1. Gout

2. Gout
Deposits of sodium urate crystals in articular, periarticular, and subcutaneous tissues
May be primary or secondary
Primary – hereditary error of purine metabolism
Secondary – drugs that inhibit uric acid excretion or another acquired disorder

3. Incidence and Risk Factors
Primary gout accounts for 90% of cases
Affects primarily middle aged men
Risk factors: obesity, HTN, thiazide diuretics, excess alcohol use

4. Pathophysiology
Uric acid is end product of purine metabolism and is excreted by the kidneys
Hyperuricemia results from
Increase in uric acid production
Underexcretion of uric acid by kidneys
Both
Diet high in purines will not cause gout, but may trigger an attack in a susceptible person

5. Clinical Manifestations
Gouty arthritis in one or more joints (but less than four
Great toe joint most common first manifestation; other joints may be the foot, ankle, knee, or wrist
Joints are tender & cyanotic
May be precipitated by trauma, surgery, alcohol ingestion, or infection

6. Clinical Manifestations
Onset usually nocturnal, with sudden swelling and excruciating pain
May have low grade fever
Usually subsides within 2-10 days
Joints are normal, with no symptoms between attacks

7. Complications Joint deformity Osteoarthritis
Tophi may produce draining sinuses that may become infected
Renal stones, pyelonephritis, obstructive renal disease

8. Chronic Gout

9. Diagnosis History & physical examination Family history of gout
Diagnostic studies

10. Diagnostic Studies Serum uric acid levels > 6 mg/dl
May be caused by other factors
24 hour urine uric acid levels
Synovial fluid aspiration contains uric acid crystals
Seldom necessary, as diagnosis based on clinical symptoms possible in 80% of cases
X-rays appear normal in early stages; tophi appear as eroded areas of bone

11. Collaborative Care Acute attack
Colchicine produces dramatic antiiflammatory effects with relief within hours
NSAIDs for additional pain relief
Corticosteroids (po or intraarticular)
Adrenocorticotropic hormone (ACTH)
Joint aspiration to decompress

12. Collaborative Care Prevention of acute attacks
Colchicine combined with:
allopurinol (Zyloprim, Alloprim) – blocks production of uric acid
probenecid (Benemid), sulfinpyrazone (Anturane) – inhibit tubular reabsorption of uric acid
febuxostat (Uloric) – inhibits xanthine oxidase, recently shown to reduce serum uric acid levels

13. Collaborative Care Dietary measures
Weight reduction
Avoidance of alcohol
Avoidance of foods high in purines
High: Sardines, anchovies, herring, mussels, liver, kidney, goose, venison, meat soups, sweetbreads, beer & wine
Moderate: Chicken, salmon, crab, veal, mutton, bacon, pork, beef, ham

14. Collaborative Care Prevention of renal stones
Increase fluid intake to maintain adequate urine output
Allopurinol
ACE inhibitor losartin (Cozar) – promotes urate diuresis

15. Nursing Care Acute gouty arthritis – pain control
Gentle, supportive care of affected joints
Immobilize and rest affected joints – bed rest or NWB
Cradle or footboard to prevent pressure from bedcovers
Monitor ROM and degree of pain

16. Nursing Care Patient/Family teaching
Gout is a chronic disease
Drug teaching
Need to monitor serum uric acid levels
Precipitating factors
Excess calorie intake, alcohol intake, purine rich foods
Fasting
Niacin, ASA, diuretics
Surgery or major medical event such as MI