Gout and Hyperuricemia

INTRODCUCTION

Gout involves hyperuricemia, recurrent attacks of acute arthritis with monosodium urate (MSU) crystals in synovial fluid leukocytes, deposits of MSU crystals in tissues in and around joints (tophi), interstitial renal disease, and uric acid nephrolithiasis.

CLINICAL PRESENTATION

Acute gout attacks are characterized by rapid onset of excruciating pain, swelling, and inflammation. The attack is typically monoarticular, most often affecting the first metatarsophalangeal joint (podagra), and then, in order of frequency, the insteps, ankles, heels, knees, wrists, fingers, and elbows. Attacks commonly begin at night, with the patient awakening with excruciating pain. Affected joints are erythematous, warm, and swollen. Fever and leukocytosis are common. Untreated attacks last from 3 to 14 days before spontaneous recovery.

Acute attacks may occur without provocation or be precipitated by stress, trauma, alcohol ingestion, infection, surgery, rapid lowering of serum uric acid by uric acid–lowering agents, and ingestion of drugs known to elevate serum uric acid concentrations

DIAGNOSIS

• Definitive diagnosis requires aspiration of synovial fluid from the affected joint and identification of intracellular crystals of MSU monohydrate in synovial fluid leukocytes.
• When joint aspiration is not feasible, a presumptive diagnosis is based on presence of characteristic signs and symptoms, as well as the response to treatment.

TREATMENT

Goals of Treatment: Terminate the acute attack, prevent recurrent attacks, and prevent complications associated with chronic deposition of urate crystals in tissue

NSAIDS 1) Tab Naprox (Naproxen) 500 mg, 1 tab PO BD or Tab Indocid (indomethacin) 25-50mg, 1 tab PO TDS for 5-10 days Cap Risek (omeprazole) 20mg, PO BD, 30 minutes before meal 2) Colchicine: Tab Crycol 0.5mg, 2 tabs PO stat 3) Corticosteroids: Inj Medrol (Methyl prednisolone) 40 mg IV OD TREATMENT OF HYPERURICEMIA IN GOUT Xanthine Oxidase Inhibitors

Zyloric (Allopurinol) lowers uric acid levels in a dose-dependent manner. ACR guidelines recommend a starting dose no greater than 100 mg daily and then gradually titrating every 2 to 5 weeks up to a maximum dose of 800 mg/day until the serum urate target is achieved.

Urigo (Febuxostat) also lowers serum uric acid in a dose-dependent manner. The recommended starting dose is 40 mg once daily. Increase the dose to 80 mg once daily for patients who do not achieve target serum uric acid concentrations after 2 weeks of therapy