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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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