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The GOUT C. T. Allred, M.D. 2/4/10

The GOUT C. T. Allred, M.D. 2/4/10. Clinical Syndromes. Acute gouty arthritis – the first episode. Usually preceded by hyperuricemia for years First MTP joint (podagra - 50%), other foot joint, ankle or knee in 30% of first time cases.

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The GOUT C. T. Allred, M.D. 2/4/10

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  1. The GOUTC. T. Allred, M.D. 2/4/10

  2. Clinical Syndromes • Acute gouty arthritis – the first episode. • Usually preceded by hyperuricemia for years • First MTP joint (podagra - 50%), other foot joint, ankle or knee in 30% of first time cases. • Usually monoarticular (80%) with first case. Can be polyarticular in recurrent cases. • First episode is frequently excruciating building up over several hours, to the point a person cannot stand to have a sheet touching.

  3. Acute gout • The redness is sometimes shiny, sometimes dull. • Warm. • Very tender to touch.

  4. Acute gout • Other common areas of affliction.

  5. Acute gout

  6. Acute gout

  7. Gout risk factors • “Classic” – an obese,hypertensive man, age 30 to 50, frequent imbiber of alcohol (especially beer)

  8. Gout risk factors • Women = men over age 65. • Trauma to joint. • Hospitalization for anything. (20% of gout sufferers will have an attack in hospital.) • Diet high in meat and fish. • Chronic renal insufficiency.

  9. Gout risk factors • Medications: • Diuretics – thiazides and furosamide. • Nicotinic acid (niacin). • Aspirin. • Cyclosporine (gengraf, neoral). • Ehtambutol. • Pyrazinamide. • Levodopa.

  10. Gout Dx. • Pt. may be febrile. • WBC may be elevated. • ESR 50 to 80 range. • CRP elevated. • Uric acid may be normal 20 to 40% of the time at the time of the attack. • Definitive dx. – intracellular monosodium urate crystals in synovial fluid.

  11. Definitive dx. – intracellular monosodium urate crystals in synovial fluid.

  12. Gout – presumtive dx. without arthrocentesis • A classic history of one or more episodes on monoarticular arthritis followed by periods completely free of symptoms. • Max. inflamation within 24 hours. • Rapid resolution with colchicine tx. • Podagra. • Hyperuricemia. • Subcortical bone cysts apparent on x ray.

  13. Differential dx. • Septic joint. • Pseudogout – calcium pyrophosphate dihydrate crystal arthropathy. Usually knee or wrist. • Reactive arthritis. • For polyarticular arthritis, RA, SLE, psoriatic, etc. • Always consider the background info.

  14. X ray in gout

  15. Treatment of acute gout • Colchicine 1.2 mg stat, then .6 mg q 2 hours until relief or 6 mg. • Problem is virtually everyone gets N/V and/or diarrhea after about 3 doses. • If it works, suggestive but not diagnostic of gout. • Other serious problems – renal and hepatic injury, CNS dysfunction, neuromyopathy especially in elderly or those with decreased renal or liver function.

  16. Treatment of acute gout • NSAIDs: • Indocin 50 mg q 6 to 8 hours x 24 to 48 hours, then decrease to 25 tid x 3 to 5 days. • Works well. Highest risk of GI bleed of NSAIDs. • Ibuprofen 800 mg q 8 hours x 24 to 48 hours, then 400 to 600 tid x 3 to 5 days. • Naprosyn 750 mg first dose, then 250 tid x 2 days, then bid x 3 days. • Almost any other NSAID will work if high enough doses. Start early!!!!!

  17. Treatment of acute gout • NSAIDs • The usual problem is renal insufficiency, hypertension, heart failure, ulcers or bleeding that keeps one from utilizing. • Again start early.

  18. Treatment of acute gout • Corticosteroids • Prednisone 40 to 60 per day x 2 to 3 days, then taper over 3 to 7 days. • Triamcinolone 40 to 60 mg IM x 1. • Intra-articular injection, dose dependent on the joint. • Have to make sure you have the diagnosis before injecting.

  19. Hyperuricemia • Treat when gout 2 to 3 x per year. • Asymptomatic and uric acid > 12. • Tophaceous gout. • Gout and any history of kidney stones. • Gout with renal insufficiency. • Acute uric acid nephropathy.

  20. Hyperuricemia tx. • Most patients are underexcreters – 85%. • Those pts could be treated with uricosuric drugs – probenecid and sulfinpyrazone. • Probenecid is well tolerated. • Can’t use if kidney stones, renal insufficiency. • Some drug interactions. • Need to produce at least 1500 ml urine per day. • Start at 250 mg bid increasing to 1000 mg 2 to 3 x/d over several weeks. • Target is < 6 uric acid level. • Need a 24 hour urine for uric acid to demonstrate not an overproducer.

  21. Hyperuricemia tx. • Xanthine oxidase inhibitors: • Allopurinol • Start at 100 mg/d for 2 weeks and increase by 100 mg bid every two weeks until at 300 mg/d. • Increase dose thereafter to achieve uric acid < 6. • Adjust dose for creatine clearance less than 80 ml/mim. • Drug interactions – cyclophosphamide, azathioprine, mercaptopurine. Increase incidence of rash with ampicillin. • Problems: 3 to 5% develop rash, leukopenia, thrombocytopenia, diarrhea, and drug fever. • 1 in 1000 will develop allopurinol hypersensitivity syndrome – rash, fever, hepatitis, eosinophilia, acute renal failure with up to 25% mortality.

  22. Hyperuricemia tx. • Xanthine oxidase inhibitors: • Febuxostat (Urolic) • A new drug. • Same drug interactions. • Expensive compared to allopurinol. • Start at 40 mg/d, increase to 80 if not at goal in 2 to 4 weeks. • Monitor LFTs “periodically.” • Increased incidence of CV events compared to allopurinol.

  23. Hyperuricemia tx. • Colchicine prophylaxis • .6 mg 1 to 2 x/d depending on creatine clearance. Don’t use if less than 10 and take q 2-3 days if 10 to 20. • Use the first 3 to 6 months when instituting uric acid lowering therapy. • Rasburicase (elitek) • IV med to be used to prevent tumor lysis syndrome.

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