1. GOUT: DIAGNOSIS AND MANAGEMENT

2. Gout Metabolic disorder due to excessive accumulation of uric acid in tissues leading to acute and chronic arthritis and soft tissue and bone deposition of uric acid (tophi).

3. Abrupt onset often at night 75% of initial attacks in first MTP joint Usually monoarticular, may be polyarticular Attack subsides in 3-10 days Na + urate crystals in synovial fluid Hyperuricemia may or may not be present Acute Gouty Arthritis

4. The victim goes to bed and sleeps in good health. About 2 o’clock in the morning he is awakened by a severe pain in the great toe; more rarely in the heel, ankle or instep.

5. The pain is like that of a dislocation, and yet the parts feel as if cold water were poured over them…Now it is a violent stretching and tearing of the ligaments – now it is a gnawing pain, and now a pressure and tightening.

6. So exquisite and lively meanwhile is the feeling of the part affected, that it cannot bear the weight of the bedclothes nor the jar of person walking in the room. The night is spent in torture. - Thomas Sydenham (1624-1689)

7. QUESTION: Who gets gout?

8. ANSWER: Individuals with prolonged hyperuricemia

9. So who gets hyperuricemia?

10. Overproduction (10%) (80 % idiopathic) Ethanol HGPRT or G6PD deficiency PRPP synthetase overactivity Myeloproliferative disorders Cytotoxic chemotherapy Sickle-cell anemia Hyperuricemia

12. Hyperuricemia Underexcretion (90%) (80% idiopathic) Renal insufficiency Drugs and toxins – Diuretics – Ethanol – Cyclosporine A – Pyrazinamide – Lead nephropathy – Low dose aspirin Ketosis

13. So who gets gout? Young and middle-aged men Young and middle-aged men Individuals with hypertension, obesity,renal insufficiency, metabolic syndrome, organ transplants Individuals with hypertension, obesity,renal insufficiency, metabolic syndrome, organ transplants Patients on diuretics Patients on diuretics Beer drinkers Beer drinkers

14. Who doesn’t get gout? Women Women  Unless  Post-menopausal  Renal insufficiency  Chronic diuretic use  Myeloproliferative disorder

15. The prevalence of gout is increasing Patients with CHF and renal disease are surviving longer Patients with CHF and renal disease are surviving longer Obesity/metabolic syndrome epidemic Obesity/metabolic syndrome epidemic More organ transplants More organ transplants Less estrogen used Less estrogen used Low dose aspirin use Low dose aspirin use

16. GOUT: DIAGNOSIS Presentation Presentation Patient demographics Patient demographics Physical findings Physical findings Differentiate from: Differentiate from:  Sepsis  RA  Spondyloarthropathy(psoriasis, reactive)  Lyme

17. GOUT: DIAGNOSIS Arthrocentesis and crystal identification Arthrocentesis and crystal identification Serum uric acid may be misleading and is not a good diagnostic test for acute gout. Serum uric acid may be misleading and is not a good diagnostic test for acute gout.

20. TREATMENT OF ACUTE GOUT NSAIDS NSAIDS Intra-articular steroids Intra-articular steroids Prednisone Prednisone Colchicine Colchicine  PO – no fun  IV – be careful (limited availability)

21. TREATMENT OF RECURRENT GOUT PO daily low-dose colchicine PO daily low-dose colchicine  Colchicine neuromypathy Lower serum uric acid level Lower serum uric acid level

22. TREATMENT OF HYPERURICEMIA: INDICATIONS Repeated or severe acute gout attacks Repeated or severe acute gout attacks Patient preference Patient preference Tophaceous/erosive gout Tophaceous/erosive gout Chemotherapy of hematologic malignancies Chemotherapy of hematologic malignancies Nephrolithiasis Nephrolithiasis

23. Treatment of Hyperuricemia Decrease uric acid production Decrease uric acid production  Allopurinol  Febuxostat (Uloric) Uricosuric agents Uricosuric agents  Probenecid  Sulfinpyrazone

24. TREATMENT OF HYPERURICEMIA: ALLOPURINOL/FEBUXOSTAT Marked hyperuricemia Marked hyperuricemia Increased urinary uric acid excretion Increased urinary uric acid excretion Tophaceous or erosive gout Tophaceous or erosive gout Renal insufficiency Renal insufficiency Nephrolithiasis Nephrolithiasis

25. TREATMENT OF HYPERURICEMIA: URICOSURICS Low urinary uric acid excretion Low urinary uric acid excretion Mild renal insufficiency Mild renal insufficiency (Probenecid, sulfinpyrazone)

26. TREATMENT PEARLS Aspirin makes gout worse. Aspirin makes gout worse. Allopurinol/febuxostat is a treatment for hyperuricemia and not acute gout. Allopurinol/febuxostat is a treatment for hyperuricemia and not acute gout. Giving allopurinol or febuxostat during an acute attack will prolong the attack. Giving allopurinol or febuxostat during an acute attack will prolong the attack. Starting allopurinol/febuxostat may provoke attacks. Starting allopurinol/febuxostat may provoke attacks. Therefore add colchicine for 6-12 mos. Therefore add colchicine for 6-12 mos.