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When In Gout.
1. WHEN IN GOUT
Amit Gir, MD
NOON CONFERENCE
March 4, 2011
BLUE TEAM
Mark Gennis, M.D.
Olha Norman, M.D.
Matt Mauck, M.D.
Mostafa Ahmed, M3
Note: The following lecture contains only 0.3% of your recommended daily educational value.
6. If you’re not supposed
to have lots of acid in
your blood, then what
is GOUT?
7. If you’re not supposed
to have lots of acid in
your blood, then what
is GOUT?
An inflammatory response to elevated
crystalized uric acid levels depositing
into joint spaces leading to destruction
and pain
29. WHAT CAUSES GOUT?
Increased uric acid levels usually asymptomatic
Gouty Attacks:
•Increased urate crystals released
•Form de novo in the joint space
•Trauma
•Surgeries
•Medications (allopurinol, diuretics, cyclosporine)
35. WHO GETS GOUT?
•2x Men vs. Women
•Estrogen has mild uricosuric effect
•(i.e. gout rare in pre-menopausal)
36. WHO GETS GOUT?
•2x Men vs. Women
•Estrogen has mild uricosuric effect
•(i.e. gout rare in pre-menopausal)
•Rare < age 30: unless genetic defect
37. WHO GETS GOUT?
•2x Men vs. Women
•Estrogen has mild uricosuric effect
•(i.e. gout rare in pre-menopausal)
•Rare < age 30: unless genetic defect
•(HGPRT ↓, ↑ PRP synthetase activity)
38. WHO GETS GOUT?
•2x Men vs. Women
•Estrogen has mild uricosuric effect
•(i.e. gout rare in pre-menopausal)
•Rare < age 30: unless genetic defect
•(HGPRT ↓, ↑ PRP synthetase activity)
High in elderly because:
39. WHO GETS GOUT?
•2x Men vs. Women
•Estrogen has mild uricosuric effect
•(i.e. gout rare in pre-menopausal)
•Rare < age 30: unless genetic defect
•(HGPRT ↓, ↑ PRP synthetase activity)
High in elderly because:
•Prevalence of Metabolic Syndrome
40. WHO GETS GOUT?
•2x Men vs. Women
•Estrogen has mild uricosuric effect
•(i.e. gout rare in pre-menopausal)
•Rare < age 30: unless genetic defect
•(HGPRT ↓, ↑ PRP synthetase activity)
High in elderly because:
•Prevalence of Metabolic Syndrome
•Diuretic Use
41. WHO GETS GOUT?
•2x Men vs. Women
•Estrogen has mild uricosuric effect
•(i.e. gout rare in pre-menopausal)
•Rare < age 30: unless genetic defect
•(HGPRT ↓, ↑ PRP synthetase activity)
High in elderly because:
•Prevalence of Metabolic Syndrome
•Diuretic Use
•Low dose ASA Use
42. WHO GETS GOUT?
•2x Men vs. Women
•Estrogen has mild uricosuric effect
•(i.e. gout rare in pre-menopausal)
•Rare < age 30: unless genetic defect
•(HGPRT ↓, ↑ PRP synthetase activity)
High in elderly because:
•Prevalence of Metabolic Syndrome
•Diuretic Use
•Low dose ASA Use
(Our pt had iatrogenic menopause)
50. CLINICAL PRESENTATION
•Redness, swelling, intense pain
•Fever/Chills
•Usually at night
•Monoarticular
•Commonly 1st metatarsophalangeal (Greek for “Big Toe”) joint
•Lasts 5-7 days (severe up to 2 weeks)
51. CLINICAL PRESENTATION
•Redness, swelling, intense pain
•Fever/Chills
•Usually at night
•Monoarticular
•Commonly 1st metatarsophalangeal (Greek for “Big Toe”) joint
•Lasts 5-7 days (severe up to 2 weeks)
•Can be self-limited
52. CLINICAL PRESENTATION
•Redness, swelling, intense pain
•Fever/Chills
•Usually at night
•Monoarticular
•Commonly 1st metatarsophalangeal (Greek for “Big Toe”) joint
•Lasts 5-7 days (severe up to 2 weeks)
•Can be self-limited
•Chronic ➝ polyarticular/UE
64. DIAGNOSIS
Clinical Dx (any 6 of the following)
>1 acute arthritis attack
65. DIAGNOSIS
Clinical Dx (any 6 of the following)
>1 acute arthritis attack
> Max inflammation developed within a day
66. DIAGNOSIS
Clinical Dx (any 6 of the following)
>1 acute arthritis attack
> Max inflammation developed within a day
One joint
67. DIAGNOSIS
Clinical Dx (any 6 of the following)
>1 acute arthritis attack
> Max inflammation developed within a day
One joint
Redness of Joint
68. DIAGNOSIS
Clinical Dx (any 6 of the following)
>1 acute arthritis attack
> Max inflammation developed within a day
One joint
Redness of Joint
1st toe pain/swelling
69. DIAGNOSIS
Clinical Dx (any 6 of the following)
>1 acute arthritis attack
> Max inflammation developed within a day
One joint
Redness of Joint
1st toe pain/swelling
Unilateral tarsal joint
70. DIAGNOSIS
Clinical Dx (any 6 of the following)
>1 acute arthritis attack
> Max inflammation developed within a day
One joint
Redness of Joint
1st toe pain/swelling
Unilateral tarsal joint
Suspected Tophus
71. DIAGNOSIS
Clinical Dx (any 6 of the following)
>1 acute arthritis attack
> Max inflammation developed within a day
One joint
Redness of Joint
1st toe pain/swelling
Unilateral tarsal joint
Suspected Tophus
Hyperuricemia
72. DIAGNOSIS
Clinical Dx (any 6 of the following)
>1 acute arthritis attack
> Max inflammation developed within a day
One joint
Redness of Joint
1st toe pain/swelling
Unilateral tarsal joint
Suspected Tophus
Hyperuricemia
Asymmetric joint swelling on PE or XR
73. DIAGNOSIS
Clinical Dx (any 6 of the following)
>1 acute arthritis attack
> Max inflammation developed within a day
One joint
Redness of Joint
1st toe pain/swelling
Unilateral tarsal joint
Suspected Tophus
Hyperuricemia
Asymmetric joint swelling on PE or XR
Cysts w/o Erosions on XR
74. DIAGNOSIS
Clinical Dx (any 6 of the following)
>1 acute arthritis attack
> Max inflammation developed within a day
One joint
Redness of Joint
1st toe pain/swelling
Unilateral tarsal joint
Suspected Tophus
Hyperuricemia
Asymmetric joint swelling on PE or XR
Cysts w/o Erosions on XR
Negative Joint Fluid Cx
75. DIAGNOSIS
Clinical Dx (any 6 of the following)
>1 acute arthritis attack
> Max inflammation developed within a day
One joint
Redness of Joint
1st toe pain/swelling
Unilateral tarsal joint
Suspected Tophus
Hyperuricemia
Asymmetric joint swelling on PE or XR
Cysts w/o Erosions on XR
Negative Joint Fluid Cx
Urate microcystals in joint fluid during attack
83. TREATMENT
NOT Required to determine if under-
excretor or over-producer
Under or Over excreters respond to allopurinol
84. TREATMENT
NOT Required to determine if under-
excretor or over-producer
Under or Over excreters respond to allopurinol
Allopurinol Intolerance ➝ verify no Hx
of Nephrolithasis and an under-excretor
91. TREATMENT
Gouty Arthritis
NSAIDS (caution: renal disease, bleeding, ulcers, elderly)
Corticosteroids - 40 mg/day (caution: DM)
-Intra-articular Steroid Injection (Once infection R/O)
Colchicine
Most effective: one joint, <24 hrs
Normal renal function ➝ 2 or 3 six mg doses a day until
relief
92. TREATMENT
Gouty Arthritis
NSAIDS (caution: renal disease, bleeding, ulcers, elderly)
Corticosteroids - 40 mg/day (caution: DM)
-Intra-articular Steroid Injection (Once infection R/O)
Colchicine
Most effective: one joint, <24 hrs
Normal renal function ➝ 2 or 3 six mg doses a day until
relief
Avoid IV form ➝ bone marrow/neuromuscular tox
