Study on clinical and paraclinical characteristics of patients with gout disease diagnosed by the 2015 EULAR/ACR criteria

Objectives: To analyze the clinical and para-clinical characteristics of patients with gout disease diagnosed by the 2015 EULAR/ACR criteria. Subjects and methods: 31 patients who were diagnosed with gout disease were selected. The study had focused on age, gender, lifestyles, history and current patterns of gout, VAS (Visual Analog Scale) index, plasma uric acid levels, hs-CRP, ESR, ultrasound images of affected joints.

Journal of military pharmaco-medicine STUDY ON CLINICAL AND PARACLINICAL CHARACTERISTICS OF PATIENTS WITH GOUT DISEASE DIAGNOSED BY THE 2015 EULAR/ACR CRITERIA Ton Thanh Tung*; Nguyen Ngoc Chau* SUMMARY Objectives: To analyze the clinical and para-clinical characteristics of patients with gout disease diagnosed by the 2015 EULAR/ACR criteria Subjects and methods: 31 patients who were diagnosed with gout disease were selected The study had focused on age, gender, lifestyles, history and current patterns of gout, VAS (Visual Analog Scale) index, plasma uric acid levels, hs-CRP, ESR, ultrasound images of affected joints Results: The majority were male (96.8%) The mean age of onset was 47.3 ± 15.2 years, the common age group of onset was from 20 to 40 (41.9%) and commonly with the heavy pain (74.2%) 45.2% of patients were not diagnosed with the first episode of gout lower than previous study’s with statistical significance, the mean time for the definite diagnosis was 4.64 ± 4.4 years Hs-CRP and ESR were two common inflammatory markers 19.4% of patients had normal range of uric acid The double contour lesion accounted for 29.0% There was a moderate positive correlation between the 2015 EULAR/ACR classification criteria for gout scores and the frequency of recurrence attacks of gout per year (r = 0.46; p < 0.05) Conclusions: The clinical and para-clinical characteristics of patients were almost consistent with the previous studies There was an increase in the rate of patients diagnosed with the first attack of gout The higher score of the EULAR/ACR 2015 classification for gout predicted the higher frequency of recurrence attacks of gout per year *Keywords: Gout disease; EULAR/ACR 2015; Clinical, paraclinical characteristics INTRODUCTION Gout is the most prevalent form of inflammatory arthritis and is associated with impaired quality of life There are many criteria for diagnosing gout disease, existing criteria for the classification of gout have suboptimal sensitivity and/or specificity and were developed at a time when advanced imaging was not available Therefore, it is necessary to develop a new diagnostic tool The 2015 EULAR/ACR gout classification criteria are developed using a data-driven and decision analytic approach, have excellent performance characteristics and incorporate current modern evidence regarding gout, has higher sensitivity (92%) and higher specificity (89%) than existing criteria In Vietnam, Bennett & Wood classification criterion has been mainly used to diagnose gout disease, the advantages of these criteria are to diagnose based on clinical manifestations, easy to remember and apply but with low sensitivity and specificity Thus, this study aims: To use new criteria EULAR/ACR 2015 to diagnose gout disease and analyze the collected clinical and paraclinical characteristics of patients * 103 Military Hospital Corresponding author: Nguyen Ngoc Chau (chau70@gmail.com) Date received: 30/06/2017 Date accepted: 06/08/2017 158 Journal of military pharmaco-medicine SUBJECTS AND METHODS Subjects * Inclusion criteria: 31 patients including 30 male patients were treated in the Rheumatology and Endocrinology Department, 103 Hospital - Diagnosed with gout disease by the EULAR/ACR 2015 criteria - The affected joints were in inflammatory condition with or without joint effusion * Exclusion criteria: Suspected bacterial infection of the joints or other infection conditions that affect to the evaluation of the inflammatory investigation results Methods Cross-sectional, descriptive analysis * Examination and diagnosis: - Take a history, age, gender; examine the affected joints and assess pain levels of joints (VAS), investigate ESR, hs-CRP, plasma uric acid concentration, performed ultrasound the affected joints for detecting double contour - Patients with gout disease were definitely diagnosed by the 2015 EULAR/ACR criteria * Method of data analysis: Collected data were analyzed by the medical statistical method using SPSS 23.0 software RESULTS AND DISCUSSIONS Clinical characteristics and paraclinical * Clinical characteristics: In total, we identified 31 patients with gout disease In most cases, the classification diagnosis was made by the 2015 EULAR/ACR criteria with the total mark more than marks (96.8%) Only one patient with poor clinical findings was diagnosed by detecting urate crystal using polarized light microscopy In our study, the mean age of onset was rather young (47.3 ± 15.2) The most common age group of onset was 20 - 40 (41.9%) This result was consistent with the result of Hoang Thi Thu Trang (48.8%) It also suggested that the onset of gout had the tendency of rejuvenation This matched with the tendency of having metabolism diseases in our modern society The group with overweight and obesity accounted for 41.9%, the mean BMI was 22.4 ± 2.6 This result was also consistent with the result of Hoang Thi Thu Trang studied on Vietnamese (50.1%) In the study of L Annemans (2010), obesity accounted for 27.7% of UK patients [2] According to Lucía Cea Soriano (2011), this rate was 65.99% [6] Recent studies have approved that obesity played an important role in increasing the prevalence of gout [7] The heavy pain was the highest ratio (74.2%) and the mean VAS was 73.5 ± 21.2 The result was consistent with the result of Hoang Thi Thu Trang (68.8%) [1], Pham Thi Minh Nham (79.2%) [5] The result also matched with the intensely painful condition in the pathophysiology of gout 159 Journal of military pharmaco-medicine Table 1: Inhabit of alcoholic beverage using Quantity Acid uric p Min - Max Alcohol (n = 26) Quantity (g/day) 108.3 ± 80.9 16 - 320 (83.9%) Time (year) 31.9 ± 14.5 - 60 Beer (n = 14) Quantity (g/day) 57.3 ± 37.2 - 120 (45.2%) Time (year) 27.7 ± 12.2 10 - 50 497.9 ± 110.4 > 0.05 485.2 ± 90.9 We have known that alcohol and beer had played a big role in increasing the uric acid concentration by the mechanisms of overproduction and reduced excretion uric acid In our study, 100% of patients had the history of using too much alcohol or beer in the long term (83.9% of patients used alcohol, 45.2% of patients used beer) The mean quantity of alcohol using was 108.3 ± 80.9 g/day, the mean quantity of beer using was 57.3 ± 37.2 g/day However, in our study, alcohol and beer affected to the uric acid concentration equally without statistical significance (p > 0.05) Table 2: Diagnostic features Diagnostic features Diagnosed with the first episode Time to be definitely diagnosed with gout disease (years) Number of patients Percentage Yes 17 54.8 No 14 45.2 Min year Max 15 years 4.64 ± 4.4 years Diagnosing gout has been a challenge to the physicians in many cases because of its various manifestations In our study, there was still a high ratio of patients who were not diagnosed with the first episode (45.2%) The mean time for the definite diagnosis was 4.64 years In the study of Hoang Thi Thu Trang, this rate was higher than ours (68.75%, p < 0.05) This may be in the study of Hoang Thi Thu Trang using the Bennet Wood criteria so the sensitivity and the specificity were lower With whom the diagnosis was not established by the first episode, the 160 shortest time for the definite diagnosis was year, the longest time was 15 years and the mean time was 4.64 ± 4.4 years Our result was shorter than the previous study of Le Thi Vien (2006): 5.98 ± 5.9 years [3] and consistent with the result of Hoang Thi Thu Trang (2.34 ± 5.19 years) Because the patients paid more and more attention to their health, so they visited hospital earlier, at the same time, the level of expertise of general doctors have improved and physicians in primary health care facilities have had a better understanding of gout Journal of military pharmaco-medicine * Paraclinical characteristics: 80.6% of patients in our study had elevated uric acid level The mean plasma uric acid was 503.9 ± 106.4 µmol/L These results were consistent with previous studies Hoang Thi Thu Trang (69.4%; 499.13 ± 143.0 µmol/L) [1], Pham Hoai Thu (65.3%; 470.2 ± 120.1 µmol/L) [4] However, 19.4% of patients were diagnosed acute gout and acute flare of chronic gout with normal plasma uric acid concentration This rate was similar to the result in the study by Hoang Thi Thu Trang (30.6%) [1] This result showed that the uric acid concentration was not the definitive factor to activate the acute flares of gout This had reported by previous studies of many authors [8] Gout is an inflammatory joint disease So investigating the markers of inflammatory condition could show us the level of the inflammation Hs-CRP, ESR and WBC were the common inflammatory markers In our study, the elevated level of hs-CRP was more common (80.6%), followed by the elevated level of ESR (53.6%), WBC was almost normal (54.8%) with the mean WBC 8.39 ± 4.9 These results were consistent with the results of Hoang Thi Thu Trang (93.8%, 73.1% and 55.9%) [1] The results matched with the clinical manifestations of acute gout and acute flares of chronic gout disease The WBC increased without statistically significant difference (42.5% vs 54.8%, p > 0.05), this was absolutely consistent with the infectious inflammatory process of gout disease Synovitis was the most common lesion on the ultrasound (41.9%), followed by the double contour (29.0%) This result was also similar to a previous study [1] The double contour was a very valuable lesion for diagnosing gout on ultrasound It indicated the deposition of urate crystals in the joints and distributed marks into the total 2015 score if positive In our study, we met cases who were detected tophi on ultrasound (6.5%) Table 3: Plasma uric acid features Plasma acid uric (µmol/L) Acute gout (n = 23) Acute flare of chronic gout (n = 8) Total n % n % n % Increase 20 64.5 16.1 25 80.6 Normal 9.7 9.7 19.4 491.2 ± 141.9 p 478.3 ± 142.3 503.9 ± 106.4 > 0.05 80.6% of patients had elevated uric acid level, 19.4% of patients had a normal plasma uric acid level The mean plasma uric acid was 503.9 ± 106.4 µmol/L There was no difference of uric acid level between acute gout and acute flare of chronic gout (p > 0.05) 161 Journal of military pharmaco-medicine The correlation of the EULAR/ACR 2015 classification for gout scores with the frequency of recurrent attacks per year Frequency (numbers per year) Through analyzing the data of 31 patients, we found that there was a moderate positive correlation between the 2015 EULAR/ACR criteria classification for gout scores and the frequency of recurrence attacks of gout per year (r = 0.46; p < 0.05) These result showed that the higher scores of the EULAR/ACR 2015 classification for gout may predict the higher frequency of recurrence of gout No previous studies mentioned about this We considered if there will be a cut-off value of the 2015 EULAR/ACR classification criteria for gout scores that has meaning in prevention management of gout but needs more studies 30 25 20 15 10 y = 0.8842x - 2.8457 R2 = 0.2086 0 10 15 20 25 EULAR/ACR classification for gout marks Figure 1: The correlation between the EULAR/ACR 2015 classification for gout scores with the frequency of recurrence attacks of gout per year CONCLUSION - The majority were male (96.8%) with the mean age of onset 47.3 ± 15.2 years, the common age group of onset was from 20 to 40 (41.9%) and commonly with the heavy pain (74.2%) 45.2% of patients were not diagnosed with the first episode lower than previous study’s with statistical significance, the mean time for the definite diagnosis was 4.64 ± 4.4 years - 19.4% of patients who were diagnosed acute gout and acute flare of chronic gout, had normal value Hs-CRP and ESR were 162 two common inflammatory markers The double contour lesion accounted for 29.0% - There was a moderate positive correlation between the EULAR/ACR 2015 classification for gout scores and the frequency of recurrence attacks of gout per year (r = 0.46; 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Department, 103 Hospital - Diagnosed with gout disease by the EULAR/ACR 2015 criteria - The affected joints were in inflammatory condition with or without joint effusion * Exclusion criteria: Suspected... acute gout and acute flare of chronic gout (p > 0.05) 161 Journal of military pharmaco-medicine The correlation of the EULAR/ACR 2015 classification for gout scores with the frequency of recurrent... EULAR/ACR classification for gout marks Figure 1: The correlation between the EULAR/ACR 2015 classification for gout scores with the frequency of recurrence attacks of gout per year CONCLUSION