Clinical Case #6 By Chen, chun-Yu (Kim) Chen, I -chun (Afra) Chen, I -chun (Afra)

When he was 30 years old, a construction worker developed redness and swelling of the instep of his right foot without a recognized antecedent injury. The affected area was intensely painful and tender. Hot soaks were applied, and after 10 years he was able to return to work. When he was 30 years old, a construction worker developed redness and swelling of the instep of his right foot without a recognized antecedent injury. The affected area was intensely painful and tender. Hot soaks were applied, and after 10 years he was able to return to work. During the following 2 years, he experienced increasingly frequent episodes of intense inflammation of joints of the feet. The swelling and pain persisted for longer and longer periods of time. In one attack where he developed a swelling on the back of his heel, he went to his physician, who diagnosed gout and prescribed high dose colchine. During the following 2 years, he experienced increasingly frequent episodes of intense inflammation of joints of the feet. The swelling and pain persisted for longer and longer periods of time. In one attack where he developed a swelling on the back of his heel, he went to his physician, who diagnosed gout and prescribed high dose colchine. His serum uric was 12 mg/dl and urate monohydrate crystals were isolated from an ulcerated tophaceous mass on his heel. His serum uric was 12 mg/dl and urate monohydrate crystals were isolated from an ulcerated tophaceous mass on his heel.

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1.what is the primary therapeutic objective during an acute attack of gouty arthritis? Answer: Answer: Arthritis is treated first and hyperuricemia later 。 Arthritis is treated first and hyperuricemia later 。

2.Should immediate steps be taken to lower serum uric acid ?Why or why not ? Answer: Answer: no,because sudden reduction often precipitates further episodes of gouty arthritis no,because sudden reduction often precipitates further episodes of gouty arthritis

3.What drugs can be used to prevent a recurrence of gout until serum uric acid levels are reduced ? -NSAIDs: -NSAIDs: -Colchicine -Colchicine -corticosteroids -corticosteroids -analgesics -analgesics

4.Describe the actions of the 2 classes of drugs available for the control of hyperuricemia? NSAIDs and Uricosuric drugs NSAIDs and Uricosuric drugs –NSAIDs  Reduce inflammation caused by leukocytic reactions to the deposition of uric acid crystals.  NSAIDs block prostaglandins, the substance that dilates blood vessels and causes inflammation and pain of gout. –Uricosuric drugs  Inhibit the reabsorption of uric acid by a weak acid carrier mechanism at the proximal part of nephron  Work by helping the kidneys get rid of the excess uric acid produced in the body.

5.What factors determine which of these drug to use for treatment? In acute gout attacks NSAIDs, colchicine, and corticosteroids are considered for use. In chronic gout attacks the anti-metabolite (allopurinol) and uricosuric drugs are considered. In acute gout attacks NSAIDs, colchicine, and corticosteroids are considered for use. In chronic gout attacks the anti-metabolite (allopurinol) and uricosuric drugs are considered. –Acute gout:  NSAIDs are the preferred medication for gout –Side effects  Upset stomach  Bleeding  Kidney damage  High potassium levels  Retention of sodium and potassium

5.What factors determine which of these drug to use for treatment?(cont.)  Colchicine is very effective, but the side effects can be intolerable by many patients. –These side effects include:  Diarrhea  Vomiting  Nausea  Abdominal pain  Cramps  Suppression of blood cell production in the bone marrow.  Corticosteroids aren ’ t as effective as NSAIDs or colchicine –Side effects:  Retention of sodium with swelling  High blood pressure  Pain  Discomfort  Joint damage if over used

5.What factors determine which of these drug to use for treatment?(cont.) –Chronic Gout:  Allopurinol –Action  Inhibit Xanthine oxidase  Prevents the formation of uric acid –Side effects  Upset stomach  Skin rash  Decrease in number of white blood cells  Liver or kidney damage  Inflammation of blood vessels (vasculitis)  Uricosuric drugs –Action  Promote excretion of uric acid –Probenicid & Sulfinpyrazone, Side effects  Headache  Nausea  Vomiting  Kidney stones

6.Should this patient be told to avoid alcohol? Why or why not? Yes, the patient should avoid certain types of alcohol such as beer,because it contains high contents of purine. There seems to be a link between incidence of gout and alcohol intake. Yes, the patient should avoid certain types of alcohol such as beer,because it contains high contents of purine. There seems to be a link between incidence of gout and alcohol intake.

7.What analgesic would you tell the patient to avoid for treatment of a headache? Why ? Aspirin should be avoided, because at low doses which is what is recommended for headaches aspirin causes formation of urate. In order for Aspirin to be used as a uricosuric drug it has to have elevated doses. Aspirin should be avoided, because at low doses which is what is recommended for headaches aspirin causes formation of urate. In order for Aspirin to be used as a uricosuric drug it has to have elevated doses. –Low dose  1-2 gm/day  Decrease rate of urate excretion and elevate plasma urate concentration.

7.What analgesic would you tell the patient to avoid for treatment of a headache? Why?(cont.) –Intermediate dose  2-3 gm/day  Does not alter urate excretion –Large dose  >5 gm/day –Uricosuric and lowers plasma urate levels