Gout is a chronic disorder of urate metabolism that causes recurrent attacks of inflammatory arthritis. It is most common in men over 40 years of age. Risk factors include purine-rich foods, alcohol, caffeine, trauma, and certain genetic mutations. An acute gout attack causes sudden severe pain, swelling, and tenderness in joints like the toe. Chronic gout results in deposits of urate crystals that form chalk-like tophi under the skin. Treatment involves medications to prevent attacks like NSAIDs, colchicine, allopurinol, and febuxostat or uricosurics. Surgery may be needed in advanced cases with joint destruction.

1. GOUT
PRESENTER – DR SAGAR T P

2. INTRODUCTION
• It’s a chronic heterogeneous disorder of urate
metabolism.
• The word gout is derived from the latin word ‘gutta’
• THE DISEASE OF THE KINGS

3. EPIDIMIOLOGY
• Most common inflammatory arthritis in men >40 years
• M:F::10:1
• Western > India
• Urban > rural
• INCIDENCE – IN INDIA 0.3 %
IN WORLD 0.3 to .6

4. PREDISPOSING FACTORS
1. PURINE RICH FOODS
2. CAFFEINE
3. DRUGS -
4. ALCOHOL
5. TRAUMA
6. DISEASES – a) Lesch-Nyhan syndrome
b) Von Gierke’s disease
c) Syndrome X
7. GENETIC MUTATIONS- SLC22A9, SLC22A12, ABCG2

5. BIOCHEMICAL BASIS OF GOUT
• Biologically significant hyperuricemia >6.8

6. Metabolic defect

7. CLASSIFICATION
1. PRIMARY
2. SECONDARY - Leukemia
- Pernicious anemia
- Hemolyic anemia
- Polycythemia
- Anti cancer therapy

9. CLINICAL PRESENTATION
• STAGES
• Stage 1: Asymtomatic hyperuricemia
• Stage 2: Acute gout attacks
• Stage 3 : Intercritical period
• Stage 4: Chronic tophaceous gout

11. ACUTE GOUT -
• Pain –
• swelling
• Fever
• O/E –
• Joints-warm,
erythematous
• tenderness
• Attacks resolve within days to weeks without treatment
• Mc affects the MTP joint of great toe, 1st MTP joint- PODAGRA
• Second attack within 1 year in 60% ppl, within 3 yrs in 80% ppl

13. CHRONIC GOUT –
• Foreign body granuloma surrounding
deposits of MSU crystals
• Chalk like subcutaneous nodule(s) under
transparent skin , often with overlying
vascularity
• Increased risk for nephrolithiasis

14. CHRONIC GOUT

15. LAB INVESTIGATIONS
• Serum Uric acid
• 24hrs Urine collection for uric acid
• BUN
• Creatinine level
• CBC
• ESR/CRP

16. SYNOVIAL FLUID ANALYSIS
• “Polarized light microscopy” – gold standard
• Crystals – intracellular during attacks
• Needle and rod shaped
• Strong negative birefringence
• Cell count elevated from 2,000 to 60,000

17. RADIOLOGY

19. MRI IN GOUT

21. DIFFERENTIAL DIAGNOSIS
• ACUTE
1. Septic arthritis
2. Bursitis
3. Cellulitis
4. Tenosynovitis
5. Traumatic arthritis
6. Sarcoid arthritis
• CHRONIC
1. Nodular RA
2. RA (Heberden and Bouchard)
3. Sarcoid arthritis
4. Xanthomatosis

22. Treatment
• MEDICAL
1.ACUTE GOUT-
NSAIDS- ETORICOXIB(NEUCOXIA) 120MG FOR 1 WEEK
NAPROXEN 750-1G PO IN DIVIDED DOSES
INDOMETHACIN- 150MG PO DAILY FOR 3 DAYS IN DIVIDED DOSES
THEN 100MG PO DAILY FOR 4-7 DAY

23. COLCHICINE
• Mechanism Of Action –
• Inhibits E-selectin-mediated adhesiveness for neutrophils and
diminishes neutrophil L-selectin expression, random motility,
chemotaxis, PLA2 activation, and IL-1 expression, as well as the
stimulated elaboration of PLAF (platelet-activating factor) and the
chemotatic factors CCF and LTB4
• Biliary and faecal excretion
• Dose - 1.2mg stat, 0.6mg after 1 hour and then after 12 hour until gout
flare resolves
• 0.6mg OD/ BID
• S/E - nausea, vomiting , diarrohea

24. 2. CHRONIC GOUT
URIC ACID SYNTHESIS INHIBITORS
ALLOPURINOL
FEBUXOSTAT
URICOSORICS
1. PROBENACID
2. SULFINPYRAZONE

25. ALLOPURINOL
• Because at the place of purine base Allopurinol metabolized by Xanthine oxidase and
decrease uric acid concentration.

26. Uses of ALLOPURINOL : Dose = 300mg/day
1. To prevent chronic gout attacks
2. Secondary hyperuricemia
3. To treat kidney stones

27. Side effects of ALLOPURINOL
• Nausea, diarrohea, elevated liver enzymes,
Hepatic disease (granulomatous hepatitis
cholestatic jaundice, advanced liver necrosis)
• BM suppression
• Allopurinol hypersensitivity Syndrome

28. FEBUXOSTAT
• Selective inhibitor of Xanthine Oxidase
• Dose = GIVEN AT 40MG/DAY , if urate levels doesn’t decrease in 2
wks then increase to 80mg/day . Max 300mg /day
• Side effects - rash, elevation of liver enz, diarrhea

29. URICOSURIC DRUGS
DOSE = PROBENECID = 250mg BID

30. Indications of surgery -
1. Advanced tophi with joint destruction
2. Loss of involved joint movements associated with pain
3. Tophi collection causing pressure symtoms
4. Tophaceous ulcer
5. Cosmetic

31. Surgical options
• Removal of tophi
• Joint fusion
• Joint replacement

32. LONG TERM COMPLICATIONS OF THE DISEASE
• Joint Damage and Deformity
• Kidney Stones
• Kidney Disease
• Heart Disease
• Other Conditions – Cataracts, Dry eye syndrome