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Rapid response to:

Clinical Review

Diagnosis and management of gout

BMJ 2006; 332 doi: (Published 01 June 2006) Cite this as: BMJ 2006;332:1315

Rapid Response:

Poverty of interest in Disease of Abundance

Dear Sir,

Congratulations to Dr. Underwood for his excellent review of
Diagnosis & management of Gout [1]. Gout is considered a disease
associated with abundance and overindulgence like old Roman ways. There
seems to be a lack of interest in this disease due to unexplained reasons.
Harrison’s Principles of Internal Medicine devotes only 1½ page to this
disease [2]. However Davidson’s Principles and Practice of Medicine [3]
covers it in 3½ pages. As brought out well by the author, this disease
affecting 1% of the world population is likely to become more common in
future due to increasing affluence. While working in Armed Forces, we are
impressed by large number of cases of gout in Nepali Gorkha soldiers.
Perhaps it is due to their fondness for red meat and alcohol.

Few conditions can be diagnosed with more certainty or treated more
successfully and dramatically than gout. Gout is a prominent member of
‘Club of unilateral diseases’ like Bell’s palsy, Trigeminal Neuralagia,
Herpes Zoster, Migraine, Poliomyelitis, Filariasis, wherein the clinical
features are predominantly unilateral in majority of patients. What is the
cause of unilateralism of clinical features of these diseases is a well
guarded secret of nature, but this fact definitely helps in arriving at
the correct diagnosis of these diseases. Unilateral acute podagra (painful
swelling of great toe) is the usual presenting feature of majority of
cases of Gout. Contrary to common belief, normal serum urate concentration
does not exclude the diagnosis. In fact this situation is pretty common in
clinical practice.

Treatment of acute gouty arthritis is well summed up in the box
‘Patient’s story’ of the article [1]. Colchicine is rarely used in
treatment of acute Gout because of its not easy availability and marked
gastrointestinal side effects. Indomethacin and diclofenac have almost
replaced colchicine because of their equal efficacy and few side effects.
We have never felt the need to use oral or intra-articular corticosteroids
in acute gout.

References :

1. Underwood M. Diagnosis and management of Gout. BMJ 2006; 332:1314-

2. Reginato AJ. Gout and other crystal arthropathies in Kasper DL,
Braunwald E, Fauci AS et al (Eds) Harrison’s Principles of Internal
Medicine 16th Ed. McGraw-Hill. 2005:P 2046-2050.

3. Doherty M, Lanyon P and Ralston SH. Musculoskeletal disorders. In
Haslett C, Chilvers ER, Boon NA and Colledge NR (Eds). Davidson’s
Principles And Practice of Medicine. 19th Ed Churchill Livingstone.
2002: P 957-1047.

Competing interests:
None declared

Competing interests: No competing interests

08 June 2006
Kuldip P Anand
Head , Dept of Medicine
Ajit S Kashyap, Surekha Kashyap
Command Hospital Kolkata 700027,India