Gout ppt

1. DR KIRTIDA DESAI,
HOD, PROFESSOR,
PRACTICE OF MEDICINE
PG & Phd GUIDE

2. Defination
 Gout is an inflammatory response to
MSU(monosodium urate) crystals formed secondary
to hyperuricemia.
 Uric acid is a weak acid mainly pr. as a urate.
 Gout is seen in only 10% of patients having
hyperuricemia.
 Asymtomatic hyperuricemia does not need any
treatment.

3. Epidemiology
 Incidence- 0.2 to 3.5/1000 to 2 to 26/1000 pt
 Rare in children
 Rare in premanopausal female
 Peak age of onset in male is after 40 yr’s and increases
after age of 60.
 Cases of gout frequently associated with metabolic
disorder
 Incidence increases day by day due to change in life
style.

4.  In male average s.uric acid in prepubertal age is 3.5
mg/dl, which remain around 5.2 after puberty. Gout
occurs when it reaches more than 7.2 mg/dl
 In female normal range is around 4.7 mg and causes
gout if it increase above level of 6 mg/dl. In female
incidence increases after menopause.

6. Pathogenesis
 When concentration increases more than 6.8 mg/dl
urate gets crystalized as MSU in and around joints.
 MSU are released into the joint cavity, activate synovial
lining cells, recruits and activate mastocytes and
peripheral blood monocytes.
 At the cellular level- Inflammation induced by urate
crystals is brought by innate immune engagement of
the crystals by plasma membrane receptors.

7.  They produces various cytokines such as interleukins
eg IL- 1, IL-8 and chemokines leading to endothelial
cell activation.
- later on… neutrophil gets recruited in to jt’s, causes
phagocytosis of MSU crystals
- Autolimitation of acute inflammation by macrophage,
neutrophil necrosis and apoptosis.

8. Major clinical manifestation
 Acute synovitis
 Chronic erosive and inflammatory arthritis
 Intercritical gout
 Tophi
 Nephrolithiasis
 Interstitial nephritis

9. Causes
PRIMARY HYPERURICEMIA-
a) Increase uric acid production- Idiopathic in 10%
cases, specific enzyme deficit like HGPRT, or increase
PRPP activity
b) Decreased uric acid secretion, idiopathic in 90%
cases

10.  SECONDARY HYPERURICEMIA-
a. increase s.uric acid production- associated with
complete HGPRT deficiency , G6PD deficiency
b. increased turnover of purine
Eg- myeloproliferative disorders like
polysynthemia vera, leukemias or
- lymphoproliferative disorders eg lymphoma,
myelomas

11. C. DECREASED URIC ACID SECRETIONS-
1. renal- ckd, nephrogenic diabetes insipidus
2. increase level of organic acids- eg exercise,
starvation, crash dieting, long fast etc
3. ketoacidosis and alcohol, drugs- eg diuretics,
aspirin, pyrizinamide, ethambutol, cyclosporin etc,
use of alcohol especially beer and wine.

12.  D. HYPERCATABOLIC CONDITIONS-
 eg hyperthyroidism, hyperparathyroidism,
sarcoidosis, lead nephropathy.
 E. macroglobinemia- chronic haemolytic anemia,
exfoliative psoriasis, gaucher’s syndrome,
carcinomatosis etc

14. Risk
 Blood concentration of uric acid mainly depends on
the breakdown of nuclear proteins and dietary purine
load.
 Normal dietary purine load is 300- 600 mg/dl and Cell
breakdown produce- 600- 700 mg/dl
 These 1200 mg gets excreted through urine –
(600mg/day), and feces(200 mg/day)

15. Clinical features-
1.asymtomatic
 No need of treatment but diet control essential.
 Increase s. uric acid leads to release of ACTH which
control s.uric acid level but causes HT and vascular
diseases.
 Acute renal failure may takes place if severe rise in s.
uric acid level occurs , mainly due to cytotoxic drugs,
chemotherapy for leukemias and need immidiate
treatment.

16. 2.Acute gouty arthritis
 Site- first metatarsophalangeal joint(MTP) or a big toe or
step of the foot, ankles, knee, hands
 Atypical sites- tenosynovitis, bursitis, cellulitis
 Sydenhan’s description of gout-
-Starts suddenly at night
-Joints and surrounding tissues are swollen , hot, red, shiny,
painful
- skin overlying jt is erythematous and desquemate later
- mild fever with chill
- Single , unilateral jt involvements are common
manifestation.

17. - Migratory jt pain or cluster attacks may be seen
-Polyarticular- more in female and more seen with
diuretics
3. Intercritical gout- remission of disease may occur for
few months to 40 years

18. 4. Chronic gout- tophaceous gout
 Uncontrolled hyperuricemia of long duration of more
than 10 years.
 Tophy- firm , nodular or fusiform swellings
 In inflamed tophy overlying skin may be erythematous
 In ulcerative tophy- white chalky material, the urate
crystals may exude.
 Site- great toe, feet, hand, jt’s, olecranon, helix of the
ear.

21. 5. Renal disease
 urate nephropathy- deposition of MSU crystals in
renal interstitial tissue
 acute uric acid nephropathy
 Uric acid calculi
 Mix calculi
 Renal failure in 10 to 25%
 Agg factors HT, obesity
 It increse risk of MI, IHD

22. Investigations
 Confirm if 2 or more fasting s. uric acid level is
elevated
 Synovial fluid- is turbid, with increase neutrophils &
pr of needle shaped urate crystals.
 Gouty tophy- presance of urate crystals
 Renal function test
 Lipid function test

24.  ESR, CRP –raised
 X-ray- shows punched out erosions with overhanging
edges, mostly paraarticular, asymmetrical and and
eccentric.
 MRI- to see depth of disease.
 D/D- septic arthritis, RA

26. Treatment
 Control of acute
 Prevention of further attack
 Identification and correction of factors that
contributes to disease.
 Wt reduction
 Low purine diet- red meat, liver, kidney, sardines,
pulses, whole grain cereals
 Agg factors- beer, port wines should be avoided

27.  Drugs- thiazine diuretics and aspirin must be a
avoided
 control of metabolic disorder
 Medicines- Xanthine oxydative inhibitors eg
allopurinol, it helps to reduce s. uric acid level
 NSAID-indomethacin, neproxen, diclofanac,
etorcoxib, piroxicam
 Colchicine, 0.5 mg bd to control acute attack

28.  Colchicum: gout in person of vigorous constitution.
Gout attacking many joints; shifting from one to
another, with burning and tearing pains, aggravation
from noise, odor, touch, bright light. The toe and other
parts that get affected become swollen, red, and hot.
The pain worsens in the evening and at night.
Oedema, coldness of legs and feet with heaviness and
inability to move. urine, acidic, dark and scanty, uric
acid diathesis. Smell of food nauseates, frequent
ineffectual sneezing in morning.

29.  Ledum Pal: This effective homeopathic medicine is
used in cases where the pain travels in an upwards
direction from below. The pain is likely to start at the
feet and gradually move upwards, affecting the knees
and legs. Small joints are commonly affected. Lt
shoulder and right hip joint, hands, feet, ball of great
toe, soles of feet are involved. Tendons stiff, soles very
sensitive, tearing pain in toes, gouty nodosities. There
is a sensation of decreased warmth in the joints and in
the body. The pain improves by cold applications. The
ankle joint or big toe may be swollen, which may feels
cold to touch.

30.  Benzoic acid: This homeopathic medicine is used for
treating gout where offensive urine is experienced. The
urine becomes very offensive with a very strong odor,
which can be detected from a distance. The odor is
usually repulsive and the color of the urine is brown.-
or reddish cloudy .old nodes becomes painful, and as
the pains abate palpitation sets in, ceasing only when
pain increase. Gout from lt to rt. Extreme pain is
experienced in the big toe and the knees are swollen.
Wandering pains. Symptoms are worse in open air and
from uncovering the affected parts.

31.  Urtica urens:This remedy helps in the elimination of
uric acid from the body. The patient has a tendency to
gout and uric acid formations. The joint symptoms are
associated with hive-like eruptions. There is pain in
the shoulders (deltoid region), wrists and ankles. The
patient is worse from exposure to cool moist air, snow-
air, water and touch. It eliminate urine like odour from
the body. Rt side deltoid mainly affected, worse
rotating arms inward, could not put on coat.

32.  AntimCrudum: This is an efficient homeopathic
medicine used for treating gout. It is used when a
patient experiences gastric symptoms along with joint
pain and inflammation. The patient may develop an
increased craving for acidic food and hence, several
problems occur due to sour food and overeating. Pain
is experienced in the heels and fingers.

33.  Sabina: This homeopathic medicine is important for
treating gout in women when the patient already
suffers from another female disorder. Uterine
symptoms are experienced along with the basic
symptoms of gout. Shooting pain is experienced in the
toes and heels. The joints get swollen and look red and
shiny.

34.  Lycopodium:
 This remedy is for chronic gout, with chalky deposits
in the joints. Uric acid diathesis. Tophi, with tearing
,dragging pain in the limb. There is a pain in the heels
and feet with rigidity and swelling. One foot feels hot
and the other cold. The urine is slow to produce and
has heavy, red sediment. There may be a backache,
which is relieved by passing urine. The right side of the
body is particularly affected and all the complaints
seem to be worse, especially between 4pm and 8pm.
Uric acid stone in kidney.

35.  Rhododendron:
 This remedy can be useful for gouty swelling of the big
toe joint that flares up before a storm. Other joints
may ache and swell, especially on the right side of the
body. Pain usually is worse toward early morning and
after staying still too long. The person may feel better
from warmth and after eating.

36.  Calcarea fluorica:
 When this remedy is indicated, the finger joints may
become enlarged because of gout, and the knees and
toes may be involved. Stabbing pain is experienced,
and the joints may make a cracking sound on
movement. Discomfort is worse during weather
changes, and warmth may bring relief.

37.  Belladonna
 Symptoms that suggest this remedy are sudden onset.
Joints are swollen, red, throbbing and extremely
sensitive. It’s worse from touch and jarring. The person
may feel restless, flushed and hot.

38.  Arnica:
 This remedy is used when the pain is sore and bruised,
such as it hurts to walk. The person may be afraid to be
touched or approached because of pain.


39. Lithium carb
 Gout in knees, sides of feet and soles. Ankle joints pain
on walking.
 Swelling, tenderness and redness of joints especially of
fingers.
 Uric acid diathesis, profuse urine with uric acid
deposits. pain in heart before and at a time of
urination. suppression of gout causes heart
trobles(colchicum, nat phos),( suppression causes
stomach trouble- antim crude,lyco)