1. STRATEGIES FOR TREATING GOUT GOUT Dr. Sultan Al-Mogairen Assistant Professor & Consultant Rheumatology Division

2. Gout is clinical syndrome with monosodium urate deposition characterized biochemically by extracellular urate supersaturation and clinically manifested by arthritis, tophi and uric A nephrolithiasis. Gout continued to be a healthy problem despite the availability of effective therapy.

3. Epidemiology In the West, the most frequent microcrystalline arthritis affect approximately 0.5 to 2.8 of adult men and 0.2 to 0.6% of adult women. The highest incidence of Gout occurs between 30 & 45 yrs of age in men and between 55 & 70 yrs of age in women. Prevalence of Gout increased in countries with a high standard changing in diet, lifestyle, increased use of thiazid diuretics and Aspirin. A review in Saudi Arabia, a population with rare alcohol consumption revealed prevalence of HPU 8.42% and no cases of Gout.

4. CLINICAL FEATURES ♦ More in male and in elderly ♦More equal gender distribution ♦About 80% of initial attack are monoarticular. ♦Polyarticular first attack are more common in elderly women and in patients with Gout accompanying myeloproliferative disorder or the use of cyclosporin. ♦Common sites include instep, ankle, heel, knee, elbow (olecranon bursa) wrist & finger ♦Rare sites: shoulders, sternoclav, spine, sacroiliac and hips. There is an association with the following: -DM, hyperlipidemia, obesity, HTN, renal impairment, diuretic, and ethanol consumption.

35. MANAGEMENT Aims of Therapy 1.Anti-inflammatory 2.Anti-hyperuricemia 3.Prophylactic 4.Nutritional strategies 5.Avoid ethanol consumption and drugs inducing HPU 6.Prevention and reversal of morbid consequences of HPT, hyperlipid

36. ANTI-INFLAMMATORY NSAID, Colchicine, CST ♦Do not reverse HPU or urate deposition. ♦Often reverse pain and inflammation and disability within several days rather than several weeks as in untreated patients. ♦Best response if started in 1 st few hrs and if patient well educated give instruction for Tt with 1 st twinge to be terminated in 1 to 3 days or colchicine 0.6 mg/hr till relief or total dose 6 mg or S/E, or Indomethacin 50 mg x 3 & other NSAID alternative routes PR (NSAID).

37. Regarding NSAIDS, no clear advantages of one over another. NSAIDColchicine Effect: More predictableUnpredictable and when started after 1 st 24 hr, decreased thera- peutic effect Generally, better toleratedNarrow benefit to toxicity ratio if normal kid (abdp.) Onset: 1 hr.Slow 12 hrs. CostCheaper

38. Once anti-HPU drugs has been initiated, it should not be interrupted during acute attacks. CST after securing Dx & r/o infection if: 1.Co-existing medical illness contraindicating 1 st line (NSAID & Colchicine), or 2.Due to intolerance to them, use steroid IV, IM or IA according to number of joints involved. 3.Precaution for IA inj if patient has skin infection or on anticoagulant. However, the effect of CST are inconsistent and rebound attacks after Tt D/C are frequently seen.

40. Potential drawbacks of ACTH: 1.Depends on response of Δ and might be suboptimal if on steroid previously. 2.Failure to deliver precise dose. 3.Increased release of Androgen and mineralo cort.

42. PROPHYLAXIS FOR ACUTE ATTACKS DURING INITIATION OF ANTI-HPU DRUGS Increased urinary Ur A excreted early in the course of uricosuric Tt can promote (urinary stone formation). In addition, acute fall in S. urate conc often precipitate (Acute Gouty Arthritis). Mech: Uncertain, but probably with decreased S. Ur A PMNs more efficient in phagocytosis.

43. Risks of relapse can be minimized by long- term use of: 1.Colchicine or 2.NSAID Colchicine induced neuromyopathies and NSAID induced PUD and Rend imp. by D/C drugs after persistent normouricemia.

44. Others said that pot toxicity of prolonged use of Colchicine (neuropathies, myelotoxicity) and the fact that the only minority (10 to 15%) of patients develop flare-up of Gouty Arthritis. After initiation of Allup. or uricosuric Tt, instead, many clinicians advocate the temporary use of supplemental NSAID or Colchicine to control these attacks.

46. ANTIHYPERURICEMIA DRUGS Goals: To reduce and maintain S. urate not just to within normal range but to the mid to lower half of normal range (6.8 mg/dL = 404 mmol/L) below range of which S. urate saturate the extracellular fluid (6.8 mg/dL= half of normal range (6.8 mg/dL = 404 mmol/L) below range of which S. urate saturate the extracellular fluid (6.8 mg/dL= 404 mmol/L). 404 mmol/L). This will prevent the gouty attack and promote resorption of tophaceous deposits.

47. In the absence of clear indication for Tt with Allup, some Rheumatologist recommend uricosuric because it is safe and do not influence purine and pyramidine metabolism.

50. DIET A severely purine restricted diet has traditionally been recommended for patient with Gout. Such a diet can reduce urinary Ur A excretion by 200 to 400 mg/day. However, mean S. urate conc decrease only about 1 mg/dL (59 µ mol/L).

51. Diet with restricted purine and protein contents are unpalatable and often neither practical nor effective in the management of HPU and Gout in patients with normal dietary habit. Furthermore, with availability of potent anti- HPU drugs, this dietary approach is rarely employed except in those with severe renal insufficiency or intolerance to pharmacologic therapy.

52. If dietary changes are employed to manage Gout, it may be preferable to recommend increasing dietary protein intake from low fat dairy product and to decrease the amount of red meat and fish ingestion.

55. THANK YOU

56. سورة الإسراء آية 23-24 وَقَضَى رَبُّكَ أَلاَّ تَعْبُدُواْ إِلاَّ إِيَّاهُ وَبِالْوَالِدَيْنِ إِحْسَانًا إِمَّا يَبْلُغَنَّ عِندَكَ الْكِبَرَ أَحَدُهُمَا أَوْ كِلاَهُمَا فَلاَ تَقُل لَّهُمَآ أُفٍّ وَلاَ تَنْهَرْهُمَا وَقُل لَّهُمَا قَوْلاً كَرِيمًا وَقَضَى رَبُّكَ أَلاَّ تَعْبُدُواْ إِلاَّ إِيَّاهُ وَبِالْوَالِدَيْنِ إِحْسَانًا إِمَّا يَبْلُغَنَّ عِندَكَ الْكِبَرَ أَحَدُهُمَا أَوْ كِلاَهُمَا فَلاَ تَقُل لَّهُمَآ أُفٍّ وَلاَ تَنْهَرْهُمَا وَقُل لَّهُمَا قَوْلاً كَرِيمًا وَاخْفِضْ لَهُمَا جَنَاحَ الذُّلِّ مِنَ الرَّحْمَةِ وَقُل رَّبِّ ارْحَمْهُمَا كَمَا رَبَّيَانِي صَغِيرًا وَاخْفِضْ لَهُمَا جَنَاحَ الذُّلِّ مِنَ الرَّحْمَةِ وَقُل رَّبِّ ارْحَمْهُمَا كَمَا رَبَّيَانِي صَغِيرًا

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