GOUT

1. Gout

2. Gout
 Deposits of sodium urate crystals in articular,
periarticular, and subcutaneous tissues
 May be primary or secondary
 Primary – hereditary error of purine metabolism
 Secondary – drugs that inhibit uric acid excretion or
another acquired disorder

3. Incidence and Risk Factors
 Primary gout accounts for 90% of cases
 Affects primarily middle aged men
 Risk factors: obesity, HTN, thiazide diuretics,
excess alcohol use

4. Pathophysiology
 Uric acid is end product of purine metabolism and
is excreted by the kidneys
 Hyperuricemia results from
 Increase in uric acid production
 Underexcretion of uric acid by kidneys
 Both
 Diet high in purines will not cause gout, but may
trigger an attack in a susceptible person

5. Clinical Manifestations
 Gouty arthritis in one or more joints (but less than
four
 Great toe joint most common first manifestation;
other joints may be the foot, ankle, knee, or wrist
 Joints are tender & cyanotic
 May be precipitated by trauma, surgery, alcohol
ingestion, or infection

6. Clinical Manifestations
 Onset usually nocturnal, with sudden swelling and
excruciating pain
 May have low grade fever
 Usually subsides within 2-10 days
 Joints are normal, with no symptoms between
attacks

7. Complications
 Joint deformity
 Osteoarthritis
 Tophi may produce draining sinuses that may
become infected
 Renal stones, pyelonephritis, obstructive renal
disease

8. Chronic Gout

9. Diagnosis
 History & physical examination
 Family history of gout
 Diagnostic studies

10. Diagnostic Studies
 Serum uric acid levels > 6 mg/dl
 May be caused by other factors
 24 hour urine uric acid levels
 Synovial fluid aspiration contains uric acid crystals
 Seldom necessary, as diagnosis based on clinical
symptoms possible in 80% of cases
 X-rays appear normal in early stages; tophi appear as
eroded areas of bone

11. Collaborative Care
 Acute attack
 Colchicine produces dramatic antiiflammatory
effects with relief within 24-48 hours
 NSAIDs for additional pain relief
 Corticosteroids (po or intraarticular)
 Adrenocorticotropic hormone (ACTH)
 Joint aspiration to decompress

12. Collaborative Care
 Prevention of acute attacks
 Colchicine combined with:
 allopurinol (Zyloprim, Alloprim) – blocks production of
uric acid
 probenecid (Benemid), sulfinpyrazone (Anturane) –
inhibit tubular reabsorption of uric acid
 febuxostat (Uloric) – inhibits xanthine oxidase, recently
shown to reduce serum uric acid levels

13. Collaborative Care
 Dietary measures
 Weight reduction
 Avoidance of alcohol
 Avoidance of foods high in purines
 High: Sardines, anchovies, herring, mussels, liver,
kidney, goose, venison, meat soups, sweetbreads, beer
& wine
 Moderate: Chicken, salmon, crab, veal, mutton, bacon,
pork, beef, ham

14. Collaborative Care
 Prevention of renal stones
 Increase fluid intake to maintain adequate urine
output
 Allopurinol
 ACE inhibitor losartin (Cozar) – promotes urate
diuresis

15. Nursing Care
 Acute gouty arthritis – pain control
 Gentle, supportive care of affected joints
 Immobilize and rest affected joints – bed rest or
NWB
 Cradle or footboard to prevent pressure from
bedcovers
 Monitor ROM and degree of pain

16. Nursing Care
 Patient/Family teaching
 Gout is a chronic disease
 Drug teaching
 Need to monitor serum uric acid levels
 Precipitating factors
 Excess calorie intake, alcohol intake, purine rich foods
 Fasting
 Niacin, ASA, diuretics
 Surgery or major medical event such as MI

17. Learning Objectives :

 Learning Objectives Classify the drugs commonly
used in the treatment of gout. Mention the
indications, side effects, dosage and toxicities of
drugs used in the treatment of gout Design a plan
for treatment of gout. Prescribe the appropriate
treatment for different cases of gout. Enumerate
the tests required for monitoring of the therapy of
gout

18. Gout :
 Gout Metabolic disorder Characterized by
hyperurecamia (normal plasma urate 1-4mg/dl)
Acute gout: sudden onset of severe inflammation
in the small joint due to precipitation of urate
crystals in the joint space. Chronic gout: pain and
stiffness persist in the joint between attacks.

19. Classification of drugs
for the treatment of
Acute Gout. :
 Classification of drugs for the treatment of Acute
Gout. NSAIDs Colchicine Corticosteroid In acute
attack arthritis is treated first and Hyperuricemia
later

20. Drugs for Chronic gout :

 Drugs for Chronic gout Uricosuric Drugs:
Probenecid Sulfinpyrazone Uric acid synthesis
inhibitor Allopurinol

21. Non-steroidal Anti-
inflammatory agents
(NSAIDs) :
 Non-steroidal Anti-inflammatory agents
(NSAIDs) Strong anti-inflammatory agent:
(Indomethacin, Naproxen, Piroxicam, Diclofenac
or Etoricoxib) Given in relatively high and
quickly repeated dose. Effective in terminating
the acute attack (but my take 12-24hours)
Naproxen, Piroxicam also inhibits chemotactic
migration of leukocytes into the inflamed joint.
Once acute attack is over, reduce the dose and
continue the drug for 3-4 weeks.

22. Dose of NSAIDs for acute
attack of gout :
 NSAIDs in high doses taken with food are:
Naproxen: 750 mg immediately, then 500 mg
every 8-12 hours Diclofenac: 75—100 mg
immediately, then 50 mg every 6-8 hours
Indomethacin: 75 mg immediately, then 50 mg
every 6-8 hours. After 24-48 hours, reduced doses
are given for a further week. Contraindications:
active peptic ulcer disease/ impaired renal
function/ allergy to NSAIDs. Dose of NSAIDs for
acute attack of gout

23. Colchicine :
 Colchicine Alkaloid from Colchicum autumnale.
Suppresses gouty inflammation Neither analgesic
nor anti-inflammatory. No effect on blood uric
acid level. Acts by binding to microtubules of
neutrophils/ monocytes destroy microtubule 
loss of movement and phagocytosis by the
leucocytes. ADRs: GI upset/ bloody diarrhea/
abd.pain/ hematological disorders/loss of hair/
sometimes motor paralysis.

24. Uses:

Treatment of Acute attack: effective within first
24h of attack. A small dose (0.5 -1.5mg) taken at
first symptom of attack abort it. Dose:1mg PO
followed by 0.25mg 1-3 hourly till the acute
attack is over or total dose of 6mg is given or
diarrhea starts. Maintenance dose 0.5-1mg/day for
4-8 weeks. Prophylaxis of gout: 0.5 -1mg/day
(prevents further attack) Doses should be
decreased in renal and hepatic dysfunction

25. Corticosteroid :
 Corticosteroid Gives dramatic symptomatic relief.
Used if NSAIDs are contraindicated. If Gout is
monoarticular: intra-articular administration (e.g.
triamcinolone, 10-40mg depending of size of
joint) For Polyarticular gout: IV or Orally
Methylprednisolone 40mg/day IV tapered over 7
days. Prednisolone 40-60mg/day orally tapered
over 7 days

26. Chronic gout :
 Chronic gout Pain and stiffness persist in between
attack. Hyperuricaemia Tophi Urate stone in
kidney Progressive disability. Tophi

27. Uricosuric Drugs :
 Uricosuric Drugs Uricosuric drug enhances uric
acid excretion via kidney Uricosuric drugs are
similar to urate in structure Blocks the tubular
reabsorption of filtered urate thereby reducing
metabolic urate pool and preventing formation of
new Tophi and reduce the size of those already
present. When given with Colchicine, they lessen
the frequency of recurrences of acute gout.

28. Indications:
 Increasing frequency or severity of acute attacks.
Precautions with uricosuric drugs: (to reduce
precipitation of uric acid in urinary tract)
Maintain daily urinary output of 2 liters or more.
Maintain urinary pH above 6.0 (give potassium
citrate 30-80mEq/d) Uricosuric drugs are avoided
in patients with history of uric acid
nephrolithiasis. Aspirin in Moderate doses (<3g/d)
antagonizes the action of uricosuric agents and
aggravates hyperuricemia.

29. Probenecid :

 Probenecid Uses: Chronic gout and
hyperuricaemia: (2nd line/ adjuvant drug)
0.5g/day initially, with gradual increase to 1-2g
daily. It gradually lowers blood urate level.
Ineffective in the presence of renal insufficiency
(serum creatinine >2mg/dl) Adverse effects:
rashes, allergic dermatitis, upper GIT irritation,
and drowsiness. Inhibits excretion of penicillin,
dapsone indomethacin, and acetazolamide.

30. Sulfinpyrazone :

 Sulfinpyrazone Uses: In chronic gout: start with
100-200mg BD, gradually increase according to
response (Max. dose 800mg/d) Uricosuric action
is additive with probenecid but antagonized by
Salicylates. It inhibits platelet aggregation.
Adverse effects: gastric irritation/rashes/
hypersensitivity reaction.

31. 
Uric acid synthesis inhibitor(Allopurinol)
Hypoxanthine Xanthine Uric Acid
Xanthineoxidase Xanthineoxidase Allopurinol -ve
-ve

32. 
 Competitive inhibitor of uric acid synthesis by
inhibiting xanthine oxidase. Xanthine oxidase is
involved in the metabolism of hypoxanthine and
xanthine to uric acid. Promptly lowers plasma
urate and urinary uric acid concentration and
facilitates tophus mobilization. Allopurinol is very
effective in uric acid overproducers.

33. Dose:
 initially 100mg/d of allopurinol is given for 1
week, the dose is increased to 200 – 300mg/d, if
serum uric acid is still high. ADRs: precipitation
of acute gouty arthritis in the initial month of
therapy /GI upset/ skin rash/ alopecia. Probenecid
increases the excretion of allopurinol If patient
taking both Probenecid and allopurinol than ↑dose
of allopurinol and ↓ dose of Probenecid

34. Treatment plan for acute
attack of Gout :

 Treatment plan for acute attack of Gout Treatment
is given for symptomatic relief only As the attack
is self-limited and resolve spontaneously Toxicity
of therapy must be considered in each patient.
Arthritis is treated first and hyperuricemia later.
NSAIDs: treatment of choice when not
contraindicated.

35. Treatment plan of Acute
Gout :

 Treatment plan of Acute Gout NSAIDs
Contraindicated? Renal insufficiency Peptic ulcer
disease Congestive heart failure NSAID
intolerance Are Corticosteroids Contraindicated?
NSAIDs Antiinflamatory doses Corticosteroids
Oral Colchicine Oral or Intraarticular Steroid
Intraarticular PO Steroid

36. Indomethacin:
 75 mg immediately, then 25-50 mg every 8 hours
till the symptoms resolves (usually 5-10days)
Glucocorticoids are useful when NSAIDs are
contraindicated Monarticular Gout: intra-articular
triamcinolone, 10–40 mg. Polyarticular
gout:Methylprednisolone 40 mg/d I.V tapered
over 7 days or Prednisone, 40–60 mg/d orally
tapered over 7 days.

37. Management of gout in
between attack :
 Management of gout in between attack Low-
purine diet: Lose weight Less meat and seafood
consumption Higher intake of dairy products A
high liquid intake (daily urinary output of 2 L or
more) Avoidance of hyperuricemic medications:
(Thiazide and loop diuretics and low dose
Aspirin)

38. Drug Treatment of
Chronic gouty arthritis :
 Indication: > 2-3 attacks/year  initiate
prophylaxis. Uricosuric: for under-excretors
Probenicid: Sulfinpyrazone: toxic side effects
Avoid with renal disease Consider NSAIDs to
avoid exacerbation of gout Indications for
Allopurinol Tophaceous deposites Uric acid
consistently >9mg/dl Impaired renal function
Prophylaxis for tumor-lysis syndrome Consider
NSAID’s to avoid exacerbation Drug Treatment
of Chronic gouty arthritis

39. Tests required for
monitoring of the therapy
of gout :
 Tests required for monitoring of the therapy of
gout After the acute phase is over take steps to see
Blood uric acid level is normalized. Tophis if
present is are reversed. Nephropathy if present is
reversed or at least halted.

40. Pseudogout :
 Pseudogout Deposition of calcium containing
salts in articular surface. Occurs in many diseases
e.g. hyperperathyroidism, diabetes, wilson’s
disease etc. Ocurs in persons >60years.
Characterized by acute and recurrent arthritis
involving large joints (knee and wrist) Treatment:
NSAIDs/ intraarticular glucocorticoid/
colchicines.