Gouty Arthritis

Jeffrey A.Ongkowijaya
SMF Ilmu Penyakit Dalam RSUP Prof dr RD Kandou
Manado
Introduction
An elevated serum urate concentration
(hyperuricemia)
Recurrent attacks of acute arthritis in which
monosodium urate monohydrate crystals are
demonstrable in synovial fluid leukocytes
Aggregates of sodium urate monohydrate
crystals (tophi) deposited chiefly in and around
joints, which sometimes lead to deformity and
crippling
Renal disease involving glomerular, tubular,
and interstitial tissues and blood vessels
Uric acid nephrolithiasis
Hyperuricemia : serum uric acid >7mg%
(males) and >6mg% (females)
 Gout can also
occur as a result of
overproduction of
uric acid
Gout is an attack
of uric acid
deposits in joints
Usually found in
joints of feet and
legs
 Purines are not
properly processed
in our body
Excreted through
kidneys and urine
Hyperuricemia-
build-up of uric
acid in body and
joint fluid
Pathogenesis
Gout risk factor
Male High BMI (obesity)
Postmenopausal Diet high in meat &
female seafood
Older
Alcohol intake
1977 ACR criteria for acute gout
The presence of characteristic urate crystals in the
joint fluid, or a tophus proved to contain urate crystals
by chemical means or polarized light microscopy, or
the presence of 6 of the following 12 clinical,
laboratory, and radiographic phenomena:
1. More than one attack of acute arthritis
2. Maximum inflammation developed within 1 day
3. Monoarthritis attack
4. Redness observed over joints
5. First metatarsophalangeal joint painful or swollen
6. Unilateral first metatarsophalangeal joint attack
7. Unilateral tarsal joint attack
8. Tophus (proven or suspected)
9. Hyperuricemia
10. Asymmetric swelling within a joint on x ray/exam
11. Subcortical cysts without erosions on x ray
12. Monosodium urate monohydrate microcrystals in joint
fluid during attack
13. Joint fluid culture negative for organisms during attack
The Four Stages of Gout
Asymptomatic
Acute
Intercritical
Chronic
ASYMPTOMATIC
A- meaning without
indicates that there
are no symptoms
associated
Patient will be
unaware of what is
happening
Gout can only be
determined with the
help of a physician
 Sever and sudden
onset
Involve one or a
few joints
Frequently starts
nocturnally
Joint is warm, red,
and tender

ACUTE
INTERCRITICAL
More
concentration of
uric acid crystals
Typically no need
for drug
intervention at the
time.
CHRONIC
Continuous or persistent
over a long period of time
Treatment required
Not easily or quickly
resolved
 SYMPTOMS

Joint pain
Affects one or more joints : hip, knee, ankle,
foot, shoulder, elbow,wrist, hand, or other
joints
Great toe, ankle and knee are most common
Swelling of Joint
Stiffness
Warm and red
Possible fever
Skin lump which may drain chalky
material
Diagnosing Gout
X-rays : Punched out
erosions only 45%
of pts have them,
takes 6 yrs to develop
Arthrocentesis-
extraction of joint
fluid
Examination of joint
Patient medical
history
Treatment
 Acute gouty arthritis:
Anti- inflammatory drugs ( if s.creat < 2mg/dl, no PUD)
Colchicine preferred in pts without confirmed diagnosis of gout.
Endpoints improvement in jt symptoms/ GI symptoms/ 10 doses
taken.
NSAIDs if diagnosis confirmed. Any NSAID can be used .
Newer agents Etoricoxcib 120 OD comparable to indomethacin 50
TID.
In c/o renal failure /PUD - IM ACTH , oral /iv prednisone.
Avoid adjusting dosage of urate lowering agents.
Prophylaxis :
Only indicated if patient is started on urate lowering Rx.
Colchicine( 1-3 pills a day)/ NSAID( in colchicine intolerant).
Does not alter crystal deposition and development of tophi.
Continue till serum urate levels stabilize and no attacks for 3 6
mths.
If long term prophylactic colchicine given, check CBC ,CK every 6
mths.
 Control of hyperuricemia
Differing opinions regarding initiation esp.
around 1st attack.
Clear evidence if erosions + on X-ray / chronic
tophaceous gout/ >2 gout attacks per year.
Goal : s. urate levels < 6 mg%.
Serial s. uric acid at least once every 6 mths
upon initiation.
Choice of agents :
Xanthine oxidase inhibitor
Uricosuric agents.
Equal efficacy in pts with normal renal function and
who excrete < 800 mg/day of uric acid.
 Xanthine oxidase inhibitors
Allopurinol- only prescription drug available.
Renally excreted, therefore adjust dose if s.creat > 2mg% or
CrCl <50
Usually DOC in most patients.
S/E GI / rash / sarcoid like reaction/Allopurinol
hypersensitivity syndrome
Drug interaction esp. with 6 MP/azathioprine/
warfarin/theophylline.
Desensitization protocols exist.
Oxypurinol possible option
Uricosuric agents
Indications no h/o renal calculi , pts <60 yrs, U.A excretion <
800 mg/d
CI - + nephrolithiasis, renal insufficiency
Limit ASA to 81 mg/day
Probenecid/ Benzbromarone
 Adjuvant Rx
Control obesity, alcohol intake, hyperlipidemia ,HTN
Losartan / fenofibrate weakly uricosuric
Diet moderation in purine intake. Makes a difference of
up to 1mg % in s. uric acid.
Beer, other alcoholic beverages.
Anchovies, sardines in oil, fish roes, herring.
Yeast.
Organ meat (liver, kidneys, sweetbreads)
Legumes (dried beans, peas)
Meat extracts, consomm, gravies.
Mushrooms, spinach, asparagus, cauliflower
 Baseline
recommendations
and overall
strategic plan for
patients with gout.
This algorithm
summarizes
overall treatment
strategies and flow
of management
decisions for gout.
Recommenda-
tions for the
individual
pharmacologic
monotherapy
options for an
acute gouty
arthritis attack
Pharmacologic
antiinflammatory
prophylaxis of
gout attacks and
its relationship to
pharmacologic
urate-lowering
therapy
(ULT)
Thank you