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					                                                       acid levels can be caused by two
Gout                                                   different things:
                                                           o Overproduction (10% of
Gout - describes a disease spectrum                            patients) - synthesize
including hyperuricemia, recurrent                             abnormally high amounts
attacks of acute arthritis associated with                     of uric acid and.
monosodium urate crystals in the                           o Underexcretion (90% of
synovial fluid of joints, deposits of                          patients) – synthesize
monosodium urate crystals in tissues                           normal amounts of uric
(tophi), interstitial renal disease, and uric                  acid but they do not
acid nephrolithiasis.                                          excrete it as well as they
Hyperuricemia - an asymptomatic
condition, with an increased serum uric               Secondary hyperuricemia and
acid concentration as the only apparent                gout develop as a result of
abnormality. Uric acid levels greater                  another disease or as a result of
than 7 mg/dl are considered highly                     drug therapy.
abnormal and is associated with an                        o Hematologic causes
increased risk for gout.                                  o Chronic renal failure
                                                          o Drug induced disease
General Information
    Gout mostly effects men (95% of            1. Asymptomatic Hyperuricemia
      cases), and most women that do                Characterized by an elevated
      experience gout are                             uric acid level but patient
      postmenopausal.                                 exhibits no signs or symptoms
    The mean age at disease onset is                 of deposition such as arthritis,
      47 years old.                                   tophi, or urolithiasis.
    Risk of developing gout                        Because uric acid levels up to 13
      increases as the serum uric acid                mg/dl in men and 10 mg/dl in
      level rises (>7 mg/dl).                         women have not been shown to
    Gout has a familial tendency, 10-                be harmful there is no drug
      60% of cases occur in family                    treatment required for this stage.
      members of patients with gout.                Supportive interventions may
    Factors associated with                          include maintenance of adequate
      hyperuricemia and gout:                         urine output, avoidance of high
           o Obesity                                  purine foods, and regular
           o Hypertension                             monitoring of uric acid levels.
           o Hyperlipidemia
           o Atherosclerosis                    2. Acute Gouty Arthritis:
           o Alcohol abuse                          Presentation of gout is
                                                      characterized by painful
Causes                                                arthritic attacks of sudden
    Primary hyperuricemia and                        onset.
       gout may result from a defect in             Signs and Symptoms:
       purine metabolism or uric acid
       excretion. The increase in uric
          o Initial attack is sudden,               Sulindac – 200 mg BID to start,
            usually occurring at night               reducing the dose with
            or in early morning.                     satisfactory response.
          o Affected joints become hot,             Colchicine disrupts urate
            swollen, and extremely                   deposition and the inflammatory
            tender.                                  response that inflames the joint.
          o The most common site is                  It is best to start between 12 and
            the first                                36 hours after symptoms begin.
            metatarsophalangeal joint,               This drug is dosed 1.2 mg STAT,
            an attack here is known as               then followed by 0.6 mg every 2
            Podagra                                  hours until pain relief or until
                                                     diarrhea (80% of patients)
                                                     develops (max dose 8 mg). Can
                                                     be used for future attack given
                                                     half the dose of the initial attack
                                                     and then 0.6 mg every 2 hours in
                                                     the same manner as above.
                                                    Corticosteroids provide fast
                                                     relief and can be administered
                                                     intra-articularly (triamcinolone
                                                     hexacetonide) or taken by mouth
Figure 1. First MP Joint is the most common
                                                     (oral prednisone). This route of
site.                                                treatment is only recommended
Treatment:                                           when NSAIDS and Colchicine
o Even if untreated it will completely               have been ineffective.
   resolve on its own!
o You want to first immobilize the            3. Intercritical Gout:
   affected joint                                  The symptom free period after
o Second you want to treat the pain                   the first attack. Eventually this
   with anti-inflammatory drug                        phase is interrupted by the
   therapy…but you do not want to                     recurrence of acute attacks.
   treat the increased uric acid levels            Onset of attacks:
   until patient is stable.                           o The second attack usually
    Indomethacin – 50 mg TID until                       occurs within one year from
       pain is tolerable then dose is                     the first, although it may be
       rapidly reduced and finally                        delayed for 5-10 years. If the
       discontinued. Side effects                         increased uric acid is
       include nausea, stomach                            secondary and treated
       discomfort, headache, and                          appropriately then patients
       dizziness. You can take this                       may never experience a
       medication with food to decrease                   second attack.
       these side effects.                    Treatment:
    Naproxen – 750 mg STAT                   o Prevent by identifying and correcting
       followed by 250 mg every 8                 the cause of increased uric acid OR
       hours until attack subsides.               by administering drugs that inhibit
    the synthesis of urate or increase its          blocking its reuptake by the
    excretion.                                      kidneys, therefore it is more
o   Non-drug urate reducing –                       easily excreted.
    avoiding a high purine diet, weight            Fenofibrate (Tricor) – this is a
    loss if obese, and decreased alcohol            good choice if patient also has
    consumption.                                    high triglycerides. This agent
o   Prophylaxis – low dose colchicine               lowers uric acid levels by
    0.6 mg twice daily (assuming normal             increasing renal clearance.
    renal function). In elderly patients           Febuxostat is an investigational
    who develop loose stool or diarrhea             drug which is an alternative to
    0.6 mg every other day may be                   Allopurinol. It works the same
    suffice. Low dose NSAIDS as                     way although it may be more
    mentioned before may be effective               effective.
    but carries a higher risk of side
    effects.                                 4. Chronic Tophaceous Gout:
o   Uricosurics – Probenecid and                This may occur if gout and
    Sulfinpyrazole are preferred for              hyperuricemia go untreated for
    underexcreters. These meds work by            many years.
    blocking the reuptake of urate by the       The constant increased levels of
    kidneys therefore it is easily                uric acid lead to development of
    excreted. Probenecid is given                 tophi in the synovial, olecranon
    initially in two oral doses of 250 mg         bursae, and other periarticular
    for 1 week, and then increased to 500         locations.
    mg twice daily every 1-2 weeks until        Eventually the cartilage may be
    serum uric acid level drops < 6               destroyed and the joint may
    mg/dL (titrate to 1.5 g/day).                 become deformed.
    Sulfinpyrazole is given initially in        Allopurinol and Probenecid may
    two daily doses of 50 mg, then                be given in combo to treat severe
    increased by 100 mg weekly (titrate           situations.
    to 200 mg/day).
o   Xanthine oxidase inhibitor –                 What does this mean for
    Allopurinol blocks the final step in
                                                   seniors with gout?
    uric acid synthesis. It may be used      The treatments for gout
    for both underexcreters and              unfortunately are not normally used
    overproducers. Allopurinol is given      in senior citizens because of the
    initially in a daily dose of 100-        increased risk of GI ulcers and
    300mg/day, and then increased in         cardiovascular effects….Although in
    weekly increments if needed. The         the case of GOUT the benefit of
    main adverse effect is a rash which      treatment outweighs the risk. This
    usually subsides with a lower dose.      means it is very important for
o   Other drugs that increase uric acid      patients to consult their doctor
    excretion:                               about adverse effects to be aware of
     Losartan (Cozaar) – this is a          while on therapy!!!!
         good choice if patient is also
         hypertensive. This agent lowers
         serum uric acid levels by

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