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Gout final Gout final Presentation Transcript

  • GOUT “The disease of kings" or “Rich man's disease".
    Saurabh M. Limani
  • Definition
    Disorder of Purine metabolism characterized by recurrent attacks of acute inflammatory arthritis - a red, tender, hot, swollen joint.
    The MTP joint at the base of the big toe is the most commonly affected (~50% of cases). (chronic gout – Helix of the ear)
     it may also present as tophi, kidney stones, or urate nephropathy
    caused by elevated levels of uric acid in the blood which crystallize and are deposited in joints, tendons, and surrounding tissues.
  • Causes
    Hyperuricemia is the underlying cause of gout
    This can occur for a number of reasons, including diet, genetic predisposition, or under excretion of urate
     Renal under excretion of uric acid is the primary cause of hyperuricemia in about 90% of cases, while overproduction is the cause in less than 10%
    About 10% of people with hyperuricemia develop gout at some point in their lifetimes
    The risk, however, varies depending on the degree of hyperuricemia.
    (7 and 8.9 mg/dL – 0.5% per year >9 mg/dL - 4.5% per year)
  • Causes
    Lifestyle
    Dietary causes account for about 12% of gout.
    Alcohol, fructose-sweetened drinks, meat, and seafood (+)
    Coffee, vitamin C and dairy products as well as physical fitness (-)
    Genetics
    Familial juvenile hyperuricemic nephropathy
    Medullary cystic kidney disease
    Hypoxanthine-guanine phosphoribosyltransferase deficiency
    Medical conditions
    Metabolic syndrome
      Renal failure
      BMI >35 in male – risk increase threefold
    Medication
    Diuretics, niacin, aspirin and Cyclosporine
  • Characteristics
    Resembles arthritis
    Sudden pain in big toe, with the pain continuing to the leg
    Usually occurs after the age of 35 and is characterized by specific heritable metabolic defects
    Obesity is usually associated with a gouty condition
  • Diagnosis
    Hx and PE
    Synovial fluid
    Blood tests
    X-ray
  • Physical Examination
  • Management
    Anti inflammatory drugs
    Prophylaxis
    Control of hyperuricemia
    - xanthin oxidase inhibitor
    - uricosuric agent
    Adjuvant Rx
    - Control obesity ,ETOH intake, hyperlipidemia ,HTN
    - Losartan / fenofibrate – weakly uricosuric
    - Diet – moderation in purine intake. Makes a difference of up to 1mg % in s. uric acid
  • DIETARY MANAGEMENT
  • Dietary Management
    Restriction of Purine rich diet
    Drugs have largely replaced the need for rigid restriction of purine
    All food have some traces of nucleoprotein from which purines are derived
    Purines are synthesized in the body from simple metabolites, which are constantly available from dietary CHO, COOH, Fat and endogenous purine breakdown
    Restriction of food containing nucleoproteins is indicated in patient with high uric acid level
  • Dietary Management
    Excessive use of fats should be avoided, since fats are believed to prevent the normal excretion of urate
    Protein intake should be adequate but not excessive
    The calories should be maintained with carbohydrates
    Carbohydrates have a tendency to increase uric acid excretion
  • Acute stage
    Rigid restriction of food containing purine
    Diet high in carbohydrates, moderate in protein and low in fat
    Fluids (up to 3 liters per day) should be forced to assist the excretion of uric acid and to minimize the possibility of calculi formation
    Sodium bicarbonate or trisodium citrate
    Potassium salt of carbonate and citrate
  • Interval stage
    Dietary management + Uricosuric drugs
    Normal adequate diet adjusted to achieve ideal weight
    Moderate in protein (60 to 70 gms)
    Increase in carbohydrates and relatively low in fat
    Should avoid food high in purine
  • Severe or Advanced cases
    Limitation of protein to 50 to 70 gms daily
    (in the form of plant and dairy protein products as much as possible)
    Most of the proteins in the therapeutic diet come from cheese, eggs and milk, which are low in nucleoproteins
    Fluid should be adjusted to produce a normal UO (2000 ml)
  • Special consideration
    Alcohol
    - Mild to moderate
    - Lactic acid during the metabolism of ethanol
    Obesity
    - Reduced and maintain a body weight that is 10 to 15 % below the
    calculated normal weight
    - weight reduction should be deferred until the serum uric acid conc. Has
    been bought under control
  • Low purine diet
    Normal diet – 600 to 1000 mg of purine daily
    In cases of severe or advanced gout the purine content of the daily diet is restricted to approximately 100 to 150 mg
    Fat is kept to 40% of the caloric intake
  • FOOD GROUPING ACC. TO PURINE CONTENT
    GROUP : 1 HIGH PURINE CONTENT
    (100 to 1000 mg. of purine nitrogen per 100gms. Of food)
    Anchovies Mackerel
    Bouillon Meat extracts
    Brains Mincemint
    Broth Mussels
    Consomme Partridge
    Goose Roe
    Gravy Sardines
    Food in this list should be omitted from the diet of patients who have gout
    ( acute and remission stages)
  • GROUP 2 : MODERATE PURINE CONTENT
    (9 to 100 mg. of purine nitrogen per 100 gms. Of food)
    Meat and FishVegetables
    (except those in Grp.1)
    Fish Asparagus
    Poultry Beans, shell
    Meat Lentils
    Shellfish Mushrooms
    Peas
    Spinach
    One serving (2 to 3 oz.) of meat, fish or fowl or 1 serving (1/2 cup) vegetable
    From this group is allow each day or five days a week ( depending upon cond.)
    During remissions.
  • GROUP 3 : NEGLIGIBLE PURINE CONTENT
    Bread, enriched white Herbs
    and crackers Ice cream
    Butter or fortified margarine Milk
    (in moderation) Macaroni products
    Cake and cookies Noodles
    Carbonated beverages Nuts
    Cereal beverages Oil
    Cereals and cereal products Olives
    (refined and enriched) Pickles
  • continue..
    Cheese Popcorn
    Chocolate Puddings
    Coffee Relishes
    Condiments Rennet desserts
    Cornbread Rice
    Cream (in moderation) Salt
    Custard Sugar and sweets
    Eggs Tea
    Fats (in moderation) Vegetables (except those in Grp. 2)
    Fruit Vinegar
    Gelatin desserts White sauce
    Foods included in this group may be used daily
  • URIC ACID EXCRETION
  • HYPERTENSION AND GOUT
  • Low uric acid level
    MS
    Parkinson Disease
  • Thank you