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When In Gout.
- 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, M3 Note: The following lecture contains only 0.3% of your recommended daily educational value.
- 5. Hello Dr. Gir. Thanks for having me.
- 6. If you’re not supposed to have lots of acid in your blood, then what is GOUT?
- 7. If you’re not supposed to have lots of acid in your blood, then what is GOUT? An inflammatory response to elevated crystalized uric acid levels depositing into joint spaces leading to destruction and pain
- 9. Sure. But what causes gout?
- 10. Sure. But what causes gout?
- 11. Improper metabolism/excretion of Purines Bases (Adenosine and Guanine)
- 12. Improper metabolism/excretion of Purines Bases (Adenosine and Guanine) What the heck does that mean?
- 14. PURINE METABOLISM WTF?
- 20. DNA Synthesis
- 21. DNA Synthesis
- 23. DNA Synthesis Purine Synthesis Purine Metabolism
- 24. DNA Synthesis Purine Synthesis Purine Metabolism
- 25. WHAT CAUSES GOUT? Serum Uric Acid > 6.7 mg/dl
- 26. WHAT CAUSES GOUT? ➝ Serum Uric Acid > 6.7 mg/dl ➝ Supersaturation
- 27. WHAT CAUSES GOUT? ➝ ➝ Serum Uric Acid > 6.7 mg/dl ➝ Supersaturation
- 28. WHAT CAUSES GOUT? Increased uric acid levels usually asymptomatic
- 29. WHAT CAUSES GOUT? Increased uric acid levels usually asymptomatic Gouty Attacks: •Increased urate crystals released •Form de novo in the joint space •Trauma •Surgeries •Medications (allopurinol, diuretics, cyclosporine)
- 30. WHO GETS GOUT? 1% of Americans (3 million)
- 31. WHO GETS GOUT? 1% of Americans (3 million)
- 32. WHO GETS GOUT?
- 33. WHO GETS GOUT? •2x Men vs. Women
- 34. WHO GETS GOUT? •2x Men vs. Women •Estrogen has mild uricosuric effect
- 35. WHO GETS GOUT? •2x Men vs. Women •Estrogen has mild uricosuric effect •(i.e. gout rare in pre-menopausal)
- 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
- 37. 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)
- 38. 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:
- 39. 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
- 40. 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
- 41. 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
- 42. 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)
- 43. WHAT DOES GOUT FEEL LIKE?
- 45. CLINICAL PRESENTATION •Redness, swelling, intense pain
- 46. CLINICAL PRESENTATION •Redness, swelling, intense pain •Fever/Chills
- 47. CLINICAL PRESENTATION •Redness, swelling, intense pain •Fever/Chills •Usually at night
- 48. CLINICAL PRESENTATION •Redness, swelling, intense pain •Fever/Chills •Usually at night •Monoarticular
- 49. CLINICAL PRESENTATION •Redness, swelling, intense pain •Fever/Chills •Usually at night •Monoarticular •Commonly 1st metatarsophalangeal (Greek for “Big Toe”) joint
- 50. 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)
- 51. 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
- 52. 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
- 53. POLYARTICULAR GOUT Note: Currently there are ZERO reports of gout causing helmet-shaped heads.
- 54. CHRONIC GOUT
- 56. CHRONIC GOUT Erosive Deposits Ear Tophi
- 57. CHRONIC GOUT Erosive Deposits Ear Tophi Deforming Arthritis
- 58. CHRONIC GOUT Erosive Deposits Ear Tophi Deforming Arthritis •Women > Men •~Rheumatoid
- 59. DIAGNOSIS Acute Gouty Attack vs. Septic/Cellulitis Joint?
- 60. DIAGNOSIS Acute Gouty Attack vs. Septic/Cellulitis Joint? High/Low Serum Uric Acids NOT Sensitive/Specific
- 61. DIAGNOSIS Acute Gouty Attack vs. Septic/Cellulitis Joint? High/Low Serum Uric Acids NOT Sensitive/Specific Definitive Dx ➝ Joint Aspiriation
- 62. DIAGNOSIS
- 63. DIAGNOSIS Clinical Dx (any 6 of the following)
- 64. DIAGNOSIS Clinical Dx (any 6 of the following) >1 acute arthritis attack
- 65. DIAGNOSIS Clinical Dx (any 6 of the following) >1 acute arthritis attack > Max inflammation developed within a day
- 66. DIAGNOSIS Clinical Dx (any 6 of the following) >1 acute arthritis attack > Max inflammation developed within a day One joint
- 67. DIAGNOSIS Clinical Dx (any 6 of the following) >1 acute arthritis attack > Max inflammation developed within a day One joint Redness of Joint
- 68. DIAGNOSIS Clinical Dx (any 6 of the following) >1 acute arthritis attack > Max inflammation developed within a day One joint Redness of Joint 1st toe pain/swelling
- 69. DIAGNOSIS Clinical Dx (any 6 of the following) >1 acute arthritis attack > Max inflammation developed within a day One joint Redness of Joint 1st toe pain/swelling Unilateral tarsal joint
- 70. DIAGNOSIS Clinical Dx (any 6 of the following) >1 acute arthritis attack > Max inflammation developed within a day One joint Redness of Joint 1st toe pain/swelling Unilateral tarsal joint Suspected Tophus
- 71. DIAGNOSIS Clinical Dx (any 6 of the following) >1 acute arthritis attack > Max inflammation developed within a day One joint Redness of Joint 1st toe pain/swelling Unilateral tarsal joint Suspected Tophus Hyperuricemia
- 72. DIAGNOSIS Clinical Dx (any 6 of the following) >1 acute arthritis attack > Max inflammation developed within a day One joint Redness of Joint 1st toe pain/swelling Unilateral tarsal joint Suspected Tophus Hyperuricemia Asymmetric joint swelling on PE or XR
- 73. DIAGNOSIS Clinical Dx (any 6 of the following) >1 acute arthritis attack > Max inflammation developed within a day One joint Redness of Joint 1st toe pain/swelling Unilateral tarsal joint Suspected Tophus Hyperuricemia Asymmetric joint swelling on PE or XR Cysts w/o Erosions on XR
- 74. DIAGNOSIS Clinical Dx (any 6 of the following) >1 acute arthritis attack > Max inflammation developed within a day One joint Redness of Joint 1st toe pain/swelling Unilateral tarsal joint Suspected Tophus Hyperuricemia Asymmetric joint swelling on PE or XR Cysts w/o Erosions on XR Negative Joint Fluid Cx
- 75. DIAGNOSIS Clinical Dx (any 6 of the following) >1 acute arthritis attack > Max inflammation developed within a day One joint Redness of Joint 1st toe pain/swelling Unilateral tarsal joint Suspected Tophus Hyperuricemia Asymmetric joint swelling on PE or XR Cysts w/o Erosions on XR Negative Joint Fluid Cx Urate microcystals in joint fluid during attack
- 76. DIAGNOSIS
- 77. DIAGNOSIS
- 78. DIAGNOSIS Synovial Fluid WBC’s > 15,000 (Majority PMNs)
- 79. DIAGNOSIS Synovial Fluid WBC’s > 15,000 (Majority PMNs) If WBC’s > 50,000 ➝ Infected
- 80. DIAGNOSIS Synovial Fluid WBC’s > 15,000 (Majority PMNs) If WBC’s > 50,000 ➝ Infected Start empiric ABx unless Cx R/O Infection
- 81. TREATMENT
- 82. TREATMENT NOT Required to determine if under- excretor or over-producer
- 83. TREATMENT NOT Required to determine if under- excretor or over-producer Under or Over excreters respond to allopurinol
- 84. TREATMENT NOT Required to determine if under- excretor or over-producer Under or Over excreters respond to allopurinol Allopurinol Intolerance ➝ verify no Hx of Nephrolithasis and an under-excretor
- 86. TREATMENT Gouty Arthritis NSAIDS (caution: renal disease, bleeding, ulcers, elderly)
- 87. TREATMENT Gouty Arthritis NSAIDS (caution: renal disease, bleeding, ulcers, elderly) Corticosteroids - 40 mg/day (caution: DM)
- 88. TREATMENT Gouty Arthritis NSAIDS (caution: renal disease, bleeding, ulcers, elderly) Corticosteroids - 40 mg/day (caution: DM) -Intra-articular Steroid Injection (Once infection R/O)
- 89. TREATMENT Gouty Arthritis NSAIDS (caution: renal disease, bleeding, ulcers, elderly) Corticosteroids - 40 mg/day (caution: DM) -Intra-articular Steroid Injection (Once infection R/O) Colchicine
- 90. TREATMENT Gouty Arthritis NSAIDS (caution: renal disease, bleeding, ulcers, elderly) Corticosteroids - 40 mg/day (caution: DM) -Intra-articular Steroid Injection (Once infection R/O) Colchicine Most effective: one joint, <24 hrs
- 91. TREATMENT Gouty Arthritis NSAIDS (caution: renal disease, bleeding, ulcers, elderly) Corticosteroids - 40 mg/day (caution: DM) -Intra-articular Steroid Injection (Once infection R/O) Colchicine Most effective: one joint, <24 hrs Normal renal function ➝ 2 or 3 six mg doses a day until relief
- 92. TREATMENT Gouty Arthritis NSAIDS (caution: renal disease, bleeding, ulcers, elderly) Corticosteroids - 40 mg/day (caution: DM) -Intra-articular Steroid Injection (Once infection R/O) Colchicine Most effective: one joint, <24 hrs Normal renal function ➝ 2 or 3 six mg doses a day until relief Avoid IV form ➝ bone marrow/neuromuscular tox
- 94. TREATMENT Hyperuricemia Dietary Purine Restriction
- 95. TREATMENT Hyperuricemia Dietary Purine Restriction Alcohol
- 96. TREATMENT Hyperuricemia Dietary Purine Restriction Alcohol Anchovies
- 97. TREATMENT Hyperuricemia Dietary Purine Restriction Alcohol Anchovies Mushrooms
- 98. TREATMENT Hyperuricemia Dietary Purine Restriction Alcohol Anchovies Mushrooms Organ foods (livers, kidneys), Dried beans, peas, spinach, asparagus, cauliflower
- 99. TREATMENT Hyperuricemia Avoid Medications Thiazides Low Dose Aspirin
- 104. TREATMENT Hyperuricemia Start Pharmacologic Treatment: •Tophi •Renal Stones •↑ Frequency of Attacks
- 105. TREATMENT Hyperuricemia Start Pharmacologic Treatment: •Tophi •Renal Stones •↑ Frequency of Attacks • D/C’ing chronic therapy ➝ can worsen Sx
- 106. 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
- 107. 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)
- 108. 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)
- 110. THANK YOU
- 111. Looks like me. THANK YOU
- 112. PLAGIARIZED SOURCES 1. MKSAP 15: Rheumatology: Crystal-Induced Athropathies 2. MedScape: http://emedicine.medscape.com/article/329958-overview 3. http://mips.helmholtz-muenchen.de/genre/proj/uwe25/images/pw_purine.gif 4. http://scienceblogs.com/moleculeoftheday/images/gout-cartoon.jpg 5. http://www.enzyme-database.org/reaction/misc/miscgif/purine2.gif 6. http://images.inmagine.com/img/creatas/crs026/crs026089.jpg 7. http://www.morecoloringpages.com/coloring_pages/sm_color/boy_playing_3.gif 8. http://www.visualphotos.com/photo/2x4630684/african_baby_playing_with_blocks_bld040962.jpg 9. http://upload.wikimedia.org/wikipedia/commons/a/ac/Fluorescent_uric_acid.JPG 10. http://onlinehealthtips.net/wp-content/uploads/2010/04/Gout-pain.jpg
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