Demystifying Gout: Dr. Irina Raklyar's Expert Insights into Treatment and Management

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.

Transcript

Robert A. Kayal, MD, FAAOS, FAAHKS: 0:16

Hello and welcome to another edition of the Kale Ortho podcast. Today is January 30th 2024, and today's special guest is our very own Dr Irene Racklier. Dr Racklier is a board-certified fellowship trained rheumatologist at the Kale Orthopedic Center and we're so pleased and privileged to have you with us today, irene. Welcome to the podcast.

Irina Raklyar, MD: 0:37

Thank you for having me.

Robert A. Kayal, MD, FAAOS, FAAHKS: 0:38

First and foremost, Irene, for viewing my audience. Why don't you just take a minute and tell us a little bit about yourself and your family life and your profession in the field of rheumatology?

Irina Raklyar, MD: 0:48

I'm a board-certified rheumatologist. I grew up in New York City. I attended Brooklyn College and then SUNY Downstate Medical School, and I further went with my training to Washington DC. In Georgetown. I did my residency and fellowship there and eventually I moved back with my husband to the New York area. We landed in New Jersey with our family. I have two children, a boy and a girl.

Robert A. Kayal, MD, FAAOS, FAAHKS: 1:12

Yeah, we've been so privileged to have you. You've taken care of so many of our patients and we're just so thankful to have you in our practice and to share your expertise and to help us care for our community of patients. So you said you're a rheumatologist. What is a rheumatologist, irene?

Irina Raklyar, MD: 1:27

A rheumatologist is an internal medicine specialist that specializes in arthritis and autoimmune diseases.

Robert A. Kayal, MD, FAAOS, FAAHKS: 1:33

Got it. So in that field there's a subspecialty called inflammatory arthritis, right? What are some examples of inflammatory arthritis?

Irina Raklyar, MD: 1:43

Inflammatory arthritis is a subset of arthritis that's caused by inflammation in the joint. Examples include rheumatoid arthritis, gout, pseudo gout, psoriatic arthritis, ankylosing spondylitis, etc. We differentiate it from non-inflammatory arthritis, which is typically caused by osteoarthritis, which is just natural wear and tear of the joints or underlying mechanical issues in the joints that cause arthritis and joint pain.

Robert A. Kayal, MD, FAAOS, FAAHKS: 2:09

Yeah, you can see there are many differences between the traditional wear and tear osteoarthritis that people like myself take care of orthopedic surgeons. But you can see the need for a subspecialist such as Dr Irene Racklier in the field of rheumatology to care for these other types of arthritis. So, with respect to inflammatory arthritis, today's focus is going to be on the gout, a condition called the gout. So what is the gout, Irene?

Irina Raklyar, MD: 2:37

Gout is the most common inflammatory arthritis. It affects up to 6% of Americans, more common in men than in women, and it's typically. The hallmark of gout is typically arthritis flares that are intensely painful and debilitating. In between these flares patients will be asymptomatic. But over time, if gout goes untreated, the flares will become more frequent, more severe and those asymptomatic periods will shorten an interval.

Robert A. Kayal, MD, FAAOS, FAAHKS: 3:04

That's crazy 6% of the population.

Irina Raklyar, MD: 3:07

The incidence is also rising. It's increased in almost 50% since the 1970s and that tends to parallel the increase in cardiovascular disease and obesity and hypertension. As well.

Robert A. Kayal, MD, FAAOS, FAAHKS: 3:18

So we typically talk about gout in men, like you said, but women get it too right.

Irina Raklyar, MD: 3:22

Yeah, it's more common in women after menopause. Estrogen has a protective effect, tends to push uric acid out of the kidneys. But after, when women have menopause, the gout tends to become more common. It occurs in 2% of all women. I see a treat gout in both men and women on a daily basis.

Robert A. Kayal, MD, FAAOS, FAAHKS: 3:40

Estrogen has a protective effects in a lot of conditions like osteoporosis as well. Obviously, sometimes it's not so helpful in other conditions like cancers and stuff. But yeah, so we do see it in women. I think that's important to point out because a lot of people don't consider that diagnosis in women and think it's a condition that only occurs in men. So what is actually happening in this condition of gout?

Irina Raklyar, MD: 4:05

What happens in gout is it's the deposition of uric acid into the joints and it causes a process that's highly inflammatory. The blood level gets saturated with the uric acid and when it reaches a certain point, our cutoff 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, FAAHKS: 4:24

So what are some of the risk factors that are contributing to this elevation in uric acid?

Irina Raklyar, MD: 4:29

Well, uric acid is the unproduct of purine metabolism, which is an organic compound that we find in our diet and in other sources. Uric acid is typically excreted by 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 usually a combination of overproduction of uric acid or under excretion by the kidney. Overproduction of uric acid means that you're taking in too much through your diet or there's other risk factors, other conditions that can increase your uric acid levels, like thyroid issues or psoriasis or mild low proliferative disorders, but most commonly it's an issue at the kidney level. People are on medications that will treat high blood pressure or other issues that will dissuade your uric acid level from being excreted, and other comorbid conditions like high blood pressure or cardiovascular disease put stress on the kidneys and so, therefore, you're not able to excrete the uric acid level and it tends to accumulate in the blood.

Robert A. Kayal, MD, FAAOS, FAAHKS: 5:32

So you mentioned diet, so it sounds like there are some foods that you can consume, and maybe even beverages that contribute to the gut.

Irina Raklyar, MD: 5:39

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 commonly triggers for gut or that will raise uric acid levels, and those foods include seafood, such as shellfish or sardines or anchovies, red meats, particularly liver meats or organ meats, and sugar sweetened drinks like sodas, energy drinks, fruit juices. Conversely, vegetables that are high in purines, such as asparagus or cauliflower, and mushrooms, do not increase uric acid levels and will not promote gut.

Robert A. Kayal, MD, FAAOS, FAAHKS: 6:18

Alcohol as well.

Irina Raklyar, MD: 6:19

Alcohol as well. Yes, so alcohol, all types of alcohol. Beer tends to have a higher risk of increasing or causing gout flares than just a regular liquor or wine.

Robert A. Kayal, MD, FAAOS, FAAHKS: 6:29

Yeah, so typically these foods are broken down right Often by the liver. The liver will metabolize some of these foods and then the kidney will often try to excrete the uric acid. So that's why you mentioned sometimes there's a failure of some of it's basically a failure of metabolism, potentially right. So are there risk factors like family history that might continue as well.

Irina Raklyar, MD: 6:52

So genetics does play a component If you present with gout in your 20s or at a younger age. Gout typically presents in men at age 40s or 50s, women after menopause. If a patient presents with gout in their 20s, there's probably a high genetic predisposition to it. The other risk factors for gout are the high uric acid level, male gender, older age and the presence of being on medications that will increase uric acid levels, so diuretics or transplant medications in particular.

Robert A. Kayal, MD, FAAOS, FAAHKS: 7:21

But there is a condition called asymptomatic hyperureicemia, correct. So just because our uric acid levels are elevated, it doesn't mean that those patients are going to get the gout. Correct.

Irina Raklyar, MD: 7:31

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 high uric acid levels does not mean that you have gout, and that's something that I sometimes consult on as well. Patients will present with high uric acid levels and their primary care doctor will ask me if they need to be put on uric lowering therapy to prevent gout flares.

Robert A. Kayal, MD, FAAOS, FAAHKS: 7:53

Yeah, so a patient comes in the office and what is their typical complaint? When you start thinking along the lines of a differential diagnosis of gout?

Irina Raklyar, MD: 8:03

Yeah, so the presentation of gout is typically a hot, swollen joint. It's usually in the lower extremity, most commonly affecting the big toe or the ankle or the knee. It's a very fast onset. Usually we have a maximum onset between 12 and 24 hours. There might be some redness associated with it. Patients, the gout flares will be quite debilitating. The patients will complain that they're unable to bear weight on that joint. They're unable to tolerate any pressure. That's the typical gout flare.

Robert A. Kayal, MD, FAAOS, FAAHKS: 8:34

Unlike some of the other authorities that you manage, it tends to be what we call an oligoarthritis, correct? And it's often a monoearthritis as opposed to a bilateral condition, right? Can you elaborate on that?

Irina Raklyar, MD: 8:45

Right. So gout typically starts off in one joint. Over time, if gout goes untreated, it will start to affect more joints and that one joint in particular will become more and more severe attacks and eventually over time. One of the reasons why we do treat gout over the long term is that it will cause damage to the joints.

Robert A. Kayal, MD, FAAOS, FAAHKS: 9:03

But it's often the smaller joints, right, I guess. As opposed, like you don't typically see it, you do see it in the knee, but not so much the shoulder and not so much the hip, for instance right, right, right, right it's usually the smaller joints, but it can also affect some of the soft tissues around the joints, not just the joint itself. So for instance, the tendons, the tendon sheaths, sometimes like that. You'll see it show up that way, correct?

Irina Raklyar, MD: 9:27

So if gout goes untreated for about 10 years, you start to collect tophatous deposits and that's little collections of gout crystals and it can occur inside of the joints or outside of the joints, most commonly on the bursa, say, of the elbow, on the Achilles tendon. Sometimes we can see it in the pin of the ear, but it's collections of gout crystals that tells me, when I see tophi, that that patient certainly needs to be put on urethal lowering therapy and that the over all uric acid burden in the body is really quite high. And it's been that way for a long time.

Robert A. Kayal, MD, FAAOS, FAAHKS: 9:59

Right, so we talked about the presentation, the typical presentation. You also mentioned previously about some of the medical history, the patient's history of presinilinus, the family history, other medical comorbidities that might be contributing, such as even like renal disease, hypertension, metabolic syndrome. 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: 10:31

I look for that classic hot swollen joint. That's where I make the distinction between inflammatory arthritis and non-inflammatory arthritis. When I see if a patient complains of a joint that's been bothering them for a long time that doesn't have that classic asymptomatic period in between flares, then I'm less likely to think that it's gout. But the classic presentation is that hot swollen joint. When we see that hot swollen joint we always try and aspirate it, meaning taking fluid out of the joint, because the gold standard diagnosis for gout is seeing those uric acid crystals under the microscope. You're getting ahead of me, Sorry.

Robert A. Kayal, MD, FAAOS, FAAHKS: 11:07

So, dr Rackley you mentioned, you typically look for that red hot joint right. Does that sometimes suggest other conditions perhaps? Or is it always the gout?

Irina Raklyar, MD: 11:18

No other conditions can certainly cause a hot and swollen joint. Pseudo gout, which is almost a cousin of gout, a very similar presentation, but you see a different type of crystals under the microscope. Things like trauma, you know.

Irina Raklyar, MD: 11:31

Say, an ankle sprain or a fracture can start fracturing the big toe can certainly cause similar symptoms and any kind of infection in particular you know, cellulitis, osteomyelitis, septic arthritis just infection inside of the joint can have a similar presentation. As a rheumatologist, I'm also ruling out our other inflammatory authorities, including psoriatic arthritis and rheumatoid arthritis, which can, which can sometimes give you a similar presentation.

Robert A. Kayal, MD, FAAOS, FAAHKS: 11:59

Absolutely, and I'm so glad you mentioned all that, because when we do see patients with this presentation, the point that we'd like to drive home is that this same, fairly similar presentation can also be present with a whole myriad of other diagnoses. So we as clinicians form what we call a differential diagnosis. We listen to the patient's chief complaint, we take a history of their present illness, we look at their past medical history, et cetera, and then combine that with physical examination and other ancillary tests to form the final diagnosis. So this presentation of this red hot joint can be common with a whole plethora of other medical conditions, and it's certainly our job to help figure out what actually is causing the problem. So, case in point, we're going to show you an image of the classic presentation of a red hot joint and in this particular condition, the gout, where it's most commonly present.

Irina Raklyar, MD: 13:01

So this is a picture of the most classic presentation of gout. We call this pedagra. This is involvement of the first metatarsal phalangeal joint in the big toe of the foot. Again, gout is a hot, swollen joint and you can see the swelling. You can see the redness of the joint, this, if I were to touch it, a patient would probably wince in pain or jump off the table because it's really quite painful.

Robert A. Kayal, MD, FAAOS, FAAHKS: 13:27

Yeah, it looks painful. I mean, that looks something that you know. For me I'd say that's gout, that's infection. There's something angry going on. That patient is quite symptomatic and we didn't mention when gout presents in this toe in particular, in this joint in particular. The classic presentation is patients always complain at night when they're sleeping. That bedsheet can't even, you know, touch that area right. It's that type of excruciating pain.

Robert A. Kayal, MD, FAAOS, FAAHKS: 13:54

In orthopedics, anytime we're dealing with an inflammatory condition such as gout, calcific tendonitis, anytime there's a precipitation of crystals in the area, that sort of incites an inflammatory response that is extremely, extremely painful. For instance, calcific tendonitis of the shoulder. The presentation is very classic. These patients will often go to the emergency room in the middle of the night before even coming to see us the next day, just to find out they have a calcific tendonitis of their shoulder. So inflammatory conditions, inflammatory authorities, are debilitating and incapacitating. In general they're that kind of pain we call it like a 10 out of 10 pain, very much akin to a kidney stone. Right, a kidney stone is the same type of precipitation of calcium deposits and it incites that type of inflammatory response and that level of pain. Do you agree? Absolutely.

Irina Raklyar, MD: 14:51

So this next picture is a photo of a tophatia scout. What we're looking at is in the proximal interphalangeal joint of the patient's hand you can see this nodular swelling. This is not necessarily painful, but what this is is a collection of those uric acid crystals and it tends to collect in parts of the body they're a little bit cooler to touch or in the extremities, because that's where 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 time probably 10 years and it's been untreated and this is absolutely an indication to treat the underlying gout.

Irina Raklyar, MD: 15:35

If I were to take a look at the x-ray or do some kind of imaging, I would see damage inside of the joint. I would see swelling that looks like swelling on the x-ray as well. I would might see some of the gout crystals, because sometimes I'll be surrounded by a little bit of calcification and this is one of the primary indications to treat gout. When I look at this x-ray, I know that uric acid burden is really quite high in the body and this patient has a very high risk for cardiovascular disease as well and the uric acid levels are that high for that long of a time Uric acid levels. Uric acid will be a cardiovascular toxin, so it will predispose this patient to heart attacks and strokes and heart issues. When I see a patient like this, I tell them I'm not just treating your gout, I'm not just preventing damage, but I'm also lowering your risk for heart disease and heart attacks.

Robert A. Kayal, MD, FAAOS, FAAHKS: 16:25

So, Irene, regarding those two photographs that you so eloquently described, is it possible to convert? Is it possible for a patient to have one of those tophacious precipitations that is in a quiescent endowment state for a long period of time and then suddenly to get red and hot and inflamed?

Irina Raklyar, MD: 16:46

It can. You can certainly have a gout flare in the same location of the tophi, absolutely.

Robert A. Kayal, MD, FAAOS, FAAHKS: 16:52

Yeah, but the difference in that first picture where it was red and hot, that was active acute gout, as opposed to the other one which was what seemed to be an endowment state, quiescent endowment state and that was definitely indicative of a chronic gout condition, correct? Right Now that we discuss some of the photographs and we are really forming that differential diagnosis and deducing that this patient is going to be diagnosed with gout, are there other studies, radiographs, labs, CAT scans, MRIs, anything else you can order to really definitively diagnose the patient with the gout?

Irina Raklyar, MD: 17:30

When I see a patient for a suspected gout flare, I typically at that initial visit I will order blood work and I will order X-rays.

Irina Raklyar, MD: 17:37

The purpose of the blood work is one to check a uric acid level. Uric acid levels alone will not diagnose gout, but a high uric acid level will increase my suspicion for gout and it gives me a baseline when I start urate lowering therapy to treat the gout. In the blood work I'll also look for inflammatory markers like sedimentation rate and C-reactive protein. I'll do a regular panel of CBC and a comprehensive metabolic panel looking for kidney issues, looking for liver issues that one might be an end cause of the gout Gout can cause kidney stones and can cause kidney issues as well. In preparation for starting the patient on therapy and to help me decide which medications I will use to treat the gout flare that's why I do all of that blood work. I'll also typically do X-rays because I'm looking for evidence of prior gout damage. The indications for starting someone on urate lowering therapy include two or more gout flares in a year, seeing damage on an X-ray or the presence of the TOEFI.

Robert A. Kayal, MD, FAAOS, FAAHKS: 18:41

Can you have the gout within normal serum uric acid level?

Irina Raklyar, MD: 18:45

Absolutely. In fact, during episodes of inflammation, uric acid tends to be pushed out of the kidney, so you can't see normal uric acid levels in the time of the inflammatory arthritis.

Robert A. Kayal, MD, FAAOS, FAAHKS: 18:58

Are MRIs or CAT scans or ultrasounds warranted to help you make this diagnosis?

Irina Raklyar, MD: 19:04

MRIs are not so helpful unless you're trying to rule out concomitant causes of inflammatory arthritis. If you're looking for things that don't show up on an X-ray, like a sprain or a fracture or damage that looks like other types of inflammatory arthritis, like rheumatoid arthritis, there is a certain type of CAT scan that we can do. It's called a dual energy CT scan. That will pick up uric acid, toefi, in the joints. Sometimes that's helpful because you can't always aspirate a joint. You can't always take out the fluid to prove that it's gout. Sometimes we might order these other studies to help support our diagnosis of gout. We can also do ultrasound Ultrasound. There's a classic finding we call it the double contour sign, which shows uric acid within the joint. It requires a educated and experienced ultrasound technologists to look for that.

Robert A. Kayal, MD, FAAOS, FAAHKS: 20:00

Yeah, so, with respect to these images, they're fairly classic findings, like you mentioned, so let's discuss some of them, okay, so what are we looking at here, irina?

Irina Raklyar, MD: 20:10

We're looking at a lateral x-ray view of the elbow. The elbow joint in particular is intact, but you can see this dense swelling, this radiopaque swelling outside of the joint. There's fluid in the bursa. The bursa is a little pocket of fluid that sits outside the elbow joint. That helps protect the joint and it's commonly a site for uric acid deposits and for gout inflammation. And what we're seeing is swelling inside the joint. You can almost see it hanging off of the joint because there's a lot of fluid and inflammation going on in there.

Robert A. Kayal, MD, FAAOS, FAAHKS: 20:45

Absolutely. I mean it looks like a small little 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 that lecronon bursitis, and certainly the x-ray, the radiograph, would be very different than this projection right here. You can see, in this soft tissue swelling it is much more dense than fluid. Fluid would be almost black in nature on this radiograph, whereas this one has a more whitish appearance, approaching that density of bone. So clearly there's some precipitation here, some collection of some type of deposit of some sort, and this would be highly suggestive potentially of an inflammatory arthropathy of some sort and in this particular case, likely the gout. So let's talk about another one, dr Racklier. So, dr Racklier, let's compare and contrast now this radiograph to the elbow that we just previously discussed. What are you finding here?

Irina Raklyar, MD: 21:48

So this is an x-ray photograph of the hand and the wrist showing chronic gouty arthropathy. You can see the presence of TOFI, which is that swelling outside of the joints as well, and you can see damage inside the joints. If we were to compare to normal joints first, if we take a look at the third and the fourth finger MCP joints, metacarpophalangeal joints, those are relatively normal joints. The joint space is even symmetrical, the contours of the bone are smooth and rounded and those look relatively preserved. If we were to contrast it with the first and the fifth finger MCP joints, then we see the classic gouty damage On an x-ray. You see overhanging edges, you see sclerotic margins Rheumatologists call them rat bite erosions because it looks like a rat has bitten into them and you can see them at the MCP joints. You can see some damage at the PIP joints, the proximal interphalangeal joints, and you can also see it at the wrist as well. So this is a classic x-ray of chronic gouty arthropathy.

Robert A. Kayal, MD, FAAOS, FAAHKS: 22:53

Severe erosions, osteolysis, punched out, lesions, and this is very, very, very advanced gout.

Irina Raklyar, MD: 23:02

It's unfortunate because when we see damage like this, we can't undo. Bony damage we can prevent. My goal as a rheumatologist is obviously to help the patient feel better, but it's also to prevent bony damage. Once I see damage like this, I can't undo it. Even if I get the patient feeling better and free of gout flares, he or she still might have joint pain in the hands because of damage that's already done.

Robert A. Kayal, MD, FAAOS, FAAHKS: 23:27

Great point, great point. So, dr Ackley, are you mentioned that the classic gold standard for making this diagnosis is biopsy and evaluation for crystals on microscope? However, sometimes we're unable to get the fluid out of the joint and in those particular cases, either there's no fluid or the joint is too small to aspirate. You had mentioned that sometimes we can do a dual energy CAT scan. So this next image we're going to show you is a classic example of a dual energy CT, where we can pick up lesions consistent with TOFI and urethric precipitation for smaller joints where we are unable to aspirate that fluid. So can you please describe what you're seeing here?

Irina Raklyar, MD: 24:20

So sometimes when we have a patient presenting with tophatious gout, it can have nodules or deformities or hard deposits that are not necessarily easy to take fluid out of. So therefore we may order this dual 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 the CT scan that will help light out these gout crystals In this patient in particular. The green is those tophatious deposits. The purple usually represents keratin or other calcium materials and those are otherwise benign, but the green is proof that there is the TOFI uric acid crystals in that joint. Sometimes we might also do serial dual energy CT scans. If we are looking at those tophatious deposits, if our goal is treating them and to melt them away, we like to do serial dual energy CT scans and see how they are resolving over time.

Robert A. Kayal, MD, FAAOS, FAAHKS: 25:15

Fantastic, thank you. We talked about how we can make the diagnosis both on physical examination and imaging modalities ultrasound, x-ray, etc. Utilizing blood work as well to help with the diagnosis. But really the gold standard is what?

Irina Raklyar, MD: 25:33

Gold standard is a synovial fluid aspiration is pulling fluid out of the joint, taking a look at it under the microscope and proving that there's gout crystals.

Robert A. Kayal, MD, FAAOS, FAAHKS: 25:42

Right, because we talked that there could be some overlap both on physical examination and on history, and even on x-rays with certain conditions. So biopsy is the gold standard. So, for instance, when somebody comes 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 if that water in the knee is from arthritis, a meniscus tear, an infection, torn ligament, possibly even inflammatory orthopathy. So very often I'll end up draining that knee. I'll do what's called a knee joint aspiration.

Robert A. Kayal, MD, FAAOS, FAAHKS: 26:18

If the joint fluid is normal, it's most likely mechanical in nature, meaning a meniscus tear or arthritis, something like that.

Robert A. Kayal, MD, FAAOS, FAAHKS: 26:27

If it's bloody, I might think along the lines of is this a fracture, is this an ACL tear or something like that. If it's filled with pus, I'm concerned 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 an infection. And finally, if it's somewhat inflammatory, cloudy and it appears that maybe there's some precipitation going on, I may be concerned that this is inflammatory in nature and this patient may have to be referred to Dr Rackler for evaluation. So what we'll do is we'll take that fluid and we'll send it to the lab and if we're checking for infection, we'll typically check a gram stain check for cultures and sensitivity. But we always are trained to check for cell count with differential as well as crystal analysis. So we always want to make sure that we're not dealing with an inflammatory condition, an infection or other condition. So it's not common to have infection superimposed on inflammatory conditions and vice versa, but it can happen right.

Irina Raklyar, MD: 27:37

It can certainly happen, even when you have an established diagnosis of gout. It's always a good idea to get that aspiration, because there's no reason why it can't be an infection and gout at the same time 100%.

Robert A. Kayal, MD, FAAOS, FAAHKS: 27:48

So you look, you're drawing the fluid. Anyway, we like to test it. I test it for everything Cell count with differential, gram stain, with culture and sensitivity, and certainly crystal analysis. Every single aspiration gets tested for all that, and so when we take this fluid out and the gram stain comes back negative, there's no infection. What are we looking for with respect to what's called the 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 not infected? Is it inflammatory? What are you looking for, dr Reckler?

Irina Raklyar, MD: 28:24

So normal synovial fluid will have anywhere from zero to 2,000 white blood cells. In any kind of inflammatory state you'll have more than 2,000 white blood cells. In the setting of gout or infection you can have tens of thousands of white blood cells. The differential will be skewed more towards neutrophils, which is the active subset responsible for inflammation. And then we look for the crystal analysis, because besides gout crystals there's other types of crystals that can cause inflammation in the joint 100% and sometimes you get a white count.

Robert A. Kayal, MD, FAAOS, FAAHKS: 28:58

That's borderline. You may get like a 40,000 or 45,000 white count and that's sort of borderline. Traditionally I think most of us would say over 50,000 or in that range. We're starting to think really about an infection anywhere from, like she's saying, 2,000 to 20, 30, up to 40,000. It's typically inflammatory nature. But that's where this differential comes into play. We always order that tap by saying cell count with differential and she's focusing on the neutrophils. So we call that a shift to the left. If there's an elevated number of neutrophils, a percentage of neutrophils, it makes us quite concerned about more than likely an infection. So, dr Rackler, what are we looking at here now on this slide?

Irina Raklyar, MD: 29:47

We are looking at the presence of uric acid crystals, gout crystals, under a polarizing microscope. It has the classic needle shape appearance. It's negatively birefringent on the polarizing microscope and these are classic for gout. Meaning negatively birefringent, meaning that in one direction it looks yellow, but in the other direction it looks blue. But it has that classic appearance.

Robert A. Kayal, MD, FAAOS, FAAHKS: 30:13

Yeah, and this is something a pathologist would see under the microscope when we draw that fluid out of that patient's joint and send it to the lab, right? So we're waiting, sometimes a couple of days, for reports to come back whether or not there were crystals in the fluid and in this particular case, this is the classic slide presentation of someone that would be absolutely confirmed with the diagnosis of the gout.

Irina Raklyar, MD: 30:38

Sometimes we send rheumatologists will send our patients to our orthopedic surgeon colleagues to remove TOFI, especially if they're deforming or cosmetically unappealing or if they're located in areas where there's a lot of irritation, say the elbow or the hand. And when we look at the TOFI under the microscope we see sheets and sheets of these uric acid crystals. Interesting.

Robert A. Kayal, MD, FAAOS, FAAHKS: 31:02

Great, all right. So now that we've made the diagnosis definitively on biopsy right the gold standard we have to treat these conditions right. So what is your first line of treatment?

Irina Raklyar, MD: 31:15

So there's a couple of medications that we use to treat gout and we all we choose which medication we use based on the other comorbid conditions. Typically, the first line medications used to treat gout are colchicin, steroid or steroids or anti-inflammatory medicines. Colchicin is one of our oldest medicines in medicine. It's been around since the sixth century. It's used to treat inflammation. Steroids can be injected into the joint or can be taken orally or less commonly, you can give it through an IV or intramuscularly, and anti-inflammatory.

Irina Raklyar, MD: 31:53

Anti-inflammatory medicines are the common medicines that are typically over the counter, but we use it at anti-inflammatory doses and which one we choose really depends on what else is going on in the body. If the patient has a prior medical history of gastric ulcers or if they're on blood thinners, then we tend to avoid oral steroids or we tend to avoid the anti-inflammatories. If there is a question that there might be some underlying infection there as well, then we tend to avoid a steroid. So if the patient has kidney issues, then we tend to avoid the colchicin and the anti-inflammatory. So that's why we do the blood work in addition at that first visit to decide which medication would be appropriate and which route would be most appropriate.

Robert A. Kayal, MD, FAAOS, FAAHKS: 32:37

Right. In my experience as a North Peak surgeon, when I see these patients it's sometimes tough because they're in so much pain, like we've described, and you want to treat them so badly with a cortisone injection. But we're forced to hesitate because that's the last thing in the world we'd want to do if there was a local infection and the presentation of aseptic arthritis and acute gout flare go hand in hand. There's a tremendous amount of overlap. So a lot of times we don't really know if it's the gout or if it's aseptic or infected joint, and so time is of the essence for us to get the results of this, and the steroids, whether orally or injected locally, would be detrimental if in the face of infection. So it's restricting somewhat until we get that definitive diagnosis Right. All right, so we have to treat them with the anti-inflammatories.

Robert A. Kayal, MD, FAAOS, FAAHKS: 33:37

There's also other things that we have to do. Sometimes gout, as we alluded to previously, is primary in nature and sometimes it's secondary in nature. Right, if it's primary in nature, a lot of times we'll recommend a low purine diet, some type of nutritional counseling. If they're drinking a lot of alcohol, we'll ask them to refrain, because certainly that's contributory, especially the beer If they're eating a lot of red meats or shellfish or different types of fish. That certainly can increase the likelihood. But sometimes it's secondary gout, secondary to some metabolic conditions or other medical conditions, and so, just like any other secondary condition, the onus is on us to make that diagnosis and to make sure that that primary disorder gets treated and then the secondary manifestation of that condition often disappears. Right.

Irina Raklyar, MD: 34:34

So acute gout flare will typically last three to 10 days. Sometimes it can last for several weeks. But people will often seek out care for their gout flare, for prompt resolution of pain and for restoration of the mobility of the joint. Like I said, the joint will be very tender, unable to bear weight. People won't be. Especially, it affects the lower extremity. People won't be able to walk on that foot. So what I will do when I treat the gout flare is I will review all of the other medications that they're on, look at all of the other comorbid conditions that are going on and choose a therapy that's appropriate for them. That's not going to necessarily worsen the other things. That are the other medications that are there.

Robert A. Kayal, MD, FAAOS, FAAHKS: 35:17

With respect to the treatment of the gout, when I was in training 30 years ago or so, it was always the triad of usage of endomethacin, which is an anti-inflammatory, non-steroidal anti-inflammatory colchicin and I was told to take, I was told to prescribe, 0.6 milligrams of colchicin TID until the patients either develop nausea, vomiting, diarrhea or relief of their symptoms, and then possible use of allopurinal for prevention of recurrences. Because my training was that as patients get older, the bouts become more severe and closer in proximity to one another as well. Is that still the thought process?

Irina Raklyar, MD: 36:00

So the way that we treat acute and chronic gout differs. We don't use colchicin at those doses anymore. The most common side effect of colchicin is GI issues and diarrhea. So to put some patient on super therapeutic doses of colchicin and have them running to the bathroom with their arthritic gout flare seems savage. So we don't use-.

Robert A. Kayal, MD, FAAOS, FAAHKS: 36:27

I was saying would you rather have diarrhea or would you rather have a gout attack? We'd rather have not, we'd rather treat.

Irina Raklyar, MD: 36:32

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 kidney function. We extend the dose of the colchicin or the anti-inflammatory for up to 10 days because that's how long it'll usually take to treat a gout flare. We typically don't start your allopurinol or urate lowering therapy at that visit for the acute gout, just because it's very overwhelming. The patient is already coming to see you. They've been suffering with this gout flare, they're looking for treatment and to put them on multiple medications at that visit is very overwhelming for the patient.

Irina Raklyar, MD: 37:08

A lot of times. If we start them on the long-term treatment at the time of the acute gout flare, what might happen is that once the gout flare resolves they might stop the long-term treatment, also thinking that they're fixed. So we typically divide it into two visits One where I treat the gout flare, I get my information to think about what I'm going to be using for long-term therapy and then have them come back a week or 10 days after the gout flare has ended and we talk about chronic therapy, how to decrease the uric acid levels for the long-term, and that's when I also do the education about diet and lifestyle modifications.

Robert A. Kayal, MD, FAAOS, FAAHKS: 37:47

That's great, and in your experience you've actually seen a lot of these TOFI disappear right over time.

Irina Raklyar, MD: 37:53

Yeah, TOFI will disappear with urate lowering therapy. It doesn't happen immediately. It can take about six months to a year. For patients who have polyarticular TOFI tophatous deposits, If they have a lot of joints or if they have deforming arthritis, there is a very potent IV medication that we can use that will melt it away. But it really is reserved for the appropriate patients.

Robert A. Kayal, MD, FAAOS, FAAHKS: 38:16

Got it. So, dr Rechler, I know we focused our attention a lot on the treatment of the acute gout condition, but how do we treat chronic gout, the patient that's suffering from long-term gout?

Irina Raklyar, MD: 38:28

So we have a different subset of medications that we use to treat gout, but the cornerstone of there cornerstone is urate lowering therapy, decreasing the uric acid levels in the blood. Our goal is to decrease it to under six. If they have the presence of this TOFI, we decrease it to under five. The medications that we use are all medications that lower uric acid levels. That includes allopurinol, which has been around since the 1960s. That's kind of the go-to medicine. Fibuxa stat is a newer medication that also lowers uric acid levels and we have peglotticase, which is an IV medication which also very rapidly drops the uric acid levels.

Irina Raklyar, MD: 39:08

We use a treat-to-target approach, meaning that our goal is to get it on the uric acid levels under six or five. But initially, when we first start uric acid levels, uric urate lowering therapy, there's actually a paradoxical high risk for having a gout flare. So when we start the patient on medications we have a two-prong approach a medicine that lowers uric acid levels and a medicine that's used to prevent uric acid flares. During that time Uric acid level doesn't just naturally drop, it fluctuates and then it drops. So we'll typically use some kind of prophylaxis at the same time when the uric acid level becomes therapeutic and it stays that way for six to 12 months, we peel back on that second medicine and they're just left on that one-year lowering therapy, probably for the rest of their life.

Robert A. Kayal, MD, FAAOS, FAAHKS: 39:58

Well, it's gotten a lot more complicated since I started 25 years ago. So it's a little bit different than the endomethacin BID and Coltocene 0.6 TID right.

Irina Raklyar, MD: 40:10

Yeah Well, we have a lot more knowledge of gout, there's a lot more science behind it and we're a lot more effective at treating gout and making it easier for the patients as well.

Robert A. Kayal, MD, FAAOS, FAAHKS: 40:19

Well. I thank God that we have doctors like you at the KAL Orthopedic Center. It's been such an honor to work alongside you. You're a walking encyclopedia in the field of rheumatology and when I began this interview I thought I was talking to chat GPT. I praise you every time I make a referral of our patients to you because you are absolutely brilliant in this field and it's such an honor to have you here. So thank you so much. Don't correct me.