When In Gout.

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  • When In Gout.

    1. 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, M3Note: The following lecture contains only 0.3% of your recommended daily educational value.
    2. 2. PleaseWelcome Our Co-Speaker
    3. 3. Hello Dr. Gir.Thanks for having me.
    4. 4. If you’re not supposed to have lots of acid inyour blood, then what is GOUT?
    5. 5. If you’re not supposed to have lots of acid inyour blood, then what is GOUT? An inflammatory response to elevated crystalized uric acid levels depositing into joint spaces leading to destruction and pain
    6. 6. Sure. But whatcauses gout?
    7. 7. Sure. But whatcauses gout?
    8. 8. Improper metabolism/excretion of Purines Bases (Adenosine and Guanine)
    9. 9. Improper metabolism/excretion of Purines Bases (Adenosine and Guanine) What the heck does that mean?
    10. 10. PURINE METABOLISM
    11. 11. PURINE METABOLISM WTF?
    12. 12. Did some research...
    13. 13. Did some research...
    14. 14. DNA Synthesis
    15. 15. DNA Synthesis
    16. 16. DNA SynthesisPurine Metabolism
    17. 17. DNA Synthesis PurineSynthesis Purine Metabolism
    18. 18. DNA Synthesis PurineSynthesis Purine Metabolism
    19. 19. WHAT CAUSES GOUT?Serum Uric Acid > 6.7 mg/dl
    20. 20. WHAT CAUSES GOUT? ➝Serum Uric Acid > 6.7 mg/dl ➝ Supersaturation
    21. 21. WHAT CAUSES GOUT? ➝ ➝Serum Uric Acid > 6.7 mg/dl ➝ Supersaturation
    22. 22. WHAT CAUSES GOUT?Increased uric acid levels usually asymptomatic
    23. 23. WHAT CAUSES GOUT?Increased uric acid levels usually asymptomaticGouty Attacks:•Increased urate crystals released•Form de novo in the joint space•Trauma•Surgeries•Medications (allopurinol, diuretics, cyclosporine)
    24. 24. WHO GETS GOUT? 1% of Americans (3 million)
    25. 25. WHO GETS GOUT? 1% of Americans (3 million)
    26. 26. WHO GETS GOUT?
    27. 27. WHO GETS GOUT?•2x Men vs. Women
    28. 28. WHO GETS GOUT?•2x Men vs. Women•Estrogen has mild uricosuric effect
    29. 29. WHO GETS GOUT?•2x Men vs. Women•Estrogen has mild uricosuric effect •(i.e. gout rare in pre-menopausal)
    30. 30. 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
    31. 31. 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)
    32. 32. 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:
    33. 33. 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
    34. 34. 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
    35. 35. 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
    36. 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 •(HGPRT ↓, ↑ PRP synthetase activity) High in elderly because: •Prevalence of Metabolic Syndrome •Diuretic Use •Low dose ASA Use (Our pt had iatrogenic menopause)
    37. 37. WHAT DOES GOUT FEEL LIKE?
    38. 38. CLINICAL PRESENTATION
    39. 39. CLINICAL PRESENTATION•Redness, swelling, intense pain
    40. 40. CLINICAL PRESENTATION•Redness, swelling, intense pain•Fever/Chills
    41. 41. CLINICAL PRESENTATION•Redness, swelling, intense pain•Fever/Chills•Usually at night
    42. 42. CLINICAL PRESENTATION•Redness, swelling, intense pain•Fever/Chills•Usually at night•Monoarticular
    43. 43. CLINICAL PRESENTATION•Redness, swelling, intense pain•Fever/Chills•Usually at night•Monoarticular•Commonly 1st metatarsophalangeal (Greek for “Big Toe”) joint
    44. 44. 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)
    45. 45. 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
    46. 46. 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
    47. 47. POLYARTICULAR GOUT Note: Currently there are ZERO reports of gout causing helmet-shaped heads.
    48. 48. CHRONIC GOUT
    49. 49. CHRONIC GOUTErosive Deposits
    50. 50. CHRONIC GOUTErosive Deposits Ear Tophi
    51. 51. CHRONIC GOUTErosive Deposits Ear Tophi Deforming Arthritis
    52. 52. CHRONIC GOUTErosive Deposits Ear Tophi Deforming Arthritis •Women > Men •~Rheumatoid
    53. 53. DIAGNOSISAcute Gouty Attack vs. Septic/Cellulitis Joint?
    54. 54. DIAGNOSIS Acute Gouty Attack vs. Septic/Cellulitis Joint?High/Low Serum Uric Acids NOT Sensitive/Specific
    55. 55. DIAGNOSIS Acute Gouty Attack vs. Septic/Cellulitis Joint?High/Low Serum Uric Acids NOT Sensitive/Specific Definitive Dx ➝ Joint Aspiriation
    56. 56. DIAGNOSIS
    57. 57. DIAGNOSISClinical Dx (any 6 of the following)
    58. 58. DIAGNOSIS Clinical Dx (any 6 of the following)>1 acute arthritis attack
    59. 59. DIAGNOSIS Clinical Dx (any 6 of the following)>1 acute arthritis attack> Max inflammation developed within a day
    60. 60. DIAGNOSIS Clinical Dx (any 6 of the following)>1 acute arthritis attack> Max inflammation developed within a dayOne joint
    61. 61. DIAGNOSIS Clinical Dx (any 6 of the following)>1 acute arthritis attack> Max inflammation developed within a dayOne jointRedness of Joint
    62. 62. DIAGNOSIS Clinical Dx (any 6 of the following)>1 acute arthritis attack> Max inflammation developed within a dayOne jointRedness of Joint1st toe pain/swelling
    63. 63. DIAGNOSIS Clinical Dx (any 6 of the following)>1 acute arthritis attack> Max inflammation developed within a dayOne jointRedness of Joint1st toe pain/swellingUnilateral tarsal joint
    64. 64. DIAGNOSIS Clinical Dx (any 6 of the following)>1 acute arthritis attack> Max inflammation developed within a dayOne jointRedness of Joint1st toe pain/swellingUnilateral tarsal jointSuspected Tophus
    65. 65. DIAGNOSIS Clinical Dx (any 6 of the following)>1 acute arthritis attack> Max inflammation developed within a dayOne jointRedness of Joint1st toe pain/swellingUnilateral tarsal jointSuspected TophusHyperuricemia
    66. 66. DIAGNOSIS Clinical Dx (any 6 of the following)>1 acute arthritis attack> Max inflammation developed within a dayOne jointRedness of Joint1st toe pain/swellingUnilateral tarsal jointSuspected TophusHyperuricemiaAsymmetric joint swelling on PE or XR
    67. 67. DIAGNOSIS Clinical Dx (any 6 of the following)>1 acute arthritis attack> Max inflammation developed within a dayOne jointRedness of Joint1st toe pain/swellingUnilateral tarsal jointSuspected TophusHyperuricemiaAsymmetric joint swelling on PE or XRCysts w/o Erosions on XR
    68. 68. DIAGNOSIS Clinical Dx (any 6 of the following)>1 acute arthritis attack> Max inflammation developed within a dayOne jointRedness of Joint1st toe pain/swellingUnilateral tarsal jointSuspected TophusHyperuricemiaAsymmetric joint swelling on PE or XRCysts w/o Erosions on XRNegative Joint Fluid Cx
    69. 69. DIAGNOSIS Clinical Dx (any 6 of the following)>1 acute arthritis attack> Max inflammation developed within a dayOne jointRedness of Joint1st toe pain/swellingUnilateral tarsal jointSuspected TophusHyperuricemiaAsymmetric joint swelling on PE or XRCysts w/o Erosions on XRNegative Joint Fluid CxUrate microcystals in joint fluid during attack
    70. 70. DIAGNOSIS
    71. 71. DIAGNOSIS
    72. 72. DIAGNOSISSynovial Fluid WBC’s > 15,000 (Majority PMNs)
    73. 73. DIAGNOSISSynovial Fluid WBC’s > 15,000 (Majority PMNs) If WBC’s > 50,000 ➝ Infected
    74. 74. DIAGNOSISSynovial Fluid WBC’s > 15,000 (Majority PMNs) If WBC’s > 50,000 ➝ Infected Start empiric ABx unless Cx R/O Infection
    75. 75. TREATMENT
    76. 76. TREATMENTNOT Required to determine if under-excretor or over-producer
    77. 77. TREATMENTNOT Required to determine if under-excretor or over-producerUnder or Over excreters respond to allopurinol
    78. 78. TREATMENTNOT Required to determine if under-excretor or over-producerUnder or Over excreters respond to allopurinolAllopurinol Intolerance ➝ verify no Hxof Nephrolithasis and an under-excretor
    79. 79. TREATMENT Gouty Arthritis
    80. 80. TREATMENT Gouty ArthritisNSAIDS (caution: renal disease, bleeding, ulcers, elderly)
    81. 81. TREATMENT Gouty ArthritisNSAIDS (caution: renal disease, bleeding, ulcers, elderly)Corticosteroids - 40 mg/day (caution: DM)
    82. 82. TREATMENT Gouty ArthritisNSAIDS (caution: renal disease, bleeding, ulcers, elderly)Corticosteroids - 40 mg/day (caution: DM)-Intra-articular Steroid Injection (Once infection R/O)
    83. 83. TREATMENT Gouty ArthritisNSAIDS (caution: renal disease, bleeding, ulcers, elderly)Corticosteroids - 40 mg/day (caution: DM)-Intra-articular Steroid Injection (Once infection R/O)Colchicine
    84. 84. TREATMENT Gouty ArthritisNSAIDS (caution: renal disease, bleeding, ulcers, elderly)Corticosteroids - 40 mg/day (caution: DM)-Intra-articular Steroid Injection (Once infection R/O)ColchicineMost effective: one joint, <24 hrs
    85. 85. TREATMENT Gouty ArthritisNSAIDS (caution: renal disease, bleeding, ulcers, elderly)Corticosteroids - 40 mg/day (caution: DM)-Intra-articular Steroid Injection (Once infection R/O)ColchicineMost effective: one joint, <24 hrsNormal renal function ➝ 2 or 3 six mg doses a day untilrelief
    86. 86. TREATMENT Gouty ArthritisNSAIDS (caution: renal disease, bleeding, ulcers, elderly)Corticosteroids - 40 mg/day (caution: DM)-Intra-articular Steroid Injection (Once infection R/O)ColchicineMost effective: one joint, <24 hrsNormal renal function ➝ 2 or 3 six mg doses a day untilreliefAvoid IV form ➝ bone marrow/neuromuscular tox
    87. 87. TREATMENT Hyperuricemia
    88. 88. TREATMENT HyperuricemiaDietary Purine Restriction
    89. 89. TREATMENT Hyperuricemia Dietary Purine RestrictionAlcohol
    90. 90. TREATMENT Hyperuricemia Dietary Purine RestrictionAlcohol Anchovies
    91. 91. TREATMENT Hyperuricemia Dietary Purine RestrictionAlcohol Anchovies Mushrooms
    92. 92. TREATMENT Hyperuricemia Dietary Purine RestrictionAlcohol Anchovies MushroomsOrgan foods (livers, kidneys), Dried beans, peas, spinach, asparagus, cauliflower
    93. 93. TREATMENT HyperuricemiaAvoid Medications Thiazides Low Dose Aspirin
    94. 94. TREATMENTHyperuricemia
    95. 95. TREATMENTHyperuricemiaStart Pharmacologic Treatment:
    96. 96. TREATMENTHyperuricemiaStart Pharmacologic Treatment:•Tophi
    97. 97. TREATMENTHyperuricemiaStart Pharmacologic Treatment:•Tophi•Renal Stones
    98. 98. TREATMENTHyperuricemiaStart Pharmacologic Treatment:•Tophi•Renal Stones•↑ Frequency of Attacks
    99. 99. TREATMENT Hyperuricemia Start Pharmacologic Treatment: •Tophi •Renal Stones •↑ Frequency of Attacks• D/C’ing chronic therapy ➝ can worsen Sx
    100. 100. TREATMENT Hyperuricemia Start Pharmacologic Treatment: •Tophi •Renal Stones •↑ Frequency of Attacks• D/C’ing chronic therapy ➝ can worsen Sx• Tx Goal: Serum Uric Acid Levels < 6.0 mg/dl ➝ reabsorption
    101. 101. TREATMENT Hyperuricemia Start Pharmacologic Treatment: •Tophi •Renal Stones •↑ Frequency of Attacks• D/C’ing chronic therapy ➝ can worsen Sx• Tx Goal: Serum Uric Acid Levels < 6.0 mg/dl ➝ reabsorption DOC: Allopurinol ($4.67/mo)
    102. 102. TREATMENT Hyperuricemia Start Pharmacologic Treatment: •Tophi •Renal Stones •↑ Frequency of Attacks• D/C’ing chronic therapy ➝ can worsen Sx• Tx Goal: Serum Uric Acid Levels < 6.0 mg/dl ➝ reabsorption DOC: Allopurinol ($4.67/mo) Newer Rx: Uloric (febuxostat) not a purine analogue, both renal/liver elimination ($175/mo)
    103. 103. THANK YOU
    104. 104. Looks like me.THANK YOU
    105. 105. PLAGIARIZED SOURCES1. MKSAP 15: Rheumatology: Crystal-Induced Athropathies2. MedScape: http://emedicine.medscape.com/article/329958-overview3. http://mips.helmholtz-muenchen.de/genre/proj/uwe25/images/pw_purine.gif4. http://scienceblogs.com/moleculeoftheday/images/gout-cartoon.jpg5. http://www.enzyme-database.org/reaction/misc/miscgif/purine2.gif6. http://images.inmagine.com/img/creatas/crs026/crs026089.jpg7. http://www.morecoloringpages.com/coloring_pages/sm_color/boy_playing_3.gif8. http://www.visualphotos.com/photo/2x4630684/african_baby_playing_with_blocks_bld040962.jpg9. http://upload.wikimedia.org/wikipedia/commons/a/ac/Fluorescent_uric_acid.JPG10. http://onlinehealthtips.net/wp-content/uploads/2010/04/Gout-pain.jpg

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