Gout

CHP 18
 Gout [Gouty
arthritis]
Most common anti-inflammatory arthritis

Systemic in nature

Patho
◦ Disruption in purine metabolism leading to
uric acid and crystals deposits in joints &
body tissue

Classified as Primary or secondary

Primary
Most common
Production of uric acid is > than excretion of it by kidneys
Genetic component: X-linked trait; family hx
Commonly affects: Middle-age and older men; postmenopausal
women
Peak time of onset in men b/w 40 & 50 years
Secondary
Cause: another disease or factor: CKD, excessive diuretic use, crash diets, some
chemo agents, multiple myeloma = HYPERURICEMIA
Treatment based on treating underlying condition
Can affect any age
Assessment
Risk factors
◦ Obesity
◦ CVD
◦ Trauma
◦ Alcohol ingestion
◦ Starvation diet
◦ Diuretic use
◦ Chemo drugs
◦ CKD
Expected Findings
Severe joint pain [metatarsophalangeal joint of great toe];
Podagra

Redness, swelling, warmth of affected joint

Most common finding:

◦ Painful, swollen joint: very painful to touch or moved

Appearance of TOPHI [chronic gout]: outer ear, arms,

fingers near joints
◦ Infection is tophi irritation & break open w/yellow gritty
discharge
Diagnostics
Uric acid: Elevation >6.5 mg/d

Urinary uric acid level: confirmed by excretion of > 750 mg/dL

ESR: ELEVATED

BUN/Creat: ELEVATED

Synovial fluid aspiration [definitive] [arthrocentesis]: detect needle-like crystals in affected joint
Drug Rx
Antigout: Colchicine PO/IV

NSAIDS: Indomethacin, ibuprofen

Corticosteroids: prednisone

Chronic: Xanthine inhibitors: DOC

◦ Allopurinal: maintenance
◦ febuxostat: greater CV risk

Uricosuric: Probenecid

Pegloticase [refractory gout] IV every 2 weeks

◦ Monitor for allergic rxn during and post: protein foreign to body
Nutritional
Therapy
◦ Strict LOW PURINE DIET
◦ Avoid: organ meats, shellfish, oily fish
w/bones [sardines]
◦ Limit proteins: red and organ meats
◦ Know trigger foods & avoid
◦ Plenty of fluids
◦ pH increased with alkaline foods
◦ Low purine diet
◦ Limit alcohol intake: excessive leads to gout
attact
 Remind to follow strict low purine diet

Reinforce limiting alcohol intake

Tell to avoid starvation diets, ASA, diuretics

Nursing Limit physical or emotional stress

Encourage to increase HYDRATION

Encourage medication adherence

Meds: Xanthine inhibitors: Baseline and monitor labs:

LFT, BUN/Creatinine, CBC
Fibromyalgia
Fibromyalgia
Syndrome
Chronic pain syndrome NOT inflammatory

Pain, stiffness and tenderness at certain

“trigger points’

Pain: burning, gnawing pain

Elicited by palpating “trigger points”

Chronic fatigue, sleep disturbances &

functional impairment

Pain & tenderness come & go: vary depending

on stress, activity and weather condition
Risk Factors Expected
Findings
Females: age 30-50 years Mild to severe fatigue

Sleep disturbance
History of rheumatological conditions, chronic
fatigue, Lyme disease, trauma, flu-like illness Numbness/tingling

Sensitive to noxious stimulus: smells, loud noises, bright

Sleep deprivation lights

Headache, jaw pain, depression

Difficulty concentrating and memory

GI: abd. Pain, constipation, diarrhea, heartburn

GU: frequency, urgency, dysuria, pelvic pain

Visual changes
 Drug Therapy
Serotonin-norepinephrine reuptake inhibitors [SNRIs] & anticonvulsants: increase release of
serotonin & norepinephrine to decrease nerve pain
◦ Duloxetine, Cymbalta, milnacipran
◦ No alcohol
◦ Drowsiness

Pregabalin, neuroton [anticonvulsants]

◦ No alcohol]
◦ Drowsiness

NSAIDS: pain and inflammation

◦ Do not take on empty stomach

Tricyclic antidepressants: amitriptyline or nortriptyline: promote sleep and reduce pain or

muscle spasms: use w/caution in older adults: Confusion, ortho hypotension

Tramadol: tricyclic effects and opioid properties to help with pain relief

PT w/NSAID & possible muscle relaxants: promote comfort

Nursing
Instruct to teach regularly

Encourage home exercises

Refer to Arthritis Foundation

Refer to land, water, walking exercise pamphlet

Refer to National Fibromyalgia Association