Gå direkt till huvudinnehållet

Giktartrit

Senast uppdaterad: Senast reviderad:
Sakkunnig:

Definition:
Recidiverande akut artrit i perifera leder som beror på utfällning av uratkristaller i eller runt leder och senor.
Förekomst:
Prevalensen i Sverige är 1–2%.
Symtom:
Ofta monoartikulär artrit i nedre extremiteter, typiskt i stortåns grundled. Svår smärta, debuterar ofta på natten.
Kliniska fynd:
Röd, svullen, varm och öm led med nedsatt rörlighet där förändringarna når sitt maximum inom 24 timmar. Synliga tofi är ett sent tecken.
Diagnostik:
Diagnos kan misstänkas på typisk bild, se giktkalkylator . Definitiv diagnos kan erhållas genom analys av synovialvätska, som vid gikt visar utfällning av ljusbrytande kristaller. CRP är ofta förhöjt vid akut giktanfall. Drygt hälften av patienterna har P-urat >400 µmol/L, över referensintervallet, under pågående giktanfall. Patienten behöver akut behandling oavsett definitiv diagnos.
Behandling:
Vid akut giktanfall ges NSAID, COX-2-hämmare, kolkicin eller prednisolon. Vid återkommande giktanfall i kombination med S-urat >480 µmol/L, ålder <40 år eller multipelt ledengagemang ges uratsänkande medel. Målet är bestående minskning av S-urat till <360 µmol/L (<300 µmol/L vid förekomst av tofi/uratnjursten) för att motverka utfällning av nya uratkristaller. Levnadsvanor och vissa läkemedel höjer S-urat och förändring av dessa är en del av behandlingen.
  1. Hainer BL, Matheson E, Wilkes RT. Diagnosis, treatment, and prevention of gout. Am Fam Physician. 2014;90(12):831–836. PMID: 25591183 PubMed  
  2. Läkemedelsverket (2016). Läkemedelsbehandling av gikt. Hämtad 2016-06-02. lakemedelsverket.se  
  3. Dehlin M, Drivelegka P, Sigurdardottir V et al. Incidence and prevalence of gout in Western Sweden. Arthritis Res Ther 2016; Jul 13;18: 164. pmid:27412614 PubMed  
  4. Kim KY, Schumacher HR, Hunsche E, et al. A literature review of the epidemiology and treatment of acute gout. Clin Ther 2003;25:1593-1616. PubMed  
  5. Kapetanovic MC, Nilsson P, Turesson C et al. The risk of clinically diagnosed gout by serum urate levels: results from 30 years follow-up of the Malmö Preventive Project cohort in southern Sweden. Arthritis Res Ther. 2018;20(1):190. Published 2018 Aug 29. PMID: 30157929 PubMed  
  6. Lin KC, Lin HY, Chou P. The interaction between uric acid level and other risk factors on the development of gout among asymptomatic hyperuricemic men in a prospective study. J Rheumatol 2000;27:1501-1505. PubMed  
  7. Terkeltaub RA. Gout. N Engl J Med 2003; 349: 1647-55. PubMed  
  8. Underwood M. Diagnosis and management of gout. BMJ 2006; 332: 1315-9. PMID: 16740561 PubMed  
  9. Choi HK, Willett W, Curhan G. Fructose-rich beverages and risk of gout in women. JAMA 2010; 304: 2270-8. pmid:21068145 PubMed  
  10. Abhishek A, Roddy E, Doherty M. Gout - a guide for the general and acute physicians. Clin Med (Lond). 2017;17(1):54–59. PMID: 28148582 PubMed  
  11. Köttgen A, Albrecht E, Teumer A, et al. Genome-wide association analyses identify 18 new loci associated with serum urate concentrations. Nat Genet. 2013;45(2):145–154. PMID: 23263486 PubMed  
  12. Dessein PH, Shipton EA, Stanwix AE, Joffe BI, Ramokgadi J. Beneficial effects of weight loss associated with moderate calorie/carbohydrate restriction, and increased proportional intake of protein and unsaturated fat on serum urate and lipoprotein levels in gout: a pilot study. Ann Rheum Dis 2000;59:539-543. PubMed  
  13. Culleton BF. Uric acid and cardiovascular disease: a renal-cardiac relationship? Curr Opin Nephrol Hypertens 2001;10:371-375. PubMed  
  14. Sigurdardottir V, Svärd A, Bengtsson Boström K et al. Gikt – en känd och vanlig sjukdom Prevalens och incidens ökar – framför allt i västvärlden. Lakartidningen.se 2020-08-25. lakartidningen.se  
  15. Choi HK, Atkinson K, Karlson EW, Willett W, Curhan G . Alcohol intake and risk of incident gout in men: a prospective study . Lancet 2004; 363: 1277-81. PubMed  
  16. McAdams Demarco MA, Maynard JW, et al. Diuretic use, increased serum urate levels, and risk of incident gout in a population-based study of adults with hypertension: The Atherosclerosis Risk in Communities cohort study. Arthritis Rheum 2012; 64: 121-9. PubMed  
  17. Janssens H, Fransen J, van de Lisdonk E, van Riel P, van Weel C, Janssen MD. A diagnostic rule for acute gouty arthritis in primary care without joint fluid analysis . Archives of internal medicine 2010; 170(13): 1120-6. pmid:20625017 PubMed  
  18. Neogi T, Jansen TLTA, Dalbeth N, et al. 2015 Gout classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Ann Rheum Dis 2015;74:1789–98. pmid: 24671771 PubMed  
  19. Richette P, Doherty M, Pascual E, et al. 2018 updated European League Against Rheumatism evidence-based recommendations for the diagnosis of gout. Ann Rheum Dis. 2020;79(1):31–38. PMID: 31167758 PubMed  
  20. Wortmann RL. Gout and hyperuricemia. Curr Opin Rheumatol 2002;14:281-286. PubMed  
  21. Bellamy N, Downie WW, Buchanan WW. Observations on spontaneous improvement in patients with podagra: implications for therapeutic trials of non-steroidal anti-inflammatory drugs. Br J Clin Pharmacol 1987; 24: 33-6. PubMed  
  22. Richette P, Doherty M, Pascual E, et al. 2016 updated EULAR evidence-based recommendations for the management of gout. Ann Rheum Dis 2017 Jan; 76(1): 29-42. pmid:27457514 PubMed  
  23. Svärd A, Kapetanovic M, Bergsten U et al. Stora hälsovinster att uppnå med bättre behandling av gikt. Lakartidningen.se 2020-08-25 lakartidningen.se  
  24. Dalbeth N, Merriman TR, Stamp LK.Gout.Lancet. 2016 Oct 22;388(10055):2039-2052. Epub 2016 Apr 21.PMID:27112094. PubMed  
  25. Vinik O, Wechalekar MD, Falzon L, et al. Treatment of asymptomatic hyperuricemia for the prevention of gouty arthritis, renal disease, and cardiovascular events: a systematic literature review. J Rheumatol Suppl. 2014 Sep;92:70-4. doi: 10.3899/jrheum.140465. PMID: 25180131 PubMed  
  26. Eggebeen AT. Gout: an update. Am Fam Physician 2007; 76: 801-8. pmid:17910294 PubMed  
  27. Schlesinger N, Detry MA, Holland BK, et al. Local ice therapy during bouts of acute gouty arthritis. J Rheumatol 2002;29:331-334. PubMed  
  28. Stamp LK, O'Donnell JL, Frampton C, et al. Clinically insignificant effect of supplemental vitamin C on serum urate in patients with gout: a pilot randomized controlled trial. Arthritis Rheum 2013 ; 65(6): 1636-42. pmid:23681955 PubMed  
  29. Zhang S, Zhang Y, Liu P, et al. Efficacy and safety of etoricoxib compared with NSAIDs in acute gout: a systematic review and a meta-analysis. Clin Rheumatol. 2016 Jan;35(1):151-8. Epub 2015 Jun 24. pmid: 26099603 PubMed  
  30. van Echteld I, Wechalekar MD, Schlesinger N, et al. Colchicine for acute gout. Cochrane Database Syst Rev. 2014 Aug 15;8:CD006190. PMID: 25123076 PubMed  
  31. Billy CA;Lim RT;Ruospo M;Palmer SC;Strippoli GFM. Corticosteroid or Nonsteroidal Antiinflammatory Drugs for the Treatment of Acute Gout: A Systematic Review of Randomized Controlled Trials. J Rheumatol. 2017 Aug 1. pii: jrheum.170137. (Review) PMID: 28765243 PubMed  
  32. Rainer TH, Cheng CH, Janssens HJ, et al. Oral prednisolone in the treatment of acute gout: A pragmatic, multicenter, double-blind, randomized trial. Ann Intern Med 2016. pmid: 26903390 PubMed  
  33. Zhang YK, Yang H, Zhang JY, et al. Comparison of intramuscular compound betamethasone and oral diclofenac sodium in the treatment of acute attacks of gout. Int J Clin Pract. 2014 Jan 29.
  34. Wechalekar MD, Vinik O, Schlesinger N, Buchbinder R. Intra-articular glucocorticoids for acute gout. Cochrane Database Syst Rev. 2013;(4):CD009920. Published 2013 Apr 30. doi:10.1002/14651858.CD009920.pub2. PMID: 23633379 PubMed  
  35. Kang MH, Moon KW, Jeon YH, Cho SW. Sonography of the first metatarsophalangeal joint and sonographically guided intraarticular injection of corticosteroid in acute gout attack. J Clin Ultrasound. 2015;43(3):179–186. PMID: 25041810 PubMed  
  36. Bieber JD, Terkeltaub RA. Gout: on the brink of novel therapeutic options for an ancient disease. Arthritis Rheum 2004; 50: 2400-14. PubMed  
  37. Becker MA, Schumacher HR Jr, Wortmann RL, et al. Febuxostat, a novel nonpurine selective inhibitor of xanthine oxidase: a twenty-eight-day, multicenter, phase II, randomized, double-blind, placebo-controlled, dose-response clinical trial examining safety and efficacy in patients with gout. Arthritis Rheum 2005; 52: 916-23. pmid:16339094 PubMed  
  38. Takano Y, Hase-Aoki K, Horiuchi H, et al. Selectivity of febuxostat, a novel non-purine inhibitor of xanthine oxidase/xanthine dehydrogenase. Life Sci 2005; 76: 1835-47. PubMed  
  39. Becker MA, Schumacher HR Jr, Wortmann RL, et al. Febuxostat compared with allopurinol in patients with hyperuricemia and gout. N Engl J Med 2005; 353: 2450-61. PMID: 16339094 PubMed  
  40. Voelker R. Another Warning for Febuxostat. JAMA. 2019;321(13):1245. doi:10.1001/jama.2019.3043 DOI  
  41. Stamp LK, Barclay ML. How to prevent allopurinol hypersensitivity reactions?. Rheumatology (Oxford). 2018;57(suppl_1):i35–i41. doi:10.1093/rheumatology/kex422. PMID: 29272508 PubMed  
  42. Lim SY, Lu N, Choi HK. Septic arthritis in gout patients: a population-based cohort study. Rheumatology (Oxford) 2015; 54: 2095-9. PMID: 26170377 PubMed  
  43. Abeles AM. Hyperuricemia, gout, and cardiovascular disease: an update. Curr Rheumatol Rep. 2015;17(3):13. doi:10.1007/s11926-015-0495-2. PMID: 25740704 PubMed  
  44. Zhang T, Pope JE. Cardiovascular effects of urate-lowering therapies in patients with chronic gout: a systematic review and meta-analysis. Rheumatology (Oxford). 2017;56(7):1144–1153. PMID: 28379501 PubMed  
  45. Sultan AA, Muller S, Whittle R et al. Venous thromboembolism in patients with gout and the impact of hospital admission, disease duration and urate-lowering therapy. CMAJ 2019; 191: E597-E603. pmid:31160496 PubMed  
  46. Singh JA, Uhlig T. Chasing crystals out of the body: will treat to serum urate target for gout help us get there?. Ann Rheum Dis 2017; 76: 629-31. pmid:28031165 PubMed  
  • Anna Nager, docent och specialist i allmänmedicin, Karolinska institutet