January 30, 2024 • 41 mins
Unlock the mysteries of gout and inflammatory arthritis with Dr. Irina Raklyar, whose insights illuminate the shadows of this commonly misunderstood condition. As we sit down with this revered rheumatologist, prepare to be guided through the complex world of purine metabolism, the impact of lifestyle diseases, and the intricate dance between diet and uric acid levels. Dr. Raklyar's deep dive into the prevalence of gout among men and postmenopausal women reveals a tapestry of risk factors and physiological nuances that could change your understanding of joint health forever.
Ever wondered how a single joint can cause such immense pain? Dr. Raklyar sheds light on the excruciating reality of gouty arthritis, taking us beyond the typical swollen joint presentation to a detailed examination of tophaceous deposits and their long-term impact on the body. With her expertise, we navigate the diagnostic minefield, distinguishing gout's needle-shaped crystals from other imitators. The collaboration between rheumatologists and orthopedic surgeons comes to life, illustrating their vital role in decoding symptoms and delivering targeted treatments that restore quality of life.
The finale of our conversation with Dr. Raklyar is a tribute to the revolutionary strides made in gout management. From the stalwart allopurinol to innovative therapies like pegloticase, we explore the arsenal of medications changing the game for patients. Dr. Raklyar candidly discusses the challenges of flare prophylaxis and the journey towards maintaining optimal uric acid levels. Her heartfelt thanks to the team at Kayal Orthopaedic Center reinforces the importance of dedication and expertise in the relentless pursuit of patient relief and recovery. Join us for a session that's not just informative, but transformative for anyone touched by the world of inflammatory arthritis.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Robert A. Kayal, MD, FAAO (00:00):
Hello and welcome to another edition
of the Kale Ortho podcast.
Today is January 30th 2024, andtoday's special guest is our
very own Dr Irene Racklier.
Dr Racklier is aboard-certified fellowship
trained rheumatologist at theKale Orthopedic Center and we're
so pleased and privileged tohave you with us today, irene.
Welcome to the podcast.
Irina Raklyar, MD (00:20):
Thank you for having me.
Robert A. Kayal, MD, FAAO (00:22):
First and foremost, Irene, for
viewing my audience.
Why don't you just take aminute and tell us a little bit
about yourself and your familylife and your profession in the
field of rheumatology?
Irina Raklyar, MD (00:32):
I'm a board-certified rheumatologist.
I grew up in New York City.
I attended Brooklyn College andthen SUNY Downstate Medical
School, and I further went withmy training to Washington DC.
In Georgetown.
I did my residency andfellowship there and eventually
I moved back with my husband tothe New York area.
We landed in New Jersey withour family.
(00:53):
I have two children, a boy anda girl.
Robert A. Kayal, MD, FAAOS (00:55):
Yeah , we've been so privileged to
have you.
You've taken care of so many ofour patients and we're just so
thankful to have you in ourpractice and to share your
expertise and to help us carefor our community of patients.
So you said you're arheumatologist.
What is a rheumatologist, irene?
Irina Raklyar, MD (01:10):
A rheumatologist is an internal
medicine specialist thatspecializes in arthritis and
autoimmune diseases.
Robert A. Kayal, MD, FAAOS, (01:17):
Got it.
So in that field there's asubspecialty called inflammatory
arthritis, right?
What are some examples ofinflammatory arthritis?
Irina Raklyar, MD (01:26):
Inflammatory arthritis is a subset of
arthritis that's caused byinflammation in the joint.
Examples include rheumatoidarthritis, gout, pseudo gout,
psoriatic arthritis, ankylosingspondylitis, etc.
We differentiate it fromnon-inflammatory arthritis,
which is typically caused byosteoarthritis, which is just
natural wear and tear of thejoints or underlying mechanical
(01:49):
issues in the joints that causearthritis and joint pain.
Robert A. Kayal, MD, FAAOS (01:53):
Yeah , you can see there are many
differences between thetraditional wear and tear
osteoarthritis that people likemyself take care of orthopedic
surgeons.
But you can see the need for asubspecialist such as Dr Irene
Racklier in the field ofrheumatology to care for these
other types of arthritis.
So, with respect toinflammatory arthritis, today's
(02:15):
focus is going to be on the gout, a condition called the gout.
So what is the gout, Irene?
Irina Raklyar, MD (02:20):
Gout is the most common inflammatory
arthritis.
It affects up to 6% ofAmericans, more common in men
than in women, and it'stypically.
The hallmark of gout istypically arthritis flares that
are intensely painful anddebilitating.
In between these flarespatients will be asymptomatic.
But over time, if gout goesuntreated, the flares will
(02:42):
become more frequent, moresevere and those asymptomatic
periods will shorten an interval.
Robert A. Kayal, MD, FAA (02:47):
That's crazy 6% of the population.
Irina Raklyar, MD (02:51):
The incidence is also rising.
It's increased in almost 50%since the 1970s and that tends
to parallel the increase incardiovascular disease and
obesity and hypertension.
As well.
Robert A. Kayal, MD, FAAOS, (03:02):
So we typically talk about gout in
men, like you said, but womenget it too right.
Irina Raklyar, MD (03:06):
Yeah, it's more common in women after
menopause.
Estrogen has a protectiveeffect, tends to push uric acid
out of the kidneys.
But after, when women havemenopause, the gout tends to
become more common.
It occurs in 2% of all women.
I see a treat gout in both menand women on a daily basis.
Robert A. Kayal, MD, F (03:23):
Estrogen has a protective effects in a
lot of conditions likeosteoporosis as well.
Obviously, sometimes it's notso helpful in other conditions
like cancers and stuff.
But yeah, so we do see it inwomen.
I think that's important topoint out because a lot of
people don't consider thatdiagnosis in women and think
it's a condition that onlyoccurs in men.
(03:45):
So what is actually happeningin this condition of gout?
Irina Raklyar, MD (03:49):
What happens in gout is it's the deposition
of uric acid into the joints andit causes a process that's
highly inflammatory.
The blood level gets saturatedwith the uric acid and when it
reaches a certain point, ourcutoff is 6.8 milligrams per
deciliter.
When it reaches that threshold,it starts depositing into the
joints and causes inflammation.
Robert A. Kayal, MD, FAAOS, (04:08):
So what are some of the risk
factors that are contributing tothis elevation in uric acid?
Irina Raklyar, MD (04:12):
Well, uric acid is the unproduct of purine
metabolism, which is an organiccompound that we find in our
diet and in other sources.
Uric acid is typically excretedby the kidneys, and sometimes
it's part by the gut as well.
Over time, as people get older,uric acid levels tend to
naturally rise, and it's usuallya combination of overproduction
(04:33):
of uric acid or under excretionby the kidney.
Overproduction of uric acidmeans that you're taking in too
much through your diet orthere's other risk factors,
other conditions that canincrease your uric acid levels,
like thyroid issues or psoriasisor mild low proliferative
disorders, but most commonlyit's an issue at the kidney
(04:53):
level.
People are on medications thatwill treat high blood pressure
or other issues that willdissuade your uric acid level
from being excreted, and othercomorbid conditions like high
blood pressure or cardiovasculardisease put stress on the
kidneys and so, therefore,you're not able to excrete the
uric acid level and it tends toaccumulate in the blood.
Robert A. Kayal, MD, FAAOS, (05:15):
So you mentioned diet, so it
sounds like there are some foodsthat you can consume, and maybe
even beverages that contributeto the gut.
Irina Raklyar, MD (05:22):
So a gut alone is not caused by diet, and
diet alone will not treat gut,but we know that there's foods
and drinks that are commonlytriggers for gut or that will
raise uric acid levels, andthose foods include seafood,
such as shellfish or sardines oranchovies, red meats,
particularly liver meats ororgan meats, and sugar sweetened
(05:47):
drinks like sodas, energydrinks, fruit juices.
Conversely, vegetables that arehigh in purines, such as
asparagus or cauliflower, andmushrooms, do not increase uric
acid levels and will not promotegut.
Robert A. Kayal, MD, FA (06:02):
Alcohol as well.
Irina Raklyar, MD (06:03):
Alcohol as well.
Yes, so alcohol, all types ofalcohol.
Beer tends to have a higherrisk of increasing or causing
gout flares than just a regularliquor or wine.
Robert A. Kayal, MD, FAAOS (06:13):
Yeah , so typically these foods are
broken down right Often by theliver.
The liver will metabolize someof these foods and then the
kidney will often try to excretethe uric acid.
So that's why you mentionedsometimes there's a failure of
some of it's basically a failureof metabolism, potentially
right.
So are there risk factors likefamily history that might
(06:34):
continue as well.
Irina Raklyar, MD (06:36):
So genetics does play a component If you
present with gout in your 20s orat a younger age.
Gout typically presents in menat age 40s or 50s, women after
menopause.
If a patient presents with goutin their 20s, there's probably
a high genetic predisposition toit.
The other risk factors for goutare the high uric acid level,
male gender, older age and thepresence of being on medications
(06:59):
that will increase uric acidlevels, so diuretics or
transplant medications inparticular.
Robert A. Kayal, MD, FAAOS, (07:04):
But there is a condition called
asymptomatic hyperureicemia,correct.
So just because our uric acidlevels are elevated, it doesn't
mean that those patients aregoing to get the gout.
Correct.
Irina Raklyar, MD (07:15):
Yeah, the statistics say that about 4% of
all men will get gout, but 20%of all men have high uric acid
levels.
So just because you have highuric acid levels does not mean
that you have gout, and that'ssomething that I sometimes
consult on as well.
Patients will present with highuric acid levels and their
primary care doctor will ask meif they need to be put on uric
lowering therapy to prevent goutflares.
Robert A. Kayal, MD, FAAOS (07:37):
Yeah , so a patient comes in the
office and what is their typicalcomplaint?
When you start thinking alongthe lines of a differential
diagnosis of gout?
Irina Raklyar, MD (07:47):
Yeah, so the presentation of gout is
typically a hot, swollen joint.
It's usually in the lowerextremity, most commonly
affecting the big toe or theankle or the knee.
It's a very fast onset.
Usually we have a maximum onsetbetween 12 and 24 hours.
There might be some rednessassociated with it.
Patients, the gout flares willbe quite debilitating.
(08:09):
The patients will complain thatthey're unable to bear weight
on that joint.
They're unable to tolerate anypressure.
That's the typical gout flare.
Robert A. Kayal, MD, FAA (08:18):
Unlike some of the other authorities
that you manage, it tends to bewhat we call an oligoarthritis,
correct?
And it's often a monoearthritisas opposed to a bilateral
condition, right?
Can you elaborate on that?
Irina Raklyar, MD (08:29):
Right.
So gout typically starts off inone joint.
Over time, if gout goesuntreated, it will start to
affect more joints and that onejoint in particular will become
more and more severe attacks andeventually over time.
One of the reasons why we dotreat gout over the long term is
that it will cause damage tothe joints.
Robert A. Kayal, MD, FAAOS, (08:47):
But it's often the smaller joints,
right, I guess.
As opposed, like you don'ttypically see it, you do see it
in the knee, but not so much theshoulder and not so much the
hip, for instance right, right,right, right it's usually the
smaller joints, but it can alsoaffect some of the soft tissues
around the joints, not just thejoint itself.
So for instance, the tendons,the tendon sheaths, sometimes
like that.
(09:07):
You'll see it show up that way,correct?
Irina Raklyar, MD (09:10):
So if gout goes untreated for about 10
years, you start to collecttophatous deposits and that's
little collections of goutcrystals and it can occur inside
of the joints or outside of thejoints, most commonly on the
bursa, say, of the elbow, on theAchilles tendon.
Sometimes we can see it in thepin of the ear, but it's
collections of gout crystalsthat tells me, when I see tophi,
(09:32):
that that patient certainlyneeds to be put on urethal
lowering therapy and that theover all uric acid burden in the
body is really quite high.
And it's been that way for along time.
Robert A. Kayal, MD, FAAO (09:43):
Right , so we talked about the
presentation, the typicalpresentation.
You also mentioned previouslyabout some of the medical
history, the patient's historyof presinilinus, the family
history, other medicalcomorbidities that might be
contributing, such as even likerenal disease, hypertension,
metabolic syndrome.
(10:03):
Obesity too is a risk factor,right, so we talked about that.
And now on physical examination, what are some of the things
you're looking for?
You mentioned some tophi.
What else?
Irina Raklyar, MD (10:15):
I look for that classic hot swollen joint.
That's where I make thedistinction between inflammatory
arthritis and non-inflammatoryarthritis.
When I see if a patientcomplains of a joint that's been
bothering them for a long timethat doesn't have that classic
asymptomatic period in betweenflares, then I'm less likely to
think that it's gout.
But the classic presentation isthat hot swollen joint.
(10:36):
When we see that hot swollenjoint we always try and aspirate
it, meaning taking fluid out ofthe joint, because the gold
standard diagnosis for gout isseeing those uric acid crystals
under the microscope.
You're getting ahead of me,Sorry.
Robert A. Kayal, MD, FAAOS, (10:50):
So , dr Rackley you mentioned, you
typically look for that red hotjoint right.
Does that sometimes suggestother conditions perhaps?
Or is it always the gout?
Irina Raklyar, MD (11:01):
No other conditions can certainly cause a
hot and swollen joint.
Pseudo gout, which is almost acousin of gout, a very similar
presentation, but you see adifferent type of crystals under
the microscope.
Things like trauma, you know.
Say, an ankle sprain or afracture can start fracturing
the big toe can certainly causesimilar symptoms and any kind of
(11:22):
infection in particular youknow, cellulitis, osteomyelitis,
septic arthritis just infectioninside of the joint can have a
similar presentation.
As a rheumatologist, I'm alsoruling out our other
inflammatory authorities,including psoriatic arthritis
and rheumatoid arthritis, whichcan, which can sometimes give
you a similar presentation.
Robert A. Kayal, MD, (11:42):
Absolutely , and I'm so glad you mentioned
all that, because when we do seepatients with this presentation
, the point that we'd like todrive home is that this same,
fairly similar presentation canalso be present with a whole
myriad of other diagnoses.
So we as clinicians form whatwe call a differential diagnosis
(12:02):
.
We listen to the patient'schief complaint, we take a
history of their present illness, we look at their past medical
history, et cetera, and thencombine that with physical
examination and other ancillarytests to form the final
diagnosis.
So this presentation of thisred hot joint can be common with
a whole plethora of othermedical conditions, and it's
(12:26):
certainly our job to help figureout what actually is causing
the problem.
So, case in point, we're goingto show you an image of the
classic presentation of a redhot joint and in this particular
condition, the gout, where it'smost commonly present.
Irina Raklyar, MD (12:44):
So this is a picture of the most classic
presentation of gout.
We call this pedagra.
This is involvement of thefirst metatarsal phalangeal
joint in the big toe of the foot.
Again, gout is a hot, swollenjoint and you can see the
swelling.
You can see the redness of thejoint, this, if I were to touch
it, a patient would probablywince in pain or jump off the
(13:06):
table because it's really quitepainful.
Robert A. Kayal, MD, FAAOS (13:10):
Yeah , it looks painful.
I mean, that looks somethingthat you know.
For me I'd say that's gout,that's infection.
There's something angry goingon.
That patient is quitesymptomatic and we didn't
mention when gout presents inthis toe in particular, in this
joint in particular.
The classic presentation ispatients always complain at
night when they're sleeping.
That bedsheet can't even, youknow, touch that area right.
(13:34):
It's that type of excruciatingpain.
In orthopedics, anytime we'redealing with an inflammatory
condition such as gout, calcifictendonitis, anytime there's a
precipitation of crystals in thearea, that sort of incites an
inflammatory response that isextremely, extremely painful.
(13:55):
For instance, calcifictendonitis of the shoulder.
The presentation is veryclassic.
These patients will often go tothe emergency room in the
middle of the night before evencoming to see us the next day,
just to find out they have acalcific tendonitis of their
shoulder.
So inflammatory conditions,inflammatory authorities, are
debilitating and incapacitating.
(14:16):
In general they're that kind ofpain we call it like a 10 out
of 10 pain, very much akin to akidney stone.
Right, a kidney stone is thesame type of precipitation of
calcium deposits and it incitesthat type of inflammatory
response and that level of pain.
Do you agree?
Absolutely.
Irina Raklyar, MD (14:34):
So this next picture is a photo of a tophatia
scout.
What we're looking at is in theproximal interphalangeal joint
of the patient's hand you cansee this nodular swelling.
This is not necessarily painful, but what this is is a
(14:55):
collection of those uric acidcrystals and it tends to collect
in parts of the body they're alittle bit cooler to touch or in
the extremities, because that'swhere uric acid levels like to
precipitate out.
When I see a patient like this,I know the gout has been going
on for a very, very long timeprobably 10 years and it's been
untreated and this is absolutelyan indication to treat the
(15:17):
underlying gout.
If I were to take a look at thex-ray or do some kind of imaging
, I would see damage inside ofthe joint.
I would see swelling that lookslike swelling on the x-ray as
well.
I would might see some of thegout crystals, because sometimes
I'll be surrounded by a littlebit of calcification and this is
(15:38):
one of the primary indicationsto treat gout.
When I look at this x-ray, Iknow that uric acid burden is
really quite high in the bodyand this patient has a very high
risk for cardiovascular diseaseas well and the uric acid
levels are that high for thatlong of a time Uric acid levels.
Uric acid will be acardiovascular toxin, so it will
predispose this patient toheart attacks and strokes and
(16:00):
heart issues.
When I see a patient like this,I tell them I'm not just
treating your gout, I'm not justpreventing damage, but I'm also
lowering your risk for heartdisease and heart attacks.
Robert A. Kayal, MD, FAAOS, (16:09):
So , Irene, regarding those two
photographs that you soeloquently described, is it
possible to convert?
Is it possible for a patient tohave one of those tophacious
precipitations that is in aquiescent endowment state for a
long period of time and thensuddenly to get red and hot and
inflamed?
Irina Raklyar, MD (16:29):
It can.
You can certainly have a goutflare in the same location of
the tophi, absolutely.
Robert A. Kayal, MD, FAAOS (16:35):
Yeah , but the difference in that
first picture where it was redand hot, that was active acute
gout, as opposed to the otherone which was what seemed to be
an endowment state, quiescentendowment state and that was
definitely indicative of achronic gout condition, correct?
Right Now that we discuss someof the photographs and we are
really forming that differentialdiagnosis and deducing that
(17:00):
this patient is going to bediagnosed with gout, are there
other studies, radiographs, labs, CAT scans, MRIs, anything else
you can order to reallydefinitively diagnose the
patient with the gout?
Irina Raklyar, MD (17:14):
When I see a patient for a suspected gout
flare, I typically at thatinitial visit I will order blood
work and I will order X-rays.
The purpose of the blood work isone to check a uric acid level.
Uric acid levels alone will notdiagnose gout, but a high uric
acid level will increase mysuspicion for gout and it gives
me a baseline when I start uratelowering therapy to treat the
(17:36):
gout.
In the blood work I'll alsolook for inflammatory markers
like sedimentation rate andC-reactive protein.
I'll do a regular panel of CBCand a comprehensive metabolic
panel looking for kidney issues,looking for liver issues that
one might be an end cause of thegout Gout can cause kidney
stones and can cause kidneyissues as well.
(17:56):
In preparation for starting thepatient on therapy and to help
me decide which medications Iwill use to treat the gout flare
that's why I do all of thatblood work.
I'll also typically do X-raysbecause I'm looking for evidence
of prior gout damage.
The indications for startingsomeone on urate lowering
therapy include two or more goutflares in a year, seeing damage
(18:21):
on an X-ray or the presence ofthe TOEFI.
Robert A. Kayal, MD, FAAOS, (18:25):
Can you have the gout within normal
serum uric acid level?
Irina Raklyar, MD (18:29):
Absolutely.
In fact, during episodes ofinflammation, uric acid tends to
be pushed out of the kidney, soyou can't see normal uric acid
levels in the time of theinflammatory arthritis.
Robert A. Kayal, MD, FAAOS, (18:42):
Are MRIs or CAT scans or
ultrasounds warranted to helpyou make this diagnosis?
Irina Raklyar, MD (18:48):
MRIs are not so helpful unless you're trying
to rule out concomitant causesof inflammatory arthritis.
If you're looking for thingsthat don't show up on an X-ray,
like a sprain or a fracture ordamage that looks like other
types of inflammatory arthritis,like rheumatoid arthritis,
there is a certain type of CATscan that we can do.
It's called a dual energy CTscan.
(19:09):
That will pick up uric acid,toefi, in the joints.
Sometimes that's helpfulbecause you can't always
aspirate a joint.
You can't always take out thefluid to prove that it's gout.
Sometimes we might order theseother studies to help support
our diagnosis of gout.
We can also do ultrasoundUltrasound.
There's a classic finding wecall it the double contour sign,
(19:30):
which shows uric acid withinthe joint.
It requires a educated andexperienced ultrasound
technologists to look for that.
Robert A. Kayal, MD, FAAOS (19:44):
Yeah , so, with respect to these
images, they're fairly classicfindings, like you mentioned, so
let's discuss some of them,okay, so what are we looking at
here, irina?
Irina Raklyar, MD (19:54):
We're looking at a lateral x-ray view of the
elbow.
The elbow joint in particularis intact, but you can see this
dense swelling, this radiopaqueswelling outside of the joint.
There's fluid in the bursa.
The bursa is a little pocket offluid that sits outside the
elbow joint.
That helps protect the jointand it's commonly a site for
(20:16):
uric acid deposits and for goutinflammation.
And what we're seeing isswelling inside the joint.
You can almost see it hangingoff of the joint because there's
a lot of fluid and inflammationgoing on in there.
Robert A. Kayal, MD, (20:28):
Absolutely .
I mean it looks like a smalllittle tangerine in the back of
this patient's elbow right.
It's a common site for swelling, but most of the time that
swelling is just fluid.
Like you said, we call thatlecronon bursitis, and certainly
the x-ray, the radiograph,would be very different than
this projection right here.
(20:49):
You can see, in this softtissue swelling it is much more
dense than fluid.
Fluid would be almost black innature on this radiograph,
whereas this one has a morewhitish appearance, approaching
that density of bone.
So clearly there's someprecipitation here, some
collection of some type ofdeposit of some sort, and this
(21:12):
would be highly suggestivepotentially of an inflammatory
arthropathy of some sort and inthis particular case, likely the
gout.
So let's talk about another one, dr Racklier.
So, dr Racklier, let's compareand contrast now this radiograph
to the elbow that we justpreviously discussed.
What are you finding here?
Irina Raklyar, MD (21:32):
So this is an x-ray photograph of the hand
and the wrist showing chronicgouty arthropathy.
You can see the presence ofTOFI, which is that swelling
outside of the joints as well,and you can see damage inside
the joints.
If we were to compare to normaljoints first, if we take a look
at the third and the fourthfinger MCP joints,
(21:52):
metacarpophalangeal joints,those are relatively normal
joints.
The joint space is evensymmetrical, the contours of the
bone are smooth and rounded andthose look relatively preserved
.
If we were to contrast it withthe first and the fifth finger
MCP joints, then we see theclassic gouty damage On an x-ray
(22:14):
.
You see overhanging edges, yousee sclerotic margins
Rheumatologists call them ratbite erosions because it looks
like a rat has bitten into themand you can see them at the MCP
joints.
You can see some damage at thePIP joints, the proximal
interphalangeal joints, and youcan also see it at the wrist as
well.
So this is a classic x-ray ofchronic gouty arthropathy.
Robert A. Kayal, MD, FAA (22:37):
Severe erosions, osteolysis, punched
out, lesions, and this is very,very, very advanced gout.
Irina Raklyar, MD (22:46):
It's unfortunate because when we see
damage like this, we can't undo.
Bony damage we can prevent.
My goal as a rheumatologist isobviously to help the patient
feel better, but it's also toprevent bony damage.
Once I see damage like this, Ican't undo it.
Even if I get the patientfeeling better and free of gout
flares, he or she still mighthave joint pain in the hands
(23:09):
because of damage that's alreadydone.
Robert A. Kayal, MD, FAAO (23:10):
Great point, great point.
So, dr Ackley, are youmentioned that the classic gold
standard for making thisdiagnosis is biopsy and
evaluation for crystals onmicroscope?
However, sometimes we're unableto get the fluid out of the
joint and in those particularcases, either there's no fluid
(23:35):
or the joint is too small toaspirate.
You had mentioned thatsometimes we can do a dual
energy CAT scan.
So this next image we're goingto show you is a classic example
of a dual energy CT, where wecan pick up lesions consistent
with TOFI and urethricprecipitation for smaller joints
(23:58):
where we are unable to aspiratethat fluid.
So can you please describe whatyou're seeing here?
Irina Raklyar, MD (24:04):
So sometimes when we have a patient
presenting with tophatious gout,it can have nodules or
deformities or hard depositsthat are not necessarily easy to
take fluid out of.
So therefore we may order thisdual energy CT.
It's not a regular CT scan.
It's a dual energy CT scan,meaning there's an additional
program that is applied to theCT scan that will help light out
(24:27):
these gout crystals In thispatient in particular.
The green is those tophatiousdeposits.
The purple usually representskeratin or other calcium
materials and those areotherwise benign, but the green
is proof that there is the TOFIuric acid crystals in that joint
.
Sometimes we might also doserial dual energy CT scans.
(24:47):
If we are looking at thosetophatious deposits, if our goal
is treating them and to meltthem away, we like to do serial
dual energy CT scans and see howthey are resolving over time.
Robert A. Kayal, MD, (24:59):
Fantastic , thank you.
We talked about how we can makethe diagnosis both on physical
examination and imagingmodalities ultrasound, x-ray,
etc.
Utilizing blood work as well tohelp with the diagnosis.
But really the gold standard iswhat?
Irina Raklyar, MD (25:17):
Gold standard is a synovial fluid aspiration
is pulling fluid out of thejoint, taking a look at it under
the microscope and proving thatthere's gout crystals.
Robert A. Kayal, MD, FAAO (25:26):
Right , because we talked that there
could be some overlap both onphysical examination and on
history, and even on x-rays withcertain conditions.
So biopsy is the gold standard.
So, for instance, when somebodycomes into my office with what
we call a knee joint diffusion,or in layman's terms, water in
the knee, I'm not really sure ifthat water in the knee is from
(25:47):
arthritis, a meniscus tear, aninfection, torn ligament,
possibly even inflammatoryorthopathy.
So very often I'll end updraining that knee.
I'll do what's called a kneejoint aspiration.
If the joint fluid is normal,it's most likely mechanical in
nature, meaning a meniscus tearor arthritis, something like
(26:09):
that.
If it's bloody, I might thinkalong the lines of is this a
fracture, is this an ACL tear orsomething like that.
If it's filled with pus, I'mconcerned that there is
infection.
It would be very cloudy, hot,very murky and very much
consistent with pus in the knee.
That would be indicative of aninfection.
And finally, if it's somewhatinflammatory, cloudy and it
(26:34):
appears that maybe there's someprecipitation going on, I may be
concerned that this isinflammatory in nature and this
patient may have to be referredto Dr Rackler for evaluation.
So what we'll do is we'll takethat fluid and we'll send it to
the lab and if we're checkingfor infection, we'll typically
(26:54):
check a gram stain check forcultures and sensitivity.
But we always are trained tocheck for cell count with
differential as well as crystalanalysis.
So we always want to make surethat we're not dealing with an
inflammatory condition, aninfection or other condition.
So it's not common to haveinfection superimposed on
(27:18):
inflammatory conditions and viceversa, but it can happen right.
Irina Raklyar, MD (27:21):
It can certainly happen, even when you
have an established diagnosis ofgout.
It's always a good idea to getthat aspiration, because there's
no reason why it can't be aninfection and gout at the same
time 100%.
Robert A. Kayal, MD, FAAOS, (27:31):
So you look, you're drawing the
fluid.
Anyway, we like to test it.
I test it for everything Cellcount with differential, gram
stain, with culture andsensitivity, and certainly
crystal analysis.
Every single aspiration getstested for all that, and so when
we take this fluid out and thegram stain comes back negative,
there's no infection.
What are we looking for withrespect to what's called the
(27:55):
cell count with differential,because it can be a little dicey
sometimes.
Sometimes it can be close.
You're not really sure.
Is it infected, is it notinfected?
Is it inflammatory?
What are you looking for, drReckler?
Irina Raklyar, MD (28:07):
So normal synovial fluid will have
anywhere from zero to 2,000white blood cells.
In any kind of inflammatorystate you'll have more than
2,000 white blood cells.
In the setting of gout orinfection you can have tens of
thousands of white blood cells.
The differential will be skewedmore towards neutrophils, which
is the active subsetresponsible for inflammation.
(28:29):
And then we look for thecrystal analysis, because
besides gout crystals there'sother types of crystals that can
cause inflammation in the joint100% and sometimes you get a
white count.
Robert A. Kayal, MD, FAA (28:42):
That's borderline.
You may get like a 40,000 or45,000 white count and that's
sort of borderline.
Traditionally I think most ofus would say over 50,000 or in
that range.
We're starting to think reallyabout an infection anywhere from
, like she's saying, 2,000 to 20, 30, up to 40,000.
It's typically inflammatorynature.
(29:03):
But that's where thisdifferential comes into play.
We always order that tap bysaying cell count with
differential and she's focusingon the neutrophils.
So we call that a shift to theleft.
If there's an elevated numberof neutrophils, a percentage of
neutrophils, it makes us quiteconcerned about more than likely
(29:25):
an infection.
So, dr Rackler, what are welooking at here now on this
slide?
Irina Raklyar, MD (29:30):
We are looking at the presence of uric
acid crystals, gout crystals,under a polarizing microscope.
It has the classic needle shapeappearance.
It's negatively birefringent onthe polarizing microscope and
these are classic for gout.
Meaning negatively birefringent, meaning that in one direction
(29:51):
it looks yellow, but in theother direction it looks blue.
But it has that classicappearance.
Robert A. Kayal, MD, FAAOS (29:56):
Yeah , and this is something a
pathologist would see under themicroscope when we draw that
fluid out of that patient'sjoint and send it to the lab,
right?
So we're waiting, sometimes acouple of days, for reports to
come back whether or not therewere crystals in the fluid and
in this particular case, this isthe classic slide presentation
of someone that would beabsolutely confirmed with the
(30:19):
diagnosis of the gout.
Irina Raklyar, MD (30:21):
Sometimes we send rheumatologists will send
our patients to our orthopedicsurgeon colleagues to remove
TOFI, especially if they'redeforming or cosmetically
unappealing or if they'relocated in areas where there's a
lot of irritation, say theelbow or the hand.
And when we look at the TOFIunder the microscope we see
(30:42):
sheets and sheets of these uricacid crystals.
Interesting.
Robert A. Kayal, MD, FAAO (30:46):
Great , all right.
So now that we've made thediagnosis definitively on biopsy
right the gold standard we haveto treat these conditions right
.
So what is your first line oftreatment?
Irina Raklyar, MD (30:58):
So there's a couple of medications that we
use to treat gout and we all wechoose which medication we use
based on the other comorbidconditions.
Typically, the first linemedications used to treat gout
are colchicin, steroid orsteroids or anti-inflammatory
medicines.
Colchicin is one of our oldestmedicines in medicine.
(31:21):
It's been around since thesixth century.
It's used to treat inflammation.
Steroids can be injected intothe joint or can be taken orally
or less commonly, you can giveit through an IV or
intramuscularly, andanti-inflammatory.
Anti-inflammatory medicines arethe common medicines that are
typically over the counter, butwe use it at anti-inflammatory
(31:42):
doses and which one we choosereally depends on what else is
going on in the body.
If the patient has a priormedical history of gastric
ulcers or if they're on bloodthinners, then we tend to avoid
oral steroids or we tend toavoid the anti-inflammatories.
If there is a question thatthere might be some underlying
(32:04):
infection there as well, then wetend to avoid a steroid.
So if the patient has kidneyissues, then we tend to avoid
the colchicin and theanti-inflammatory.
So that's why we do the bloodwork in addition at that first
visit to decide which medicationwould be appropriate and which
route would be most appropriate.
Robert A. Kayal, MD, FAAO (32:20):
Right .
In my experience as a NorthPeak surgeon, when I see these
patients it's sometimes toughbecause they're in so much pain,
like we've described, and youwant to treat them so badly with
a cortisone injection.
But we're forced to hesitatebecause that's the last thing in
the world we'd want to do ifthere was a local infection and
the presentation of asepticarthritis and acute gout flare
(32:46):
go hand in hand.
There's a tremendous amount ofoverlap.
So a lot of times we don'treally know if it's the gout or
if it's aseptic or infectedjoint, and so time is of the
essence for us to get theresults of this, and the
steroids, whether orally orinjected locally, would be
(33:07):
detrimental if in the face ofinfection.
So it's restricting somewhatuntil we get that definitive
diagnosis Right.
All right, so we have to treatthem with the
anti-inflammatories.
There's also other things thatwe have to do.
Sometimes gout, as we alludedto previously, is primary in
(33:28):
nature and sometimes it'ssecondary in nature.
Right, if it's primary innature, a lot of times we'll
recommend a low purine diet,some type of nutritional
counseling.
If they're drinking a lot ofalcohol, we'll ask them to
refrain, because certainlythat's contributory, especially
the beer If they're eating a lotof red meats or shellfish or
(33:49):
different types of fish.
That certainly can increase thelikelihood.
But sometimes it's secondarygout, secondary to some
metabolic conditions or othermedical conditions, and so, just
like any other secondarycondition, the onus is on us to
make that diagnosis and to makesure that that primary disorder
gets treated and then thesecondary manifestation of that
(34:14):
condition often disappears.
Right.
Irina Raklyar, MD (34:17):
So acute gout flare will typically last three
to 10 days.
Sometimes it can last forseveral weeks.
But people will often seek outcare for their gout flare, for
prompt resolution of pain andfor restoration of the mobility
of the joint.
Like I said, the joint will bevery tender, unable to bear
weight.
People won't be.
Especially, it affects thelower extremity.
(34:39):
People won't be able to walk onthat foot.
So what I will do when I treatthe gout flare is I will review
all of the other medicationsthat they're on, look at all of
the other comorbid conditionsthat are going on and choose a
therapy that's appropriate forthem.
That's not going to necessarilyworsen the other things.
That are the other medicationsthat are there.
Robert A. Kayal, MD, FAAOS (35:01):
With respect to the treatment of the
gout, when I was in training 30years ago or so, it was always
the triad of usage ofendomethacin, which is an
anti-inflammatory, non-steroidalanti-inflammatory colchicin and
I was told to take, I was toldto prescribe, 0.6 milligrams of
colchicin TID until the patientseither develop nausea, vomiting
(35:24):
, diarrhea or relief of theirsymptoms, and then possible use
of allopurinal for prevention ofrecurrences.
Because my training was that aspatients get older, the bouts
become more severe and closer inproximity to one another as
well.
Is that still the thoughtprocess?
Irina Raklyar, MD (35:44):
So the way that we treat acute and chronic
gout differs.
We don't use colchicin at thosedoses anymore.
The most common side effect ofcolchicin is GI issues and
diarrhea.
So to put some patient on supertherapeutic doses of colchicin
and have them running to thebathroom with their arthritic
gout flare seems savage.
(36:10):
So we don't use-.
Robert A. Kayal, MD, FAAOS, F (36:10):
I was saying would you rather
have diarrhea or would yourather have a gout attack?
We'd rather have not, we'drather treat.
Irina Raklyar, MD (36:16):
We'd rather not have diarrhea and treat
through the gout attack.
So we use colchicin at normal,once or twice a day, depending
on the underlying kidneyfunction.
We extend the dose of thecolchicin or the
anti-inflammatory for up to 10days because that's how long
it'll usually take to treat agout flare.
We typically don't start yourallopurinol or urate lowering
therapy at that visit for theacute gout, just because it's
(36:39):
very overwhelming.
The patient is already comingto see you.
They've been suffering withthis gout flare, they're looking
for treatment and to put themon multiple medications at that
visit is very overwhelming forthe patient.
A lot of times.
If we start them on thelong-term treatment at the time
of the acute gout flare, whatmight happen is that once the
gout flare resolves they mightstop the long-term treatment,
(37:03):
also thinking that they're fixed.
So we typically divide it intotwo visits One where I treat the
gout flare, I get myinformation to think about what
I'm going to be using forlong-term therapy and then have
them come back a week or 10 daysafter the gout flare has ended
and we talk about chronictherapy, how to decrease the
(37:24):
uric acid levels for thelong-term, and that's when I
also do the education about dietand lifestyle modifications.
Robert A. Kayal, MD, FAA (37:30):
That's great, and in your experience
you've actually seen a lot ofthese TOFI disappear right over
time.
Irina Raklyar, MD (37:37):
Yeah, TOFI will disappear with urate
lowering therapy.
It doesn't happen immediately.
It can take about six months toa year.
For patients who havepolyarticular TOFI tophatous
deposits, If they have a lot ofjoints or if they have deforming
arthritis, there is a verypotent IV medication that we can
use that will melt it away.
(37:57):
But it really is reserved forthe appropriate patients.
Robert A. Kayal, MD, FAAOS, (38:00):
Got it.
So, dr Rechler, I know wefocused our attention a lot on
the treatment of the acute goutcondition, but how do we treat
chronic gout, the patient that'ssuffering from long-term gout?
Irina Raklyar, MD (38:11):
So we have a different subset of medications
that we use to treat gout, butthe cornerstone of there
cornerstone is urate loweringtherapy, decreasing the uric
acid levels in the blood.
Our goal is to decrease it tounder six.
If they have the presence ofthis TOFI, we decrease it to
under five.
The medications that we use areall medications that lower uric
acid levels.
(38:32):
That includes allopurinol,which has been around since the
1960s.
That's kind of the go-tomedicine.
Fibuxa stat is a newermedication that also lowers uric
acid levels and we havepeglotticase, which is an IV
medication which also veryrapidly drops the uric acid
levels.
We use a treat-to-targetapproach, meaning that our goal
(38:55):
is to get it on the uric acidlevels under six or five.
But initially, when we firststart uric acid levels, uric
urate lowering therapy, there'sactually a paradoxical high risk
for having a gout flare.
So when we start the patient onmedications we have a two-prong
approach a medicine that lowersuric acid levels and a medicine
(39:17):
that's used to prevent uricacid flares.
During that time Uric acidlevel doesn't just naturally
drop, it fluctuates and then itdrops.
So we'll typically use somekind of prophylaxis at the same
time when the uric acid levelbecomes therapeutic and it stays
that way for six to 12 months,we peel back on that second
medicine and they're just lefton that one-year lowering
(39:38):
therapy, probably for the restof their life.
Robert A. Kayal, MD, FAAOS (39:41):
Well , it's gotten a lot more
complicated since I started 25years ago.
So it's a little bit differentthan the endomethacin BID and
Coltocene 0.6 TID right.
Irina Raklyar, MD (39:53):
Yeah Well, we have a lot more knowledge of
gout, there's a lot more sciencebehind it and we're a lot more
effective at treating gout andmaking it easier for the
patients as well.
Robert A. Kayal, MD, FAAOS (40:03):
Well .
I thank God that we havedoctors like you at the KAL
Orthopedic Center.
It's been such an honor to workalongside you.
You're a walking encyclopediain the field of rheumatology and
when I began this interview Ithought I was talking to chat
GPT.
I praise you every time I makea referral of our patients to
(40:25):
you because you are absolutelybrilliant in this field and it's
such an honor to have you here.
So thank you so much.
Don't correct me.
Hello and welcome to another edition
of the Kale Ortho podcast.
Today is January 30th 2024, andtoday's special guest is our
very own Dr Irene Racklier.
Dr Racklier is aboard-certified fellowship
trained rheumatologist at theKale Orthopedic Center and we're
so pleased and privileged tohave you with us today, irene.
Welcome to the podcast.
Irina Raklyar, MD (00:20):
Thank you for having me.
Robert A. Kayal, MD, FAAO (00:22):
First and foremost, Irene, for
viewing my audience.
Why don't you just take aminute and tell us a little bit
about yourself and your familylife and your profession in the
field of rheumatology?
Irina Raklyar, MD (00:32):
I'm a board-certified rheumatologist.
I grew up in New York City.
I attended Brooklyn College andthen SUNY Downstate Medical
School, and I further went withmy training to Washington DC.
In Georgetown.
I did my residency andfellowship there and eventually
I moved back with my husband tothe New York area.
We landed in New Jersey withour family.
(00:53):
I have two children, a boy anda girl.
Robert A. Kayal, MD, FAAOS (00:55):
Yeah , we've been so privileged to
have you.
You've taken care of so many ofour patients and we're just so
thankful to have you in ourpractice and to share your
expertise and to help us carefor our community of patients.
So you said you're arheumatologist.
What is a rheumatologist, irene?
Irina Raklyar, MD (01:10):
A rheumatologist is an internal
medicine specialist thatspecializes in arthritis and
autoimmune diseases.
Robert A. Kayal, MD, FAAOS, (01:17):
Got it.
So in that field there's asubspecialty called inflammatory
arthritis, right?
What are some examples ofinflammatory arthritis?
Irina Raklyar, MD (01:26):
Inflammatory arthritis is a subset of
arthritis that's caused byinflammation in the joint.
Examples include rheumatoidarthritis, gout, pseudo gout,
psoriatic arthritis, ankylosingspondylitis, etc.
We differentiate it fromnon-inflammatory arthritis,
which is typically caused byosteoarthritis, which is just
natural wear and tear of thejoints or underlying mechanical
(01:49):
issues in the joints that causearthritis and joint pain.
Robert A. Kayal, MD, FAAOS (01:53):
Yeah , you can see there are many
differences between thetraditional wear and tear
osteoarthritis that people likemyself take care of orthopedic
surgeons.
But you can see the need for asubspecialist such as Dr Irene
Racklier in the field ofrheumatology to care for these
other types of arthritis.
So, with respect toinflammatory arthritis, today's
(02:15):
focus is going to be on the gout, a condition called the gout.
So what is the gout, Irene?
Irina Raklyar, MD (02:20):
Gout is the most common inflammatory
arthritis.
It affects up to 6% ofAmericans, more common in men
than in women, and it'stypically.
The hallmark of gout istypically arthritis flares that
are intensely painful anddebilitating.
In between these flarespatients will be asymptomatic.
But over time, if gout goesuntreated, the flares will
(02:42):
become more frequent, moresevere and those asymptomatic
periods will shorten an interval.
Robert A. Kayal, MD, FAA (02:47):
That's crazy 6% of the population.
Irina Raklyar, MD (02:51):
The incidence is also rising.
It's increased in almost 50%since the 1970s and that tends
to parallel the increase incardiovascular disease and
obesity and hypertension.
As well.
Robert A. Kayal, MD, FAAOS, (03:02):
So we typically talk about gout in
men, like you said, but womenget it too right.
Irina Raklyar, MD (03:06):
Yeah, it's more common in women after
menopause.
Estrogen has a protectiveeffect, tends to push uric acid
out of the kidneys.
But after, when women havemenopause, the gout tends to
become more common.
It occurs in 2% of all women.
I see a treat gout in both menand women on a daily basis.
Robert A. Kayal, MD, F (03:23):
Estrogen has a protective effects in a
lot of conditions likeosteoporosis as well.
Obviously, sometimes it's notso helpful in other conditions
like cancers and stuff.
But yeah, so we do see it inwomen.
I think that's important topoint out because a lot of
people don't consider thatdiagnosis in women and think
it's a condition that onlyoccurs in men.
(03:45):
So what is actually happeningin this condition of gout?
Irina Raklyar, MD (03:49):
What happens in gout is it's the deposition
of uric acid into the joints andit causes a process that's
highly inflammatory.
The blood level gets saturatedwith the uric acid and when it
reaches a certain point, ourcutoff is 6.8 milligrams per
deciliter.
When it reaches that threshold,it starts depositing into the
joints and causes inflammation.
Robert A. Kayal, MD, FAAOS, (04:08):
So what are some of the risk
factors that are contributing tothis elevation in uric acid?
Irina Raklyar, MD (04:12):
Well, uric acid is the unproduct of purine
metabolism, which is an organiccompound that we find in our
diet and in other sources.
Uric acid is typically excretedby the kidneys, and sometimes
it's part by the gut as well.
Over time, as people get older,uric acid levels tend to
naturally rise, and it's usuallya combination of overproduction
(04:33):
of uric acid or under excretionby the kidney.
Overproduction of uric acidmeans that you're taking in too
much through your diet orthere's other risk factors,
other conditions that canincrease your uric acid levels,
like thyroid issues or psoriasisor mild low proliferative
disorders, but most commonlyit's an issue at the kidney
(04:53):
level.
People are on medications thatwill treat high blood pressure
or other issues that willdissuade your uric acid level
from being excreted, and othercomorbid conditions like high
blood pressure or cardiovasculardisease put stress on the
kidneys and so, therefore,you're not able to excrete the
uric acid level and it tends toaccumulate in the blood.
Robert A. Kayal, MD, FAAOS, (05:15):
So you mentioned diet, so it
sounds like there are some foodsthat you can consume, and maybe
even beverages that contributeto the gut.
Irina Raklyar, MD (05:22):
So a gut alone is not caused by diet, and
diet alone will not treat gut,but we know that there's foods
and drinks that are commonlytriggers for gut or that will
raise uric acid levels, andthose foods include seafood,
such as shellfish or sardines oranchovies, red meats,
particularly liver meats ororgan meats, and sugar sweetened
(05:47):
drinks like sodas, energydrinks, fruit juices.
Conversely, vegetables that arehigh in purines, such as
asparagus or cauliflower, andmushrooms, do not increase uric
acid levels and will not promotegut.
Robert A. Kayal, MD, FA (06:02):
Alcohol as well.
Irina Raklyar, MD (06:03):
Alcohol as well.
Yes, so alcohol, all types ofalcohol.
Beer tends to have a higherrisk of increasing or causing
gout flares than just a regularliquor or wine.
Robert A. Kayal, MD, FAAOS (06:13):
Yeah , so typically these foods are
broken down right Often by theliver.
The liver will metabolize someof these foods and then the
kidney will often try to excretethe uric acid.
So that's why you mentionedsometimes there's a failure of
some of it's basically a failureof metabolism, potentially
right.
So are there risk factors likefamily history that might
(06:34):
continue as well.
Irina Raklyar, MD (06:36):
So genetics does play a component If you
present with gout in your 20s orat a younger age.
Gout typically presents in menat age 40s or 50s, women after
menopause.
If a patient presents with goutin their 20s, there's probably
a high genetic predisposition toit.
The other risk factors for goutare the high uric acid level,
male gender, older age and thepresence of being on medications
(06:59):
that will increase uric acidlevels, so diuretics or
transplant medications inparticular.
Robert A. Kayal, MD, FAAOS, (07:04):
But there is a condition called
asymptomatic hyperureicemia,correct.
So just because our uric acidlevels are elevated, it doesn't
mean that those patients aregoing to get the gout.
Correct.
Irina Raklyar, MD (07:15):
Yeah, the statistics say that about 4% of
all men will get gout, but 20%of all men have high uric acid
levels.
So just because you have highuric acid levels does not mean
that you have gout, and that'ssomething that I sometimes
consult on as well.
Patients will present with highuric acid levels and their
primary care doctor will ask meif they need to be put on uric
lowering therapy to prevent goutflares.
Robert A. Kayal, MD, FAAOS (07:37):
Yeah , so a patient comes in the
office and what is their typicalcomplaint?
When you start thinking alongthe lines of a differential
diagnosis of gout?
Irina Raklyar, MD (07:47):
Yeah, so the presentation of gout is
typically a hot, swollen joint.
It's usually in the lowerextremity, most commonly
affecting the big toe or theankle or the knee.
It's a very fast onset.
Usually we have a maximum onsetbetween 12 and 24 hours.
There might be some rednessassociated with it.
Patients, the gout flares willbe quite debilitating.
(08:09):
The patients will complain thatthey're unable to bear weight
on that joint.
They're unable to tolerate anypressure.
That's the typical gout flare.
Robert A. Kayal, MD, FAA (08:18):
Unlike some of the other authorities
that you manage, it tends to bewhat we call an oligoarthritis,
correct?
And it's often a monoearthritisas opposed to a bilateral
condition, right?
Can you elaborate on that?
Irina Raklyar, MD (08:29):
Right.
So gout typically starts off inone joint.
Over time, if gout goesuntreated, it will start to
affect more joints and that onejoint in particular will become
more and more severe attacks andeventually over time.
One of the reasons why we dotreat gout over the long term is
that it will cause damage tothe joints.
Robert A. Kayal, MD, FAAOS, (08:47):
But it's often the smaller joints,
right, I guess.
As opposed, like you don'ttypically see it, you do see it
in the knee, but not so much theshoulder and not so much the
hip, for instance right, right,right, right it's usually the
smaller joints, but it can alsoaffect some of the soft tissues
around the joints, not just thejoint itself.
So for instance, the tendons,the tendon sheaths, sometimes
like that.
(09:07):
You'll see it show up that way,correct?
Irina Raklyar, MD (09:10):
So if gout goes untreated for about 10
years, you start to collecttophatous deposits and that's
little collections of goutcrystals and it can occur inside
of the joints or outside of thejoints, most commonly on the
bursa, say, of the elbow, on theAchilles tendon.
Sometimes we can see it in thepin of the ear, but it's
collections of gout crystalsthat tells me, when I see tophi,
(09:32):
that that patient certainlyneeds to be put on urethal
lowering therapy and that theover all uric acid burden in the
body is really quite high.
And it's been that way for along time.
Robert A. Kayal, MD, FAAO (09:43):
Right , so we talked about the
presentation, the typicalpresentation.
You also mentioned previouslyabout some of the medical
history, the patient's historyof presinilinus, the family
history, other medicalcomorbidities that might be
contributing, such as even likerenal disease, hypertension,
metabolic syndrome.
(10:03):
Obesity too is a risk factor,right, so we talked about that.
And now on physical examination, what are some of the things
you're looking for?
You mentioned some tophi.
What else?
Irina Raklyar, MD (10:15):
I look for that classic hot swollen joint.
That's where I make thedistinction between inflammatory
arthritis and non-inflammatoryarthritis.
When I see if a patientcomplains of a joint that's been
bothering them for a long timethat doesn't have that classic
asymptomatic period in betweenflares, then I'm less likely to
think that it's gout.
But the classic presentation isthat hot swollen joint.
(10:36):
When we see that hot swollenjoint we always try and aspirate
it, meaning taking fluid out ofthe joint, because the gold
standard diagnosis for gout isseeing those uric acid crystals
under the microscope.
You're getting ahead of me,Sorry.
Robert A. Kayal, MD, FAAOS, (10:50):
So , dr Rackley you mentioned, you
typically look for that red hotjoint right.
Does that sometimes suggestother conditions perhaps?
Or is it always the gout?
Irina Raklyar, MD (11:01):
No other conditions can certainly cause a
hot and swollen joint.
Pseudo gout, which is almost acousin of gout, a very similar
presentation, but you see adifferent type of crystals under
the microscope.
Things like trauma, you know.
Say, an ankle sprain or afracture can start fracturing
the big toe can certainly causesimilar symptoms and any kind of
(11:22):
infection in particular youknow, cellulitis, osteomyelitis,
septic arthritis just infectioninside of the joint can have a
similar presentation.
As a rheumatologist, I'm alsoruling out our other
inflammatory authorities,including psoriatic arthritis
and rheumatoid arthritis, whichcan, which can sometimes give
you a similar presentation.
Robert A. Kayal, MD, (11:42):
Absolutely , and I'm so glad you mentioned
all that, because when we do seepatients with this presentation
, the point that we'd like todrive home is that this same,
fairly similar presentation canalso be present with a whole
myriad of other diagnoses.
So we as clinicians form whatwe call a differential diagnosis
(12:02):
.
We listen to the patient'schief complaint, we take a
history of their present illness, we look at their past medical
history, et cetera, and thencombine that with physical
examination and other ancillarytests to form the final
diagnosis.
So this presentation of thisred hot joint can be common with
a whole plethora of othermedical conditions, and it's
(12:26):
certainly our job to help figureout what actually is causing
the problem.
So, case in point, we're goingto show you an image of the
classic presentation of a redhot joint and in this particular
condition, the gout, where it'smost commonly present.
Irina Raklyar, MD (12:44):
So this is a picture of the most classic
presentation of gout.
We call this pedagra.
This is involvement of thefirst metatarsal phalangeal
joint in the big toe of the foot.
Again, gout is a hot, swollenjoint and you can see the
swelling.
You can see the redness of thejoint, this, if I were to touch
it, a patient would probablywince in pain or jump off the
(13:06):
table because it's really quitepainful.
Robert A. Kayal, MD, FAAOS (13:10):
Yeah , it looks painful.
I mean, that looks somethingthat you know.
For me I'd say that's gout,that's infection.
There's something angry goingon.
That patient is quitesymptomatic and we didn't
mention when gout presents inthis toe in particular, in this
joint in particular.
The classic presentation ispatients always complain at
night when they're sleeping.
That bedsheet can't even, youknow, touch that area right.
(13:34):
It's that type of excruciatingpain.
In orthopedics, anytime we'redealing with an inflammatory
condition such as gout, calcifictendonitis, anytime there's a
precipitation of crystals in thearea, that sort of incites an
inflammatory response that isextremely, extremely painful.
(13:55):
For instance, calcifictendonitis of the shoulder.
The presentation is veryclassic.
These patients will often go tothe emergency room in the
middle of the night before evencoming to see us the next day,
just to find out they have acalcific tendonitis of their
shoulder.
So inflammatory conditions,inflammatory authorities, are
debilitating and incapacitating.
(14:16):
In general they're that kind ofpain we call it like a 10 out
of 10 pain, very much akin to akidney stone.
Right, a kidney stone is thesame type of precipitation of
calcium deposits and it incitesthat type of inflammatory
response and that level of pain.
Do you agree?
Absolutely.
Irina Raklyar, MD (14:34):
So this next picture is a photo of a tophatia
scout.
What we're looking at is in theproximal interphalangeal joint
of the patient's hand you cansee this nodular swelling.
This is not necessarily painful, but what this is is a
(14:55):
collection of those uric acidcrystals and it tends to collect
in parts of the body they're alittle bit cooler to touch or in
the extremities, because that'swhere uric acid levels like to
precipitate out.
When I see a patient like this,I know the gout has been going
on for a very, very long timeprobably 10 years and it's been
untreated and this is absolutelyan indication to treat the
(15:17):
underlying gout.
If I were to take a look at thex-ray or do some kind of imaging
, I would see damage inside ofthe joint.
I would see swelling that lookslike swelling on the x-ray as
well.
I would might see some of thegout crystals, because sometimes
I'll be surrounded by a littlebit of calcification and this is
(15:38):
one of the primary indicationsto treat gout.
When I look at this x-ray, Iknow that uric acid burden is
really quite high in the bodyand this patient has a very high
risk for cardiovascular diseaseas well and the uric acid
levels are that high for thatlong of a time Uric acid levels.
Uric acid will be acardiovascular toxin, so it will
predispose this patient toheart attacks and strokes and
(16:00):
heart issues.
When I see a patient like this,I tell them I'm not just
treating your gout, I'm not justpreventing damage, but I'm also
lowering your risk for heartdisease and heart attacks.
Robert A. Kayal, MD, FAAOS, (16:09):
So , Irene, regarding those two
photographs that you soeloquently described, is it
possible to convert?
Is it possible for a patient tohave one of those tophacious
precipitations that is in aquiescent endowment state for a
long period of time and thensuddenly to get red and hot and
inflamed?
Irina Raklyar, MD (16:29):
It can.
You can certainly have a goutflare in the same location of
the tophi, absolutely.
Robert A. Kayal, MD, FAAOS (16:35):
Yeah , but the difference in that
first picture where it was redand hot, that was active acute
gout, as opposed to the otherone which was what seemed to be
an endowment state, quiescentendowment state and that was
definitely indicative of achronic gout condition, correct?
Right Now that we discuss someof the photographs and we are
really forming that differentialdiagnosis and deducing that
(17:00):
this patient is going to bediagnosed with gout, are there
other studies, radiographs, labs, CAT scans, MRIs, anything else
you can order to reallydefinitively diagnose the
patient with the gout?
Irina Raklyar, MD (17:14):
When I see a patient for a suspected gout
flare, I typically at thatinitial visit I will order blood
work and I will order X-rays.
The purpose of the blood work isone to check a uric acid level.
Uric acid levels alone will notdiagnose gout, but a high uric
acid level will increase mysuspicion for gout and it gives
me a baseline when I start uratelowering therapy to treat the
(17:36):
gout.
In the blood work I'll alsolook for inflammatory markers
like sedimentation rate andC-reactive protein.
I'll do a regular panel of CBCand a comprehensive metabolic
panel looking for kidney issues,looking for liver issues that
one might be an end cause of thegout Gout can cause kidney
stones and can cause kidneyissues as well.
(17:56):
In preparation for starting thepatient on therapy and to help
me decide which medications Iwill use to treat the gout flare
that's why I do all of thatblood work.
I'll also typically do X-raysbecause I'm looking for evidence
of prior gout damage.
The indications for startingsomeone on urate lowering
therapy include two or more goutflares in a year, seeing damage
(18:21):
on an X-ray or the presence ofthe TOEFI.
Robert A. Kayal, MD, FAAOS, (18:25):
Can you have the gout within normal
serum uric acid level?
Irina Raklyar, MD (18:29):
Absolutely.
In fact, during episodes ofinflammation, uric acid tends to
be pushed out of the kidney, soyou can't see normal uric acid
levels in the time of theinflammatory arthritis.
Robert A. Kayal, MD, FAAOS, (18:42):
Are MRIs or CAT scans or
ultrasounds warranted to helpyou make this diagnosis?
Irina Raklyar, MD (18:48):
MRIs are not so helpful unless you're trying
to rule out concomitant causesof inflammatory arthritis.
If you're looking for thingsthat don't show up on an X-ray,
like a sprain or a fracture ordamage that looks like other
types of inflammatory arthritis,like rheumatoid arthritis,
there is a certain type of CATscan that we can do.
It's called a dual energy CTscan.
(19:09):
That will pick up uric acid,toefi, in the joints.
Sometimes that's helpfulbecause you can't always
aspirate a joint.
You can't always take out thefluid to prove that it's gout.
Sometimes we might order theseother studies to help support
our diagnosis of gout.
We can also do ultrasoundUltrasound.
There's a classic finding wecall it the double contour sign,
(19:30):
which shows uric acid withinthe joint.
It requires a educated andexperienced ultrasound
technologists to look for that.
Robert A. Kayal, MD, FAAOS (19:44):
Yeah , so, with respect to these
images, they're fairly classicfindings, like you mentioned, so
let's discuss some of them,okay, so what are we looking at
here, irina?
Irina Raklyar, MD (19:54):
We're looking at a lateral x-ray view of the
elbow.
The elbow joint in particularis intact, but you can see this
dense swelling, this radiopaqueswelling outside of the joint.
There's fluid in the bursa.
The bursa is a little pocket offluid that sits outside the
elbow joint.
That helps protect the jointand it's commonly a site for
(20:16):
uric acid deposits and for goutinflammation.
And what we're seeing isswelling inside the joint.
You can almost see it hangingoff of the joint because there's
a lot of fluid and inflammationgoing on in there.
Robert A. Kayal, MD, (20:28):
Absolutely .
I mean it looks like a smalllittle tangerine in the back of
this patient's elbow right.
It's a common site for swelling, but most of the time that
swelling is just fluid.
Like you said, we call thatlecronon bursitis, and certainly
the x-ray, the radiograph,would be very different than
this projection right here.
(20:49):
You can see, in this softtissue swelling it is much more
dense than fluid.
Fluid would be almost black innature on this radiograph,
whereas this one has a morewhitish appearance, approaching
that density of bone.
So clearly there's someprecipitation here, some
collection of some type ofdeposit of some sort, and this
(21:12):
would be highly suggestivepotentially of an inflammatory
arthropathy of some sort and inthis particular case, likely the
gout.
So let's talk about another one, dr Racklier.
So, dr Racklier, let's compareand contrast now this radiograph
to the elbow that we justpreviously discussed.
What are you finding here?
Irina Raklyar, MD (21:32):
So this is an x-ray photograph of the hand
and the wrist showing chronicgouty arthropathy.
You can see the presence ofTOFI, which is that swelling
outside of the joints as well,and you can see damage inside
the joints.
If we were to compare to normaljoints first, if we take a look
at the third and the fourthfinger MCP joints,
(21:52):
metacarpophalangeal joints,those are relatively normal
joints.
The joint space is evensymmetrical, the contours of the
bone are smooth and rounded andthose look relatively preserved
.
If we were to contrast it withthe first and the fifth finger
MCP joints, then we see theclassic gouty damage On an x-ray
(22:14):
.
You see overhanging edges, yousee sclerotic margins
Rheumatologists call them ratbite erosions because it looks
like a rat has bitten into themand you can see them at the MCP
joints.
You can see some damage at thePIP joints, the proximal
interphalangeal joints, and youcan also see it at the wrist as
well.
So this is a classic x-ray ofchronic gouty arthropathy.
Robert A. Kayal, MD, FAA (22:37):
Severe erosions, osteolysis, punched
out, lesions, and this is very,very, very advanced gout.
Irina Raklyar, MD (22:46):
It's unfortunate because when we see
damage like this, we can't undo.
Bony damage we can prevent.
My goal as a rheumatologist isobviously to help the patient
feel better, but it's also toprevent bony damage.
Once I see damage like this, Ican't undo it.
Even if I get the patientfeeling better and free of gout
flares, he or she still mighthave joint pain in the hands
(23:09):
because of damage that's alreadydone.
Robert A. Kayal, MD, FAAO (23:10):
Great point, great point.
So, dr Ackley, are youmentioned that the classic gold
standard for making thisdiagnosis is biopsy and
evaluation for crystals onmicroscope?
However, sometimes we're unableto get the fluid out of the
joint and in those particularcases, either there's no fluid
(23:35):
or the joint is too small toaspirate.
You had mentioned thatsometimes we can do a dual
energy CAT scan.
So this next image we're goingto show you is a classic example
of a dual energy CT, where wecan pick up lesions consistent
with TOFI and urethricprecipitation for smaller joints
(23:58):
where we are unable to aspiratethat fluid.
So can you please describe whatyou're seeing here?
Irina Raklyar, MD (24:04):
So sometimes when we have a patient
presenting with tophatious gout,it can have nodules or
deformities or hard depositsthat are not necessarily easy to
take fluid out of.
So therefore we may order thisdual energy CT.
It's not a regular CT scan.
It's a dual energy CT scan,meaning there's an additional
program that is applied to theCT scan that will help light out
(24:27):
these gout crystals In thispatient in particular.
The green is those tophatiousdeposits.
The purple usually representskeratin or other calcium
materials and those areotherwise benign, but the green
is proof that there is the TOFIuric acid crystals in that joint
.
Sometimes we might also doserial dual energy CT scans.
(24:47):
If we are looking at thosetophatious deposits, if our goal
is treating them and to meltthem away, we like to do serial
dual energy CT scans and see howthey are resolving over time.
Robert A. Kayal, MD, (24:59):
Fantastic , thank you.
We talked about how we can makethe diagnosis both on physical
examination and imagingmodalities ultrasound, x-ray,
etc.
Utilizing blood work as well tohelp with the diagnosis.
But really the gold standard iswhat?
Irina Raklyar, MD (25:17):
Gold standard is a synovial fluid aspiration
is pulling fluid out of thejoint, taking a look at it under
the microscope and proving thatthere's gout crystals.
Robert A. Kayal, MD, FAAO (25:26):
Right , because we talked that there
could be some overlap both onphysical examination and on
history, and even on x-rays withcertain conditions.
So biopsy is the gold standard.
So, for instance, when somebodycomes into my office with what
we call a knee joint diffusion,or in layman's terms, water in
the knee, I'm not really sure ifthat water in the knee is from
(25:47):
arthritis, a meniscus tear, aninfection, torn ligament,
possibly even inflammatoryorthopathy.
So very often I'll end updraining that knee.
I'll do what's called a kneejoint aspiration.
If the joint fluid is normal,it's most likely mechanical in
nature, meaning a meniscus tearor arthritis, something like
(26:09):
that.
If it's bloody, I might thinkalong the lines of is this a
fracture, is this an ACL tear orsomething like that.
If it's filled with pus, I'mconcerned that there is
infection.
It would be very cloudy, hot,very murky and very much
consistent with pus in the knee.
That would be indicative of aninfection.
And finally, if it's somewhatinflammatory, cloudy and it
(26:34):
appears that maybe there's someprecipitation going on, I may be
concerned that this isinflammatory in nature and this
patient may have to be referredto Dr Rackler for evaluation.
So what we'll do is we'll takethat fluid and we'll send it to
the lab and if we're checkingfor infection, we'll typically
(26:54):
check a gram stain check forcultures and sensitivity.
But we always are trained tocheck for cell count with
differential as well as crystalanalysis.
So we always want to make surethat we're not dealing with an
inflammatory condition, aninfection or other condition.
So it's not common to haveinfection superimposed on
(27:18):
inflammatory conditions and viceversa, but it can happen right.
Irina Raklyar, MD (27:21):
It can certainly happen, even when you
have an established diagnosis ofgout.
It's always a good idea to getthat aspiration, because there's
no reason why it can't be aninfection and gout at the same
time 100%.
Robert A. Kayal, MD, FAAOS, (27:31):
So you look, you're drawing the
fluid.
Anyway, we like to test it.
I test it for everything Cellcount with differential, gram
stain, with culture andsensitivity, and certainly
crystal analysis.
Every single aspiration getstested for all that, and so when
we take this fluid out and thegram stain comes back negative,
there's no infection.
What are we looking for withrespect to what's called the
(27:55):
cell count with differential,because it can be a little dicey
sometimes.
Sometimes it can be close.
You're not really sure.
Is it infected, is it notinfected?
Is it inflammatory?
What are you looking for, drReckler?
Irina Raklyar, MD (28:07):
So normal synovial fluid will have
anywhere from zero to 2,000white blood cells.
In any kind of inflammatorystate you'll have more than
2,000 white blood cells.
In the setting of gout orinfection you can have tens of
thousands of white blood cells.
The differential will be skewedmore towards neutrophils, which
is the active subsetresponsible for inflammation.
(28:29):
And then we look for thecrystal analysis, because
besides gout crystals there'sother types of crystals that can
cause inflammation in the joint100% and sometimes you get a
white count.
Robert A. Kayal, MD, FAA (28:42):
That's borderline.
You may get like a 40,000 or45,000 white count and that's
sort of borderline.
Traditionally I think most ofus would say over 50,000 or in
that range.
We're starting to think reallyabout an infection anywhere from
, like she's saying, 2,000 to 20, 30, up to 40,000.
It's typically inflammatorynature.
(29:03):
But that's where thisdifferential comes into play.
We always order that tap bysaying cell count with
differential and she's focusingon the neutrophils.
So we call that a shift to theleft.
If there's an elevated numberof neutrophils, a percentage of
neutrophils, it makes us quiteconcerned about more than likely
(29:25):
an infection.
So, dr Rackler, what are welooking at here now on this
slide?
Irina Raklyar, MD (29:30):
We are looking at the presence of uric
acid crystals, gout crystals,under a polarizing microscope.
It has the classic needle shapeappearance.
It's negatively birefringent onthe polarizing microscope and
these are classic for gout.
Meaning negatively birefringent, meaning that in one direction
(29:51):
it looks yellow, but in theother direction it looks blue.
But it has that classicappearance.
Robert A. Kayal, MD, FAAOS (29:56):
Yeah , and this is something a
pathologist would see under themicroscope when we draw that
fluid out of that patient'sjoint and send it to the lab,
right?
So we're waiting, sometimes acouple of days, for reports to
come back whether or not therewere crystals in the fluid and
in this particular case, this isthe classic slide presentation
of someone that would beabsolutely confirmed with the
(30:19):
diagnosis of the gout.
Irina Raklyar, MD (30:21):
Sometimes we send rheumatologists will send
our patients to our orthopedicsurgeon colleagues to remove
TOFI, especially if they'redeforming or cosmetically
unappealing or if they'relocated in areas where there's a
lot of irritation, say theelbow or the hand.
And when we look at the TOFIunder the microscope we see
(30:42):
sheets and sheets of these uricacid crystals.
Interesting.
Robert A. Kayal, MD, FAAO (30:46):
Great , all right.
So now that we've made thediagnosis definitively on biopsy
right the gold standard we haveto treat these conditions right
.
So what is your first line oftreatment?
Irina Raklyar, MD (30:58):
So there's a couple of medications that we
use to treat gout and we all wechoose which medication we use
based on the other comorbidconditions.
Typically, the first linemedications used to treat gout
are colchicin, steroid orsteroids or anti-inflammatory
medicines.
Colchicin is one of our oldestmedicines in medicine.
(31:21):
It's been around since thesixth century.
It's used to treat inflammation.
Steroids can be injected intothe joint or can be taken orally
or less commonly, you can giveit through an IV or
intramuscularly, andanti-inflammatory.
Anti-inflammatory medicines arethe common medicines that are
typically over the counter, butwe use it at anti-inflammatory
(31:42):
doses and which one we choosereally depends on what else is
going on in the body.
If the patient has a priormedical history of gastric
ulcers or if they're on bloodthinners, then we tend to avoid
oral steroids or we tend toavoid the anti-inflammatories.
If there is a question thatthere might be some underlying
(32:04):
infection there as well, then wetend to avoid a steroid.
So if the patient has kidneyissues, then we tend to avoid
the colchicin and theanti-inflammatory.
So that's why we do the bloodwork in addition at that first
visit to decide which medicationwould be appropriate and which
route would be most appropriate.
Robert A. Kayal, MD, FAAO (32:20):
Right .
In my experience as a NorthPeak surgeon, when I see these
patients it's sometimes toughbecause they're in so much pain,
like we've described, and youwant to treat them so badly with
a cortisone injection.
But we're forced to hesitatebecause that's the last thing in
the world we'd want to do ifthere was a local infection and
the presentation of asepticarthritis and acute gout flare
(32:46):
go hand in hand.
There's a tremendous amount ofoverlap.
So a lot of times we don'treally know if it's the gout or
if it's aseptic or infectedjoint, and so time is of the
essence for us to get theresults of this, and the
steroids, whether orally orinjected locally, would be
(33:07):
detrimental if in the face ofinfection.
So it's restricting somewhatuntil we get that definitive
diagnosis Right.
All right, so we have to treatthem with the
anti-inflammatories.
There's also other things thatwe have to do.
Sometimes gout, as we alludedto previously, is primary in
(33:28):
nature and sometimes it'ssecondary in nature.
Right, if it's primary innature, a lot of times we'll
recommend a low purine diet,some type of nutritional
counseling.
If they're drinking a lot ofalcohol, we'll ask them to
refrain, because certainlythat's contributory, especially
the beer If they're eating a lotof red meats or shellfish or
(33:49):
different types of fish.
That certainly can increase thelikelihood.
But sometimes it's secondarygout, secondary to some
metabolic conditions or othermedical conditions, and so, just
like any other secondarycondition, the onus is on us to
make that diagnosis and to makesure that that primary disorder
gets treated and then thesecondary manifestation of that
(34:14):
condition often disappears.
Right.
Irina Raklyar, MD (34:17):
So acute gout flare will typically last three
to 10 days.
Sometimes it can last forseveral weeks.
But people will often seek outcare for their gout flare, for
prompt resolution of pain andfor restoration of the mobility
of the joint.
Like I said, the joint will bevery tender, unable to bear
weight.
People won't be.
Especially, it affects thelower extremity.
(34:39):
People won't be able to walk onthat foot.
So what I will do when I treatthe gout flare is I will review
all of the other medicationsthat they're on, look at all of
the other comorbid conditionsthat are going on and choose a
therapy that's appropriate forthem.
That's not going to necessarilyworsen the other things.
That are the other medicationsthat are there.
Robert A. Kayal, MD, FAAOS (35:01):
With respect to the treatment of the
gout, when I was in training 30years ago or so, it was always
the triad of usage ofendomethacin, which is an
anti-inflammatory, non-steroidalanti-inflammatory colchicin and
I was told to take, I was toldto prescribe, 0.6 milligrams of
colchicin TID until the patientseither develop nausea, vomiting
(35:24):
, diarrhea or relief of theirsymptoms, and then possible use
of allopurinal for prevention ofrecurrences.
Because my training was that aspatients get older, the bouts
become more severe and closer inproximity to one another as
well.
Is that still the thoughtprocess?
Irina Raklyar, MD (35:44):
So the way that we treat acute and chronic
gout differs.
We don't use colchicin at thosedoses anymore.
The most common side effect ofcolchicin is GI issues and
diarrhea.
So to put some patient on supertherapeutic doses of colchicin
and have them running to thebathroom with their arthritic
gout flare seems savage.
(36:10):
So we don't use-.
Robert A. Kayal, MD, FAAOS, F (36:10):
I was saying would you rather
have diarrhea or would yourather have a gout attack?
We'd rather have not, we'drather treat.
Irina Raklyar, MD (36:16):
We'd rather not have diarrhea and treat
through the gout attack.
So we use colchicin at normal,once or twice a day, depending
on the underlying kidneyfunction.
We extend the dose of thecolchicin or the
anti-inflammatory for up to 10days because that's how long
it'll usually take to treat agout flare.
We typically don't start yourallopurinol or urate lowering
therapy at that visit for theacute gout, just because it's
(36:39):
very overwhelming.
The patient is already comingto see you.
They've been suffering withthis gout flare, they're looking
for treatment and to put themon multiple medications at that
visit is very overwhelming forthe patient.
A lot of times.
If we start them on thelong-term treatment at the time
of the acute gout flare, whatmight happen is that once the
gout flare resolves they mightstop the long-term treatment,
(37:03):
also thinking that they're fixed.
So we typically divide it intotwo visits One where I treat the
gout flare, I get myinformation to think about what
I'm going to be using forlong-term therapy and then have
them come back a week or 10 daysafter the gout flare has ended
and we talk about chronictherapy, how to decrease the
(37:24):
uric acid levels for thelong-term, and that's when I
also do the education about dietand lifestyle modifications.
Robert A. Kayal, MD, FAA (37:30):
That's great, and in your experience
you've actually seen a lot ofthese TOFI disappear right over
time.
Irina Raklyar, MD (37:37):
Yeah, TOFI will disappear with urate
lowering therapy.
It doesn't happen immediately.
It can take about six months toa year.
For patients who havepolyarticular TOFI tophatous
deposits, If they have a lot ofjoints or if they have deforming
arthritis, there is a verypotent IV medication that we can
use that will melt it away.
(37:57):
But it really is reserved forthe appropriate patients.
Robert A. Kayal, MD, FAAOS, (38:00):
Got it.
So, dr Rechler, I know wefocused our attention a lot on
the treatment of the acute goutcondition, but how do we treat
chronic gout, the patient that'ssuffering from long-term gout?
Irina Raklyar, MD (38:11):
So we have a different subset of medications
that we use to treat gout, butthe cornerstone of there
cornerstone is urate loweringtherapy, decreasing the uric
acid levels in the blood.
Our goal is to decrease it tounder six.
If they have the presence ofthis TOFI, we decrease it to
under five.
The medications that we use areall medications that lower uric
acid levels.
(38:32):
That includes allopurinol,which has been around since the
1960s.
That's kind of the go-tomedicine.
Fibuxa stat is a newermedication that also lowers uric
acid levels and we havepeglotticase, which is an IV
medication which also veryrapidly drops the uric acid
levels.
We use a treat-to-targetapproach, meaning that our goal
(38:55):
is to get it on the uric acidlevels under six or five.
But initially, when we firststart uric acid levels, uric
urate lowering therapy, there'sactually a paradoxical high risk
for having a gout flare.
So when we start the patient onmedications we have a two-prong
approach a medicine that lowersuric acid levels and a medicine
(39:17):
that's used to prevent uricacid flares.
During that time Uric acidlevel doesn't just naturally
drop, it fluctuates and then itdrops.
So we'll typically use somekind of prophylaxis at the same
time when the uric acid levelbecomes therapeutic and it stays
that way for six to 12 months,we peel back on that second
medicine and they're just lefton that one-year lowering
(39:38):
therapy, probably for the restof their life.
Robert A. Kayal, MD, FAAOS (39:41):
Well , it's gotten a lot more
complicated since I started 25years ago.
So it's a little bit differentthan the endomethacin BID and
Coltocene 0.6 TID right.
Irina Raklyar, MD (39:53):
Yeah Well, we have a lot more knowledge of
gout, there's a lot more sciencebehind it and we're a lot more
effective at treating gout andmaking it easier for the
patients as well.
Robert A. Kayal, MD, FAAOS (40:03):
Well .
I thank God that we havedoctors like you at the KAL
Orthopedic Center.
It's been such an honor to workalongside you.
You're a walking encyclopediain the field of rheumatology and
when I began this interview Ithought I was talking to chat
GPT.
I praise you every time I makea referral of our patients to
(40:25):
you because you are absolutelybrilliant in this field and it's
such an honor to have you here.
So thank you so much.
Don't correct me.
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