GOUT AND PSEDOGOUT. ways to prevent and treat. by NR7

Sumerize about gout and pseudogout.Review at once glance. NR7.

1. GOUT AND PSEDOGOUT Presenter:DR . Roshan Adhikari Moderator:Dr Pramod Baral Department of Orthopaedics

2. CONTENTS Definition Epidemiology Pathophysiology Clinical features Investigation D/D Treatment

3. GOUT Def: Gout is crystal deposition disease caused by deposition of Monosodium urate crystals in joints and other tissue, secondary to hyperuricaemia . Hyperuricaemia : defined as SUA level 420mcmol/L in men and 360mcmol/L in women.

4. EPIDEMIOLOGY AND RISK FACTOR About 3%of the adult population can have gouty arthritis M:F 5:1 Male peak onset in 5 th decade and older female Prevalence is increasing. Risk factor Family history Alcohol Renal impairment Metabolic syndrome( DM,HTN,Dyslipidemia,Obesity )

5. Causes of Hyperurecemia

6. PATHOPHYSIOLOGY Hyperuricaemia is a prerequisite for formation of urate crystals but pH, temperature, presence and absence of natural inhibitors ae also important. Purine Degradation AMP > Inosine > hypoxanthine > xanthine > uric acid GMP > Guanosine > guanine > xanthine > uric acid ElevateUric acid level (increase production or under excreation ) Uric acid crystals form (when solubility level exceeds)

7. Cont.. Release of Uric acid crystals in extracellular space Induce inflammation Chronic cumulative urate crystal deposition to tissue resulting in Tophi formation.

8. Clinical features 1 Asymtomatic Hyperurecemia 2 Acute gouty arthritis 1 st MTP joint M/C, others knee, ankle, midfoot elbow and wrist. Rapid onset, reaching Max severity in 2-6hrs, worse in early morning, often described as worst pain ever Extreme tenderness, so patient unable to wear a sock, walk or bear the touch of bedclothes.

9. Cont.. Marked swelling with overlying red and shiny skin. Self limiting over 5-14 days

10. 3 Chronic tophaceous gout

11. Invetigation Serum uric acid (Normal levels do not rule out gout) Raised neutrophil , ESR, CRP (non specific) Urine uric acid ( excreation of >800mg/dl on regular diet in the absence of drugs suggests overproduction) If overproduction is suspected, measurement of erythrocyte hypoxanthine guanine phosphoribosyl transferase (HGPRT) And PRPP level may be indicated. Screaning for risk factors – serum creatinine , LFT, glucose and lipids

12. Cont.. Radiograph In acute attack- Normal or soft tissue swelling In chronic gout- Erosion may be seen: classically away from joint margin, being “punched-out” with a rounded or oval shape and overhanging edge

13. Cont.. Aspiration of joint/ tophi negatively birefringent needle shaped MSU crystals

14. D/D 1 Septic arthritis

15. Cont.. 2 RA 3 Pseudogout 4 Acute inflammaatory osteoarthritis 5 cellulities

16. Treatment Aims of treatment To relive pain To prevent future attack To reduce or reverse the chronic complication of joint destruction and tophi formation

17. Cont.. 1 Acute Gout A) NSAID – DOC(without comorbid ) INDOMETHACIN 25-50MG TDS NAPROXEN 500MG BD A Decrescendo Regime- Using large dose at first, tapering over 5-7 days B) Steroid I/A if 1 joint is affected Orally or IM if polyarticular

18. Cont….. C) Colchine Given within 36hrs of attack Treatment should be initiated early 0.5 mg 4times /day tapering over a week. (A/E diarrhoea /nausea) D) Non drugs treatment Rest Ice pack splinting

19. Cont.. 2.Management between attack: Intend to minimize urate deposition in tissues & reduce the frequency & severity of recurrences. Diet Avoidence of Hyperuricemic medications ( Thiazide & loop diuretis ) C. Colchine prophylaxis D. Reduction Serum Uric Acid

20. Cont… 3. Chronic Gout A)Patient education: Appropirate life style Modification. Weight reduction. Dietary advise – reduction of alcohal and fructose consumption. B) Urate lowering therapy.

21. URIC ACID METABOLISM

22. Cont.. Methods of urate lowering I) Xanthine oxidase inhibitors—decrease uric acid synthesis ( Allopurinol,Febuxostsat ) (It can trigger a paradoxial flare of gout therefore it should not be started until at least 4 weeks after the last acute attack and prophylaxis should be offer NSAID or low dose colchine )

23. Cont.. Allopurinol : Dose: 100mg/day 50mg/day for stage 4 CKD Dose titrated upwards every 2-5 weeks to acheive the target SUA level. Max. dose 800mg/day Interactions With Ampicillin ----Drug rash with Probencid . Allopurinol Half life of probencid . Probincid excreation of Allopurinol . Febuxostat : Dose: 40mg/day– if target SUA is not reached in 4 weeks --- to 80mg/day then to Max. 120mg/day.

24. Cont. 2.Uricosuric Drugs. increased uric acid excreation by inhibiting its tubular reabsorption . ( probencid , sulfinpyrazone .) Probencid :( 0.5gm/day orally) . Avoid in age>60, renal stones, CC<50ml/min , tophi , increased uric acid excretion Prophalyxis during cytotoxic therapy. 3. Pegloticase – Recombinant uricase that lowers uric acid by oxidizing urate to allontoin . used for tophaceous Gout, refactory to conventinal therapy. Dose: 8mg IV every 2 weeks.

25. Cont… 4 Surgery Indication: Poor hand function Intolerable deformity Infected or ulcerted tophi Compressive neuropathy cosmetic Surgery on large Tophaceous depoit – risk of delayed post OP wound healing due to poor circulation

26. Pseudogout CPPD is usually the consequence of cartilage changes related to ageing, degeneration, enzymatic degration which result in deposition of CPP crystals Pseudogout : Acute form of CPPD disease is CPP crystal arthritis

27. EULAR

28. C/F pain, swelling ,tenderness and effusion of major joint(knee) Risk factor

29. INVESTIGATION Inv. For D/D For confirm fluid aspiration of joint fluid analysis for crystals: Rhomboid shaped and positively birefringent .

30. X-RAY

31. D/D Gout Septic arthritis RA Acute inflammaatory osteoarthritis cellulities

32. TREATMENT Rest Aalgesia Aspiration & steroid injection Colchicine (0.6mg may be added in chronic recurrent case) Anakinara (IL-1inhibitors) use when other herapies are contraindicated.

33. THANK YOU

34. References Apley and Solomons 10 th edition Davidon`s Principles and Practice of Medicine Current Medical Diagnosis & treatment. Harrison`s Principles Of Internal Medicine 18 th edition