CPG Gout Presentation

8/7/2019 CPG Gout Presentation

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Adi Asraf b Yusof


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` Gout is defined as a peripheral arthritis resulting

from the deposition of sodium urate crystals in one

or more joints.

` Uric acid or urate (its salt) is the end product ofpurine metabolism

` Ethnic groups in Malaysia and China have higher

mean urate levels than most Caucasian

populations.


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` Typical sequence involves progression through: asymptomatic hyperuricemia

acute gouty arthritis

x Acute, self limiting, monoarticular

x Lower limbs more commonly affected

interval or intercritical gout

chronic or tophaceous gout

x Polyarticular, formation of tophi


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` Tophi chalky deposits of MSU crystal

Subcutaneous & painless

Firm, nodular & fusiform swelling Common sites include, digits of hands and feet


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Feature Typical Gout Elderly onset

Age of onset Peak in mid 40s Over 65 yrs

Sex distribution Men > women Men = women,

If over 80 yrs old

men < women

Presentation Monoarticular

Lower extremity

(podagra mostly)

Polyarticular

Upper extremity

Tophi After yrs of attack May occur early

Associated feature Obesity

Hyperlipidemia

HPT

Heavy drinker

Renal insufficiecy

Diuretic use


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` Clinical diagnosis Fulfill 2 out of 4 criteria

x History of at least 2 attacks of painful joint swelling with

complete resolution within 2 weeks

x Clear history/observation ofpodagra

x Presence of tophus

x Rapid response to colchicine within 48 hrs after tx started

` Definitive diagnosis Synovial fluid analysis (monosodium urate, MSU crystal

seen in synovial fluid)


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` a painful condition of the big toe caused by gout


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` Baseline investigation Full blood count (FBC)

Renal profile

RBS

Lipid profile

Urinalysis

` Further investigation 24-hour urinary excretion


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` Useful if renal calculus prove to be urate in nature

` Indicated if uricosuric agent used


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` Joint aspiration Definitive

Based on synovial fluid char + crystal identification

(MSU)

` Skeletal X-ray Usually normal in acute gouty arthritis

Chronic tophaceous gout: soft tissue abnormalities +

erosive bone lesion

` Renal imaging


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Acute gouty arthritis Chronic tophaceous gout


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` Aim to: Achieve IBW

Prevent acute attacks of gout

serum urate level

` Weight reduction gradual (0.5-1 kg/week)` Restrict alcohol intake - renal excretion of purine

` Reduce purine-rich food intake (i.e. red meat,seafood)

` Consume low fat dairy product` Maintain adequate fluid intake (2-3L)


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Asymptomatic Hyperuricaemia

` Serum urate conc abnormally high (male: >7.0 mg/dL,female: 6.0 mg/dL)

` But with no signs/symptoms of urate deposition

` Investigate the contributing factors` If drug-induced (i.e. thiazide diuretics), discontinued or

changed if clinically appropriate.

` Generally, no pharmacologic treatment required

unless Persistent severe hyperuricaemia

Persistent elevated urinary excretion of urate

Tumour lysis syndrome


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` group of metabolic complications that can occur after

treatment of cancer, usually lymphomas and leukemia,

and sometimes even without treatment. These

complications are caused by the break-down products

of dying cancer cells and include hyperkalemia,

hyperphosphatemia, hyperuricemia and

hyperuricosuria, hypocalcemia, and consequent acute

uric acid nephropathy and acute renal failure.

` Treatment targeted at specific metabolic syndrome


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` Acute Gouty arthritis` NSAIDs

Any NSAIDs other than aspirin Rapidly effective in inflammation and pain, particularly ifgiven right

away after acute attack. C/I in pt with hx of peptic ulcer disease, hypertension, renal impaired &

cardiac failure` COX2 inhibitor

For those at risk ofpeptic ulcer disease or intolerant to NSAIDs Better safety profile in terms ofgastric bleeding C/I in pt with active peptic ulcer disease, HPT, renal impaired and cardiac

failure.

` Colchicine Alternative drug for those C/I with both NSAIDs and COX2 inhibitor However, most prominent side effect is profuse diarrhea thus limit it

usefulness particularly in elderly pt.


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` Acute Gouty arthritis

` Glucocorticoids In elderly people and those C/I with either NSAIDs & COX2

inhibitor, glucocorticoids may be preferred.

Only forshort term treatment, thus side effects are rare

Several RoA are available; intrarticular, intramuscular and also

oral.

`

Allopurinol* Not to be started unless the acute attack had resolved

If pt on long term allopurinol, DO NOT STOP the treatment

during acute attack


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` Chronic Gouty arthritis Aim to reduce sUA level < 6.0mg/dL

Started afteracute attack well controlled (1-2 wks)

NSAIDs, colchicine DO NOT urate level

Hypouricaemic drugs NO analgesic + anti-

inflammatory effect

Lifelong treatment


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` Allopurinol Xanthine oxidase inhibitor -> hypouricaemic drugs

Superior than probenecid

Adjust in renal impaired pt

In normal pt start at 100-150mg OD, increase by 100-

150mg every 4 weeks -> 300mg OD

Max dose: 800mg daily


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` Probenecid Alternative to allopurinol

C/I in pt with UA overproduction + overexcretion, urate

nephropathy


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` Urate nephropathy urine output

x Maintain water intake of 3L/day or more

x In ESRF, limit fluid intake

urine pH

x Target urine pH: 6.5 7

x Potassium citrate

urate excretion

x By dietary purine intakex Allopurinol


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` Urate nephrolothiasis Radioluscent in nature

Ultrasound imaging preffered

Extracorpeal shockwave lithotripsy & percutaneous

nephrolithotomy can be used to treat intrarenal stones (5-

15mm) and complex staghorn stones

Pure urate stones readily chemolysed by potassium

citrate or sodium bicarbonate.


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Purine nucleotides

Hypoxanthine

Xanthine

Uric acid

Xanthine

oxidase

Alimentary

excretion

Urinary

excretion

Tissue deposition

in excess

Urate crystal microtophi

Phagocytosis

with acute

inflammation

and arthritis

Uricosurics

Colchicine NSAIDs

Allopurinol


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` Last resort

` Considered in Advanced tophi deposition -> major joint destruction

Loss of joint movement + severe pain Tophi collection -> pressure symptom

Tophaceous ulcer

Cosmetic (i.e. ear lobe tophi)


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` CPG: Management ofGout (Oct 2008)

` MICROMEDEX(R) Healthcare Series Vol. 146

` Lexi-Comp Drug Information Version 1.4.1

` http://www.gout.com/professional/gout_information/prevalence_and_incidence.aspx

` MOH Drug Formulary 2009

` http://www.merriam-webster.com

` http://www.buzzle.com/articles/purine-rich-foods.html


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CPG Gout Presentation

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