Presentation on theme: "GOUT Disease caused by tissue deposition of Monosodium urate crystals as a result of supersatuaration of extra cellular fluid with MSU."— Presentation transcript:
1GOUTDisease caused by tissue deposition of Monosodium urate crystals as a result of supersatuaration of extra cellular fluid with MSU.
2Hyperuricemia Serum uric acid above normal level for age and sex. >7mg for adult men and > 6mg for adult women.Only 15-20% of all patient with hyperuricemia develop gout.Why we produce uric acid :End product of purine metabolism but human do not have enzyme uricase to convert it to allantoin (highly soluble)
3Mechanism of Hyperuricemia PURINES DEGREDATION PRODUCTOVERPRODUCTION OF URATEENDOGENOUS OR EXOGENOUSUNDEREXCRETION OF URATE (RENAL)90% OF GOUT PATIENTCOMBINATION OF THE ABOVE TWO
4EPIDEMIOLOGY Disease of adult men with peak in 5th decade. Very rare before puberty and in premenopausal women.Less than 25% of hyperuricemic develop GOUTDuration and serum uric acid directly correlate with Gout development20% family history
5Primary Under excretion: Idiopathic 90% of patients with hyperuricemia.Normal excretion of uric acid only when serum uric acid highOver production :rareIdiopathicHypoxanthine-guanine phosphoribosyltransferase deficiencyPhosphoribosyl-1-pyrophosphate synthetase super activity.
6ACQUIRED CAUSES OF HYEPERURICEMIA URATE OVERPRODUCTIONExcess dietary purine consumptionAccelerated ATP degradation : alcohol abuse,glycogen storage disease,Myeloproliferative and Lymphoproliferative disorders both causing increased nucleotide turnover.
7ACQUIRED CAUSES OF HYEPERURICEMIA Urate under excretionRenal diseasePoly cystic kidney diseaseHyperparathyroidismHypothyroidismHypertension
9ALCOHOL MECHANISM OF HYPERURICEMIA Increases lactic acid production which reduces renal excretion of urate.Increases Urate synthesis because of increased ATP degradation.Beer also contain purine guanosine.
10Stages of Gout Prolonged a symptomatic hyperuricemia(years) Acute intermittent GoutChronic tophaceous Gout
11GOUT: CLINICAL MANIFESATATION Recurrent Gouty Arthritis( articular and periarticular.TophiUric acid urinary calculiInterstitial nephropathy with renal function impairment
24MANAGEMENT OF ACUTE GOUT NSAID:indomethacin used more than other NSAIDs my use any other NSAIDs at full dose like ibuprofen 800mg TID or Naprosyn 500mg bid expect to as effective as indomethacin and my be less toxicKnow NSAID toxicitiesKnow NSAIDs contraindications,
25CONTINUE ACUTE GOUT MANAGMENT Colchicine: 0.6-1mg bid oralLimited because of toxicityMain side effects GI :abdominal pain/diarrhea/nauseaNeed adjustment in renal impairmentMay cause myelosuppressionMay be linked to azospermia and infertilityIV Colchicine very toxic to bone marrow
26CONTINUE ACUTE GOUT MANAGEMENT Steroids safe for acute management with fast results,and when NSAID and Colchicine use not warrantedIntra-articular injection of triamcinolone is fastest way to get relief ,at the same time can get synovial fluid for analysisOral or parentral steroids e.g.:prednisolone oral mg daily for 5-7 days ,equivalent doses of IV steroids may be used if unable to take oralAlways make sure no infection coexist.
27Prophylaxis Till hyperuricemia controlled May use ColchicineNSAID
28Prevention and control of hyperuricemia indications 1-recurrent attacks of Gout2-renal stones3-tophaceous Gout4-chronic gout with joint damage and erosions5-hyperuricemia uric acid > 12mg/dl6-24 hr urine excretion of >1100 mg uric acid
29Uricosuric agents Probencid,sulfinprazone Who is good candidate1-age <602-Creatinine clearance >50ml/min3-24 hr urine of uric acid < 700mg(under excretion)4-No history of renal stone
30Xanthine oxidase inhibitor Allopurinol Hyperuricemia with :Urinary uric acid >1000mgUric acid nephropathyNephrolithiasisBefore chemotherapyRenal insufficiency GFR<50Allergy to Uricosuric agents
31Allopurinol Average dose 300mg Renal impairment use lower dose May precipitate acute gout when first usedSide effects can be very serious range from dyspepsia,headache,diarrhea,rash,to more severe including fever,esosinophilia,interstitial nephritis,hepatitis,vasculitis,acute renal failure,toxic epidermal necrolysis,and hypersensitivity syndrome.
32Gout in transplnatPatient usually on Steroids,azathioprine,cyclosporineColchicine and NSAID use potentially toxicAllopurinol increase level of azathioprine and toxicitySteroids intra-articular ,oral or parentral can be usedMay need adjust or change transplant medications