, such as a bag of frozen peas or some ice wrapped inside a towel. Apply the ice pack to your joint for approximately 20 minutes. Do not apply ice directly to your skin and do not apply it for more than 20http://www.fitango.com/categories.php?id=87 31
  33. 33. Treatment minutes at a time because this could damage the skin. Medication Non-steroidal anti-inflammatory drugs (NSAIDs) are a type of painkiller usually recommended as an initial treatmenthttp://www.fitango.com/categories.php?id=87 32
  34. 34. Treatment for gout. They work by reducing the levels of pain and inflammation. NSAIDs often used to treat gout include: -- diclofenac -- indometacin -- naproxenhttp://www.fitango.com/categories.php?id=87 33
  35. 35. Treatment If you have been prescribed NSAIDs for gout, it is best to keep them near you at all times so you can use them at the first sign of a gout attack. Continue to take your medication throughout the attack and forhttp://www.fitango.com/categories.php?id=87 34
  36. 36. Treatment 48 hours after the attack has finished. NSAIDs should be prescribed together with a medication called a proton pump inhibitor (PPI) that reduces the risk of the NSAID causing indigestion, stomach ulcers and bleeding from the stomach.http://www.fitango.com/categories.php?id=87 35
  37. 37. Treatment People with reduced kidney function or those with conditions such as stomach ulcers or bleeding should avoid using NSAIDs. Colchicine If you are unable or do not want to take NSAIDs, or if NSAIDs are ineffective, colchicine can be used instead. Colchicine is derived fromhttp://www.fitango.com/categories.php?id=87 36
  38. 38. Treatment the Autumn crocus plant. It is not a painkiller, but works by reducing the ability of the urate crystals to inflame the joint lining (synovium), which reduces some of the inflammation and pain associated with a gout attack.http://www.fitango.com/categories.php?id=87 37
  39. 39. Treatment Colchicine can be an effective treatment for gout. However, it should be used at low doses since it can cause upsets, including: -- nausea -- abdominal pain -- diarrhoeahttp://www.fitango.com/categories.php?id=87 38
  40. 40. Treatment Colchicine can cause major gut problems if taken in too high a dose. It is important to follow the recommended dose. For most people, this means taking no more than two to four tablets a day. Corticosteroidshttp://www.fitango.com/categories.php?id=87 39
  41. 41. Treatment Corticosteroids are a type of steroid sometimes used to treat severe cases of gout that do not respond to other treatment (above). A short course of steroid tablets often provides relief, but cant be used long-term as they cause side effects including: -- weight gainhttp://www.fitango.com/categories.php?id=87 40
  42. 42. Treatment -- thinning of the bones (osteoporosis) -- bruising -- muscle weakness -- thinning of the skin -- increased vulnerability to infectionhttp://www.fitango.com/categories.php?id=87 41
  43. 43. Treatment Corticosteroids can also exacerbate diabetes and glaucoma (an eye condition which can cause blindness if untreated). Corticosteroids may not be suitable for you if you have: -- bone marrow disease -- impaired kidney functionhttp://www.fitango.com/categories.php?id=87 42
  44. 44. Treatment -- impaired liver function -- heart failure Corticosteroids can also be given by injection, either into muscle or directly into the affected joint, which can provide rapid pain relief.http://www.fitango.com/categories.php?id=87 43
  45. 45. Treatment Lifestyle changes: Food Some foods are high in purines. Avoiding eating the foods below frequently or in large quantities can help reduce the risk of a gout attack:http://www.fitango.com/categories.php?id=87 44
  46. 46. Treatment -- meat, particularly kidney, liver, veal, turkey and venison -- seafood, particularly anchovies, herring, mackerel, sardines, fish roe, mussels and scallops -- certain types of vegetables, such as asparagus, kidney beans, lima beans, lentils and spinachhttp://www.fitango.com/categories.php?id=87 45
  47. 47. Treatment -- foods or supplements that contain yeast extract, such as Marmite and Quorn Weight If you are overweight, the levels of uric acid in your blood often rise. Losing weight will help reduce your uric acid levelshttp://www.fitango.com/categories.php?id=87 46
  48. 48. Treatment significantly. If you need to lose weight, it is important to follow a balanced, calorie-controlled diet. Do not crash diet. A high- protein, low-carbohydrate diet should be avoided because high-protein foods oftenhttp://www.fitango.com/categories.php?id=87 47
  49. 49. Treatment contain high levels of purines. Ensure you get plenty of regular exercise. Not only will this reduce your urate levels and decrease your risk of developing gout, it will also make you feel more energised and healthier.http://www.fitango.com/categories.php?id=87 48
  50. 50. Treatment If you have a gout attack, keep the joint rested and elevated (raised). Avoid exercise that puts strain on the affected muscles or joints. Swimming is a good way to stay fit without putting pressure on your joints as the water supports your weight.http://www.fitango.com/categories.php?id=87 49
  51. 51. Treatment Read more about losing weight safely and getting fit with exercise. Water It is important to drink plenty of water. Aim to drink about 1.2 litres (six-to-eight glasses) a day, or more if you are exercising orhttp://www.fitango.com/categories.php?id=87 50
  52. 52. Treatment when it is hot. Keeping yourself well hydrated will reduce the risk of crystals forming in your joints. Alcohol Some types of alcoholic drinks are associated with a greater risk of developing gout than others.http://www.fitango.com/categories.php?id=87 51
  53. 53. Treatment Beer and stout, which contain significant quantities of purines, carry a greater risk for the development of gout than equivalent units of spirits, such as vodka and whiskey.http://www.fitango.com/categories.php?id=87 52
  54. 54. Treatment A survey has shown that daily consumption of a small glass of wine is not associated with an increased risk of developing gout. However, binge drinking of any kind of alcohol can bring on an attack in people who have previously suffered with gout. Men should not drinkhttp://www.fitango.com/categories.php?id=87 53
  55. 55. Treatment more than three-to-four units of alcohol a day and women no more than two-to-three units a day.http://www.fitango.com/categories.php?id=87 54
  56. 56. Causes Gout is caused by a build-up of uric acid in the blood. Uric acid is a waste product that forms when the body breaks down chemicals in the cells known as purines.http://www.fitango.com/categories.php?id=87 55
  57. 57. Causes Most uric acid is removed from the body through the kidneys. A small amount is removed through the digestive system. Uric acid Uric acid usually remains dissolved in your blood and passes through your kidneys into your urine so it can be passed out of your body.http://www.fitango.com/categories.php?id=87 56
  58. 58. Causes If you produce too much uric acid or excrete too little when you urinate, the uric acid will build up and may cause microscopic crystals to form, usually in a joint or surrounding tissue. The crystals may spill over from the joint cartilage into the jointhttp://www.fitango.com/categories.php?id=87 57
  59. 59. Causes space where they trigger a reaction from the soft lining (synovium), which produces the intense pain and inflammation associated with gout.http://www.fitango.com/categories.php?id=87 58
  60. 60. Risks Some things can increase the amount of uric acid in your blood, making you more likely to develop gout. These risk factors fall into one of two categories:http://www.fitango.com/categories.php?id=87 59
  61. 61. Risks -- medical conditions known to increase levels of uric acid, such as obesity, high blood pressure (hypertension), high lipid levels and long-standing impairment of kidney function -- lifestyle factors, such as diet or certain types of medication that you may be takinghttp://www.fitango.com/categories.php?id=87 60
  62. 62. Risks These risk factors are discussed in more detail below. Medication Certain types of medication can increase your uric acid levels and your risk of developing gout. These include:http://www.fitango.com/categories.php?id=87 61
  63. 63. Risks -- diuretics, used to treat high blood pressure (hypertension) or an abnormal build-up of fluid in your body -- niacin, used to treat high cholesterol Sex Men are more likely to develop gout than women because their urichttp://www.fitango.com/categories.php?id=87 62
  64. 64. Risks acid levels rise during puberty. During the menopause, women experience a similar, albeit smaller, rise in their uric acid levels. This explains why symptoms start later in women than in men. Diethttp://www.fitango.com/categories.php?id=87 63
  65. 65. Risks Foods naturally high in purines include: -- beef -- pork -- bacon -- lamb -- seafoodhttp://www.fitango.com/categories.php?id=87 64
  66. 66. Risks -- liver -- kidneys Alcohol Alcoholic drinks raise the level of uric acid in the blood by increasing its production in the liver and by reducing how much ishttp://www.fitango.com/categories.php?id=87 65
  67. 67. Risks passed out in urine. Beer and spirits do so more than wine, and beer also contains significant quantities of purines. (Moderate consumption of wine – one or two glasses a day – should not significantly increase your risk ofhttp://www.fitango.com/categories.php?id=87 66
  68. 68. Risks gout). Family history Studies have shown that gout often runs in families. Around one-in-five people with gout have a close family member who also has the condition.http://www.fitango.com/categories.php?id=87 67
  69. 69. Risks Medical conditions Medical conditions that can increase your risk of developing gout include: -- high blood pressure (hypertension) -- diabetes, both type 1 diabetes and type 2 diabeteshttp://www.fitango.com/categories.php?id=87 68
  70. 70. Risks -- kidney disease -- having high levels of fat and cholesterol levels in your blood Susceptibility Gout attacks occur most frequently in the joints of the feet andhttp://www.fitango.com/categories.php?id=87 69
  71. 71. Risks hands, possibly because the temperature in these joints is often lower than the rest of the body, which increases the likelihood of crystals forming. It is still uncertain why some people are more susceptible to crystalhttp://www.fitango.com/categories.php?id=87 70
  72. 72. Risks formation and gout than others with equally high blood levels of uric acid. Many people with a high level of uric acid in their blood and tissues never develop gout. One theory is that certain genes you inherit from your parents mayhttp://www.fitango.com/categories.php?id=87 71
  73. 73. Risks make you more likely to develop gout by causing your kidneys that are otherwise healthy to be relatively inefficient at excreting uric acid. Several genes have recently been identified that are associated with high uric acid levels and gout and which influence uric acidhttp://www.fitango.com/categories.php?id=87 72
  74. 74. Risks elimination by the kidney.http://www.fitango.com/categories.php?id=87 73
  75. 75. Prevention Two methods used to try to prevent further attacks of gout are: -- medication to reduce uric acid levels -- making lifestyle changes to reduce uric acid levelshttp://www.fitango.com/categories.php?id=87 74
  76. 76. Prevention **Medication Usually recommended on a long-term basis for: -- frequent attacks of gout and signs of tophi under the skin (tophi are small white lumps that can form under the skin)http://www.fitango.com/categories.php?id=87 75
  77. 77. Prevention **Medication -- evidence of joint damage; either in terms of associated symptoms or damage detected by X-ray -- a history of kidney stones The main treatment for gout is known as urate- lowering therapy or ULT. The goal of ULT is to lower uric acid levels below thehttp://www.fitango.com/categories.php?id=87 76
  78. 78. Prevention **Medication levels required for crystals to form (the saturation point). This should also help to dissolve existing crystals leading to an effective cure for gout. But to maintain the "cure" you would need to continue with ULT on a daily basis.http://www.fitango.com/categories.php?id=87 77
  79. 79. Prevention **Medication Many people with gout begin ULT as soon as they are diagnosed to reduce the frequency of attacks and the risk of developing joint damage. This has to be balanced against possible side effects that can occur with ULT, although these are rare.http://www.fitango.com/categories.php?id=87 78
  80. 80. Prevention **Medication Discuss the potential benefits and disadvantages of ULT with your GP or the doctor in charge of your care. If you agree to start ULT, usually the ULT medication to try first is called allopurinol. Allopurinolhttp://www.fitango.com/categories.php?id=87 79
  81. 81. Prevention **Medication Allopurinol helps to lower uric acid levels by inhibiting the enzyme (xanthine oxidase) responsible for converting purines into uric acid, thus reducing the production of uric acid. However, allopurinol is not a painkiller and will have no effect during an attack of gout.http://www.fitango.com/categories.php?id=87 80
  82. 82. Prevention **Medication Allopurinol is a tablet taken once a day and usually for up to a year or two before all crystals have dissolved and no further attacks can occur. The medication will then usually be taken for the rest of your life.http://www.fitango.com/categories.php?id=87 81
  83. 83. Prevention **Medication It can take a while to assess the most effective dose for your circumstances. You may need to have several blood tests to find the most effective dose. When you first start taking allopurinol it can sometimes cause a gouthttp://www.fitango.com/categories.php?id=87 82
  84. 84. Prevention **Medication attack, because rapid reduction of uric acid levels to below the saturation point causes existing crystals in joint cartilage to partially dissolve and become smaller. The smaller crystals can escape more easily or “shed” from thehttp://www.fitango.com/categories.php?id=87 83
  85. 85. Prevention **Medication cartilage into the joint cavity and then inflame the joint lining (synovium). The risk of this happening is reduced by slowly increasing the dose of allopurinol from a low starting dose (e.g. 100mg daily) to thehttp://www.fitango.com/categories.php?id=87 84
  86. 86. Prevention **Medication recommended dose. You may continue to have gout attacks until all the existing crystals have dissolved, which is perfectly normal. So if this does happen, dont lose confidence in the effectiveness of ULT. Its important to persevere with treatment to achieve the maximumhttp://www.fitango.com/categories.php?id=87 85
  87. 87. Prevention **Medication benefit. If you do develop a flare-up of gout while taking allopurinol, continue the medication while your doctor prescribes additional treatment to settle the attack. Although allopurinol is taken without any side effects in mosthttp://www.fitango.com/categories.php?id=87 86
  88. 88. Prevention **Medication patients, around 10% do experience problems. A skin rash is the most common side effect. In most cases, it’s mild and soon goes away. However, in a small number of cases, it can be a sign of an allergic reaction. If you develop a skin rash while taking allopurinol, stophttp://www.fitango.com/categories.php?id=87 87
  89. 89. Prevention **Medication taking the medication immediately and contact your GP for advice. It may be necessary to stop taking allopurinol and try an alternative ULT (see below). Other side effects of allopurinol include:http://www.fitango.com/categories.php?id=87 88
  90. 90. Prevention **Medication -- indigestion -- headache -- diarrhoea If you are currently being treating with immunosuppressant medications (often used to prevent your body rejecting a donated organ)http://www.fitango.com/categories.php?id=87 89
  91. 91. Prevention **Medication or a type of medication called cyclophosphamide (used in the treatment of some cancers) then you will probably not be able to take allopurinol for safety reasons. Allopurinol may also not be suitable if you have severe kidney disease.http://www.fitango.com/categories.php?id=87 90
  92. 92. Prevention **Medication Patients with kidney problems may be started on a lower dose (50mg daily) and have lower monthly increases (50mg) of allopurinol. Those with severe kidney disease may not even be started on allopurinol, but prescribed an alternative ULT such as febuxostat. Febuxostathttp://www.fitango.com/categories.php?id=87 91
  93. 93. Prevention **Medication Febuxostat acts in the same way as allopurinol by inhibiting the enzyme (xanthine oxidase) that produces uric acid, thus reducing the body’s production of uric acid. However, unlike allopurinol, it is broken down by the liver and nothttp://www.fitango.com/categories.php?id=87 92
  94. 94. Prevention **Medication the kidney, so can be used in patients with kidney disease without concerns over side effects. Also unlike allopurinol, it only comes in two doses (80mg or 120 mg daily). Because even 80 mg daily may quickly reduce uric acid levelshttp://www.fitango.com/categories.php?id=87 93
  95. 95. Prevention **Medication below the saturation point, initiation of even the lowest dose of febuxostat often triggers acute attacks. To try to reduce the frequency and severity of this side effect your doctor may prescribe you regular daily oral NSAID or colchicinehttp://www.fitango.com/categories.php?id=87 94
  96. 96. Prevention **Medication (one-to-two tablets daily) for up to six months following the start of febuxostat as “prophylaxis” (preventative treatment). Common side effects of febuxostat include: -- an increased number of acute gout attacks (discussed above)http://www.fitango.com/categories.php?id=87 95
  97. 97. Prevention **Medication -- diarrhoea -- headache -- feeling sick -- skin rash If you experience more serious symptoms such as breathinghttp://www.fitango.com/categories.php?id=87 96
  98. 98. Prevention **Medication difficulties or facial swelling, stop taking febuxostat and contact your GP for advice. Currently, febuxostat is not considered suitable for people with heart problems (especially heart failure), or with serious kidneyhttp://www.fitango.com/categories.php?id=87 97
  99. 99. Prevention **Medication disease. Less commonly used ULT medications Less commonly used ULT medications include: -- benzbromarone -- sulphinpyrazonehttp://www.fitango.com/categories.php?id=87 98
  100. 100. Prevention **Medication -- probenecid They work by helping the kidneys to remove uric acid from the body. Sulphinpyrazone and probenecid are now rarely used as they are not as effective as other types of ULT medications and are not suitable forhttp://www.fitango.com/categories.php?id=87 99
  101. 101. Prevention **Medication people with kidney disease. Benzbromarone is more effective in removing uric acid and can be used in people with kidney disease. These types of medication tend only to be used if people are unable to take allopurinol or febuxostat. They need to be prescribed under thehttp://www.fitango.com/categories.php?id=87 100
  102. 102. Prevention **Medication supervision of a specialist.http://www.fitango.com/categories.php?id=87 101

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