1. Gout Familial metabolic disease characterized by : Acute arthritis Uric acid stones in the kidneys Hyperuricemia

2. High blood uric acid levelMost uric acid is excreted by kidneysBlood  monosodium urate ♂>♀ Rare before puberty Breakdo wn of product of the body’s purine (nucleic acid) metaboli sm.

3. Aetiology of raised uric acid level Idiopathic decrease in uric acid excretion (75%) Increase uric acid production due to increased cell turn over (tumors), increase uric acid synthesis (specific enzyme defect) High dietary purine intake Impaired uric acid excretion secondary to thiazide diuretics, chronic Renal failure

6. What is the treatment for gout ?

7. DRUGS USED IN TEATMENT OF GOUT Most therapeutic strategies for gout involve lowering the uric acid level below the saturation point (<6 mg/dL), thus preventing the deposition of urate crystals. This can be accomplished by: 1.interfering with uric acid synthesis with allopurinol 2.increasing uric acid excretion with probenecid or sulfinpyrazone, large doses of aspirin 3.inhibiting leukocyte entry into the affected joint with colchicine, 4.administration of NSAIDs Most therapeutic strategies for gout involve lowering the uric acid level below the saturation point (<6 mg/dL), thus preventing the deposition of urate crystals. This can be accomplished by: 1.interfering with uric acid synthesis with allopurinol 2.increasing uric acid excretion with probenecid or sulfinpyrazone, large doses of aspirin 3.inhibiting leukocyte entry into the affected joint with colchicine, 4.administration of NSAIDs

8. Aaarrrgghhh!!

9. 1 Asymptomatic Stage 2 Acute stage 3 Intercritical stage 4 Chronic stage

10. urate levels rise in the blood, but produces no symptoms ASYMPTOMATIC STAGE

11. ACUTE STAGE

12. symptom-free intervals between gout episodes. Most people have a second attack from six months to two years, while others are symptom-free for five to 10 years. INTERCRITICAL STAGE

13. CHRONIC STAGE

14. Broad lines in treatment of gout Non- pharmacologic pharmacologic Acute gouty arthritis Prevention of recurrent attack

15. Non-pharmacologic Therapy

19. Control….

21. Acute gouty arthritis NSAIDscolchicinecorticosteroid

22. 1. NSAIDs

23. Inhibits pain & inflammation. Inhibits urate crystal phagocytosis by decreasing the migration of granulocytes into the inflammatory area. ( Indomethacin is commonly used & it may replace colchicine. Aspirin in therapeutic doses is contraindicated as it compete with uric acid secretion in proximal tubule.

24. 2. Colchicine

25. Basyir Bin Kamaruzaman (15)

26. OVERVIEW A plant alkaloid Used for the treatment of acute gouty attacks and prophylaxis Neither a uricosuric nor an analgesic agent, yet relieves pain in acute attacks of gout Prophylactic effect which reduces the frequency of acute attacks

27. MECHANISM OF ACTIONS Binds to tubulin > disrupt mobility of granulocytes to affected area Inhibits the synthesis and release of the leukotrienes B ₄ and interleukin-8 Decrease production of TNF- α by macrophages

28. PHARMACOKINETICS Administered orally, followed by rapid absorption from the GI tract Reaches peak plasma levels within 2 hoursAlso available combined with probenecid Recycled in the bile and is excreted unchanged in the faeces or urine. Use should be avoided in patients with a creatinine clearance of less than 50 mL/min. PHA PHARMACOKINETICS

29. THERAPEUTIC USES Treatment for Mediterranean Fever Colchicine is currently used for prophylaxis of recurrent attacks and will prevent attacks in more than 80 percent of patients. The anti-inflammatory activity of colchicine is specific for gout, usually alleviating the pain of acute gout within 12 hours

30. Adverse effects Diarrhea is a common adverse effect. May cause nausea,vomiting,abdominal cramps. Chronic use may cause, alopecia, bone marrow depression, peripheral neuritis, myopathy. Also,affect fertility

31. Acute intoxication Burning throat pain. Bloody diarrhea. Shock. Hematuria. C.N.S.depression.

32. Contraindication & Precaution Contraindicated in pregnancy Should be used with caution in hepatic, renal or cardiovascular diseases.

33. 3. Corticosteroids

34. Prevention of recurrent attack Inhibition of uric acid synthesis Allopurinol Uricosuric drugs - Probenacid -Sulfinpyrazone -Large doses of aspirin

35. Inhibition of uric acid synthesis

36. Mechanism of action

37. Pharmacokinetics 80% absorbed after oral administration. Metabolized to active metabolite alloxanthine. Given once daily. Drug & its metabolite are excreted in the feces & urine.

38. Pharmacokinetics

39. Therapeutic Uses It is drug of choice in patient with:

40. Chronic tophaceous deposits (reabsorption is more rapid)

41. High serum uric acid in patients with impaired renal functions.

42. uric acid stones or nephropathy.

43. used to prevent increased uric acid levels in patients receiving cancer chemotherapy

44. ALLOPURINOL (SIDE EFFECTS AND DRUG INTERACTIONS)

45. Side Effects (most common) exacerbation of an acute attack of gout

46. Maculopopular skin rash

47. nausea, diarrhea

48. Side Effects (less common) Body : fever, headache CVS : vasculitis

49. Thrombocytopenia Epistaxis

50. Drug Interactions With oral anticoagulant: Potentiates warfarin and dicumarol inhibits their metabolism in liver

51. With anticancer : 6-mercaptopurine and azathioprine inhibits their metabolism (doses are reduced up to 75%

52. With ampicillin : Increases frequency of skin rash Prolongs half life of Chlorpropamide both compete for excretion in renal tubule

53. Uricosuric drugs

54. Probenecid is a uricosuric drug that increases uric acid excretion in the urine primarily used in treating gout Probenecid

55. Sulfinpyrazone Sulfinpyrazone is a metabolite of phenylbutazone Metabolized into an active metabolite in the liver.

56. Mechanism of action Uricosuric drugs ( probenecid, sulfinpyrazone, large dose of aspirin) block the active transport sites of the proximal tubules(middle segment ) the reabsorption of uric acid is decreased.

57. Clinical uses Should not be started until 2-3 weeks after an acute attack. In chronic gout when : Evidence of tophi appears Plasma levels of uric acid are so high that may cause tissue damage

58. Clinical uses ( continue) Urine volume should be maintained at a high level, and urinary pH kept alkaline. Probenecid is a general inhibitor of the tubular secretion of organic acids, so it is used to prolong action of other weak organic acids as some antibiotics e.g. penicillin.

59. DRUG INTERACTIONS Probenecid prolong the action of some antibiotics as: penicillin and cephalosporins

60. Side effects Acute attack of gout Risk of uric acid stone GIT upset Allergic rash

61. Adverse effects ( continue) Nephrotic syndrome ( probenecid) Aplastic anemia ( not common )

62. Contra-indications History of urinary tract stone Impaired renal function Recent acute gouty attack Administration of low doses of aspirin

63. THANK YOU