GOUT:DIAGNOSIS AND MANAGEMENT

GoutMetabolic disorder due to excessive Metabolic disorder due to excessive accumulation of uric acid in tissues accumulation of uric acid in tissues leading to acute and chronic arthritis leading to acute and chronic arthritis and soft tissue and bone deposition of and soft tissue and bone deposition of uric acid (tophi).uric acid (tophi).

Abrupt onset often at night

75% of initial attacks in first MTP joint

Usually monoarticular, may be polyarticular

Attack subsides in 3-10 days

Na+ urate crystals in synovial fluid

Hyperuricemia may or may not be present

Acute Gouty ArthritisAcute Gouty Arthritis

The victim goes to bed and sleeps in good health. About 2 o’clock in the morning he is awakened by a severe pain in the great toe; more rarely in the heel, ankle or instep.

The pain is like that of a dislocation, and yet the parts feel as if cold water were poured over them…Now it is a violent stretching and tearing of the ligaments – now it is a gnawing pain, and now a pressure and tightening.

So exquisite and lively meanwhile is the feeling of the part affected, that it cannot bear the weight of the bedclothes nor the jar of person walking in the room. The night is spent in torture. - Thomas Sydenham (1624-1689)

QUESTION: Who gets gout?

ANSWER: Individuals with prolonged hyperuricemia

So who gets hyperuricemia?

Overproduction (10%)

(80 % idiopathic)

Ethanol

HGPRT or G6PD deficiency

PRPP synthetase overactivity

Myeloproliferative disorders

Cytotoxic chemotherapy

Sickle-cell anemia

HyperuricemiHyperuricemiaa

HyperuricemiHyperuricemiaaUnderexcretion (90%)

(80% idiopathic)Renal insufficiencyDrugs and toxins

–Diuretics

–Ethanol

–Cyclosporine A

–Pyrazinamide

–Lead nephropathy

–Low dose aspirin

Ketosis

So who gets gout?

Young and middle-aged menYoung and middle-aged men Individuals with hypertension, obesity,renal Individuals with hypertension, obesity,renal

insufficiency, metabolic syndrome, organ insufficiency, metabolic syndrome, organ transplantstransplants

Patients on diureticsPatients on diuretics Beer drinkersBeer drinkers

Who doesn’t get gout?

WomenWomen UnlessUnless

Post-menopausalPost-menopausalRenal insufficiencyRenal insufficiencyChronic diuretic useChronic diuretic useMyeloproliferative disorderMyeloproliferative disorder

The prevalence of gout is increasing Patients with CHF and renal disease are Patients with CHF and renal disease are

surviving longersurviving longer Obesity/metabolic syndrome epidemicObesity/metabolic syndrome epidemic More organ transplantsMore organ transplants Less estrogen usedLess estrogen used Low dose aspirin useLow dose aspirin use

GOUT: DIAGNOSIS

PresentationPresentation Patient demographicsPatient demographics Physical findingsPhysical findings Differentiate from:Differentiate from:

SepsisSepsis RARA Spondyloarthropathy(psoriasis, reactive)Spondyloarthropathy(psoriasis, reactive) LymeLyme

GOUT: DIAGNOSIS

Arthrocentesis and crystal identificationArthrocentesis and crystal identification Serum uric acid may be misleading and is Serum uric acid may be misleading and is

not a good diagnostic test for acute gout.not a good diagnostic test for acute gout.

TREATMENT OF ACUTE GOUT

NSAIDSNSAIDS Intra-articular steroidsIntra-articular steroids PrednisonePrednisone ColchicineColchicine

PO – no funPO – no fun IV – be careful (limited availability)IV – be careful (limited availability)

TREATMENT OF RECURRENT GOUT

PO daily low-dose colchicinePO daily low-dose colchicine Colchicine neuromypathyColchicine neuromypathy

Lower serum uric acid levelLower serum uric acid level

TREATMENT OF HYPERURICEMIA: INDICATIONS

Repeated or severe acute gout attacksRepeated or severe acute gout attacks Patient preferencePatient preference Tophaceous/erosive goutTophaceous/erosive gout Chemotherapy of hematologic Chemotherapy of hematologic

malignanciesmalignancies NephrolithiasisNephrolithiasis

Treatment of Hyperuricemia

Decrease uric acid productionDecrease uric acid production AllopurinolAllopurinol Febuxostat (Uloric)Febuxostat (Uloric)

Uricosuric agentsUricosuric agents ProbenecidProbenecid SulfinpyrazoneSulfinpyrazone

TREATMENT OF HYPERURICEMIA: ALLOPURINOL/FEBUXOSTAT

Marked hyperuricemiaMarked hyperuricemia Increased urinary uric acid excretionIncreased urinary uric acid excretion Tophaceous or erosive goutTophaceous or erosive gout Renal insufficiencyRenal insufficiency NephrolithiasisNephrolithiasis

TREATMENT OF HYPERURICEMIA: URICOSURICS

Low urinary uric acid excretionLow urinary uric acid excretion Mild renal insufficiencyMild renal insufficiency

(Probenecid, sulfinpyrazone)(Probenecid, sulfinpyrazone)

TREATMENT PEARLS

Aspirin makes gout worse.Aspirin makes gout worse. Allopurinol/febuxostat is a treatment for Allopurinol/febuxostat is a treatment for

hyperuricemiahyperuricemia and not acute gout. and not acute gout. Giving allopurinol or febuxostat during an Giving allopurinol or febuxostat during an

acute attack will prolong the attack.acute attack will prolong the attack. Starting allopurinol/febuxostat may provoke Starting allopurinol/febuxostat may provoke

attacks.attacks. Therefore add colchicine for 6-12 mos.Therefore add colchicine for 6-12 mos.