Gout is a disorder caused by elevated levels of uric acid in the blood that can lead to painful inflammation in joints. It most commonly affects the big toe. It is caused by either overproduction or underexcretion of uric acid by the kidneys, leading to uric acid crystal formation in joints. Risk factors include diet high in purines, obesity, genetics, and certain medical conditions. Treatment focuses on controlling uric acid levels through medications and dietary changes like limiting purine-rich foods and alcohol.

1. GOUT “The disease of kings" or “Rich man's disease".Saurabh M. Limani

2. DefinitionDisorder 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 nephropathycaused by elevated levels of uric acid in the blood which crystallize and are deposited in joints, tendons, and surrounding tissues.

4. CausesHyperuricemia is the underlying cause of goutThis 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 lifetimesThe 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)

5. CausesLifestyleDietary 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 (-)GeneticsFamilial juvenile hyperuricemic nephropathy Medullary cystic kidney disease Hypoxanthine-guanine phosphoribosyltransferase deficiencyMedical conditionsMetabolic syndrome Renal failure BMI >35 in male – risk increase threefold MedicationDiuretics, niacin, aspirin and Cyclosporine

6. CharacteristicsResembles arthritisSudden pain in big toe, with the pain continuing to the legUsually occurs after the age of 35 and is characterized by specific heritable metabolic defectsObesity is usually associated with a gouty condition

10. DiagnosisHx and PESynovial fluidBlood testsX-ray

11. Physical Examination

12. ManagementAnti inflammatory drugsProphylaxisControl of hyperuricemia- xanthin oxidase inhibitor - uricosuric agentAdjuvant 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

14. DIETARY MANAGEMENT

15. Dietary ManagementRestriction of Purine rich dietDrugs have largely replaced the need for rigid restriction of purineAll food have some traces of nucleoprotein from which purines are derivedPurines are synthesized in the body from simple metabolites, which are constantly available from dietary CHO, COOH, Fat and endogenous purine breakdownRestriction of food containing nucleoproteins is indicated in patient with high uric acid level

16. Dietary ManagementExcessive use of fats should be avoided, since fats are believed to prevent the normal excretion of urateProtein intake should be adequate but not excessiveThe calories should be maintained with carbohydratesCarbohydrates have a tendency to increase uric acid excretion

17. Acute stageRigid restriction of food containing purine Diet high in carbohydrates, moderate in protein and low in fatFluids (up to 3 liters per day) should be forced to assist the excretion of uric acid and to minimize the possibility of calculi formationSodium bicarbonate or trisodium citrate Potassium salt of carbonate and citrate

18. Interval stageDietary management + Uricosuric drugsNormal adequate diet adjusted to achieve ideal weightModerate in protein (60 to 70 gms)Increase in carbohydrates and relatively low in fatShould avoid food high in purine

19. Severe or Advanced casesLimitation 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 nucleoproteinsFluid should be adjusted to produce a normal UO (2000 ml)

20. Special consideration Alcohol- Mild to moderate - Lactic acid during the metabolism of ethanolObesity- 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

21. Low purine dietNormal diet – 600 to 1000 mg of purine dailyIn cases of severe or advanced gout the purine content of the daily diet is restricted to approximately 100 to 150 mgFat is kept to 40% of the caloric intake

23. FOOD GROUPING ACC. TO PURINE CONTENTGROUP : 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 SardinesFood in this list should be omitted from the diet of patients who have gout ( acute and remission stages)

24. 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 SpinachOne 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.

25. 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

26. 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 sauceFoods included in this group may be used daily

28. URIC ACID EXCRETION

31. HYPERTENSION AND GOUT

33. Low uric acid levelMSParkinson Disease

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