gout; state of art
TRANSCRIPT
![Page 1: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/1.jpg)
![Page 2: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/2.jpg)
State of Art
![Page 3: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/3.jpg)
![Page 4: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/4.jpg)
goutBY:
Abdallah Allam MSc Assistant Lecturer. Department of Physical Medicine,
Rheumatology and Rehabilitation
Faculty of Medicine, Tanta University. Egypt
![Page 5: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/5.jpg)
![Page 6: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/6.jpg)
What is the function of uric acid
And purines ?
![Page 7: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/7.jpg)
![Page 8: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/8.jpg)
What is the normal ?
![Page 9: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/9.jpg)
Rees, F. et al. (2014) Optimizing current treatment of goutNat. Rev. Rheumatol. doi:10.1038/nrrheum.2014.32
![Page 10: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/10.jpg)
Reginato, A. M. et al. (2012) The genetics of hyperuricaemia and gout Nat. Rev. Rheumatol. doi:10.10.38/nrrheum.2012.144
![Page 11: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/11.jpg)
24 hs urine uric acid excretion
600-800 mg
![Page 12: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/12.jpg)
Metabolic pathway
![Page 13: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/13.jpg)
![Page 14: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/14.jpg)
![Page 15: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/15.jpg)
![Page 16: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/16.jpg)
Serum urate level greater than approximately
6.8 mg/dL, the saturation point of urate in
biological fluids, is the underlying cause of gout.
![Page 17: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/17.jpg)
Why gout doesn’t affect animals?
![Page 18: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/18.jpg)
![Page 19: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/19.jpg)
Diet and gout
![Page 20: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/20.jpg)
![Page 21: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/21.jpg)
![Page 22: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/22.jpg)
![Page 23: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/23.jpg)
![Page 24: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/24.jpg)
Cherries as one-half cup, or 10 to 12 cherries.==>1- DECREASES SERUM URIC ACID2- Prevents flares3- Reduces pain and inflammation
![Page 25: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/25.jpg)
![Page 26: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/26.jpg)
Epidemiology
![Page 27: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/27.jpg)
BMJ VOLUME 332 3 JUNE 2006
![Page 28: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/28.jpg)
Etiology
![Page 29: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/29.jpg)
Over production(5-10%)
Genetic
Acquired
![Page 30: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/30.jpg)
Genetic - HGPRT deficiency X linked,
*partial Kelly Seeg Miller
*complete Lish Nyhan- G6PD deficiency ( LACTIC )- Over PR1P synthetase
( sensory neural hearing loss).
Acquired- Diet- Obesity - Tumors- Chemotherapy- Alcohol(Lactate, ATP,
Purine guanosine)- Vigorous exercise.- Psoriasis.
![Page 31: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/31.jpg)
Under excretion(90-95%)
Genetic
Acquired
![Page 32: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/32.jpg)
Genetic - Down.- PCD.
Acquired *Decreased exc.- RF- KETO ACIDOSIS - LACTIC ACIDOSIS- HYPERTRIGLYCERIDEMIA
*increased Abs.- Dehydration- Starvation - Insulin R- Drugs
![Page 33: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/33.jpg)
Associated with:Obesity,
Hypertension,
Diabetes (Bell shaped curve),
Sleep Apnea Syndrome.
Hyperlipidaemia.
![Page 34: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/34.jpg)
Pathogenesis
![Page 35: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/35.jpg)
Why gout doesn’t always hurt?
![Page 36: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/36.jpg)
![Page 37: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/37.jpg)
![Page 38: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/38.jpg)
Why MSU precipitates in the periphery ?
![Page 39: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/39.jpg)
· MSU precipitates at the periphery of the body, where
lower body temperatures may reduce the solubility of
MSU.
· Albumin levels decrease, which causes decreased
urate solubility
· Change in ion concentration & decreases of PH
enhance urate deposition
· Trauma promotes urate crystal precipitation
![Page 40: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/40.jpg)
Mechanism of acute attack
![Page 41: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/41.jpg)
![Page 42: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/42.jpg)
![Page 43: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/43.jpg)
OA and Gout
![Page 44: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/44.jpg)
![Page 45: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/45.jpg)
![Page 46: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/46.jpg)
![Page 47: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/47.jpg)
Gouty tophus and erosions
![Page 48: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/48.jpg)
![Page 49: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/49.jpg)
How does acute attack subside alone?
![Page 50: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/50.jpg)
Rheumatology 2005;44:1090–1096
![Page 51: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/51.jpg)
![Page 52: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/52.jpg)
Heat
Stress steroid release
![Page 53: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/53.jpg)
C/P
![Page 54: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/54.jpg)
1 -Early onset.
2 -Classic.
3 -Late onset.
4 -NSAIDs masked.
![Page 55: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/55.jpg)
1 -Early onset.
![Page 56: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/56.jpg)
![Page 57: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/57.jpg)
HPRT
![Page 58: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/58.jpg)
2 -Classic.
![Page 59: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/59.jpg)
![Page 60: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/60.jpg)
![Page 61: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/61.jpg)
![Page 62: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/62.jpg)
![Page 63: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/63.jpg)
![Page 64: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/64.jpg)
CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 75 • SUPPLEMENT 5 JULY 2008
![Page 65: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/65.jpg)
![Page 66: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/66.jpg)
Normal serum uric acid during attack
![Page 67: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/67.jpg)
![Page 68: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/68.jpg)
![Page 69: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/69.jpg)
![Page 70: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/70.jpg)
![Page 71: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/71.jpg)
![Page 72: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/72.jpg)
3 -Late onset.
![Page 73: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/73.jpg)
![Page 74: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/74.jpg)
Perioperative goutNSAID MASKED GOUTORGAN TRANSPLANTATION
![Page 75: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/75.jpg)
Diagnostic work up
![Page 76: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/76.jpg)
1 -Laboratory investigations
-Plain x-ray
-MSK U/S -DECT
2 -Imaging
3 -Arthrocentesis
![Page 77: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/77.jpg)
Laboratory investigations
![Page 78: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/78.jpg)
![Page 79: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/79.jpg)
24 hs urine collection (not done
during attack)
>800mg / d over producers
<400 mg / d under excretors
![Page 80: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/80.jpg)
Imaging
![Page 81: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/81.jpg)
Plain X-ray
![Page 82: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/82.jpg)
Soft tissue swelling.
Dorsoplantar radiograph
shows mild soft tissue
swelling medial to the first
metarsophalangeal joint .
![Page 83: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/83.jpg)
Dorsopalmar radiograph
shows soft tissue masses
around the fourth proximal
interphalangeal joint and
radial to the fifth
metacarpophalangeal joint.
The joint spaces are normal.
![Page 84: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/84.jpg)
![Page 85: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/85.jpg)
![Page 86: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/86.jpg)
MSK U/S
![Page 87: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/87.jpg)
![Page 88: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/88.jpg)
![Page 89: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/89.jpg)
![Page 90: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/90.jpg)
![Page 91: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/91.jpg)
![Page 92: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/92.jpg)
![Page 93: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/93.jpg)
![Page 94: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/94.jpg)
![Page 95: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/95.jpg)
![Page 96: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/96.jpg)
![Page 97: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/97.jpg)
![Page 98: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/98.jpg)
![Page 99: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/99.jpg)
![Page 100: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/100.jpg)
![Page 101: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/101.jpg)
DECT
![Page 102: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/102.jpg)
![Page 103: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/103.jpg)
Dual-energy CT imaging of tophi in patients with gout
![Page 104: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/104.jpg)
![Page 105: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/105.jpg)
Arthrocentesis
Gold standard
![Page 106: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/106.jpg)
(A) Monosodium urate crystals of gout appear as fine yellow needlelike crystals that are negatively birefringent under compensated polarized light.
(B) In contrast, crystals of calcium pyrophosphate dihydrate (CPPD) crystal deposition disease are rhomboid in shape and weakly positively birefringent under compensated polarized light ABC
![Page 107: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/107.jpg)
![Page 108: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/108.jpg)
![Page 109: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/109.jpg)
![Page 110: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/110.jpg)
Criteria for Diagnosis
![Page 111: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/111.jpg)
![Page 112: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/112.jpg)
![Page 113: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/113.jpg)
![Page 114: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/114.jpg)
![Page 115: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/115.jpg)
DD
![Page 116: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/116.jpg)
![Page 117: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/117.jpg)
![Page 118: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/118.jpg)
![Page 119: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/119.jpg)
![Page 120: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/120.jpg)
Procalcitonin ???
![Page 121: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/121.jpg)
![Page 122: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/122.jpg)
![Page 123: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/123.jpg)
![Page 124: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/124.jpg)
![Page 125: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/125.jpg)
Medications
![Page 126: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/126.jpg)
ProbenicidSulfinpyrazone
FebuxostateLosartan
Fenofibrate Vit C
LeflunomideLisinopril
AllopurinolFebuxostate
Pegloticase Rasburicase
![Page 127: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/127.jpg)
![Page 128: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/128.jpg)
Colchicine
![Page 129: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/129.jpg)
Rees, F. et al. (2014) Optimizing current treatment of goutNat. Rev. Rheumatol. doi:10.1038/nrrheum.2014.32
![Page 130: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/130.jpg)
![Page 131: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/131.jpg)
![Page 132: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/132.jpg)
![Page 133: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/133.jpg)
![Page 134: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/134.jpg)
Colchicine Creatinine clml/min
Dose >50 0.6 mg twice daily
35-49 0.6 mg once daily
10-34 0.6 every 2 or 3 days
<10 stop
![Page 135: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/135.jpg)
![Page 136: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/136.jpg)
![Page 137: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/137.jpg)
![Page 138: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/138.jpg)
Avoided in RT TTT by cyclosporine
neuromyotoxicity myopathy (proximal + increased
creatinine + EMG STOP FOR 3 WEEKS CURE
![Page 139: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/139.jpg)
![Page 140: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/140.jpg)
![Page 141: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/141.jpg)
Treat to Target• < 6 mg/dl
• < 5 mg/dl
• < 4 mg/dl ( tophaceous gout)
![Page 142: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/142.jpg)
![Page 143: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/143.jpg)
Rees, F. et al. (2014) Optimizing current treatment of gout Nat. Rev. Rheumatol. doi:10.1038/nrrheum.2014.32
![Page 144: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/144.jpg)
XOI
![Page 145: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/145.jpg)
![Page 146: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/146.jpg)
![Page 147: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/147.jpg)
Allopurinol GFRml/min
Dose N 300 mg/d
60 200mg/d
30 50-100 mg/d
![Page 148: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/148.jpg)
ALLOPURINOL HYPERSENSITIVITY SYNDROME
• 5- 10%
• Morbidity and mortality: 20-30%
• MAJOR RISKS:
R I 75%
Diuretic TTT 50%
• ONSET 2-4 WKS
C/P: skin rash , esinophilia, fever, hepatic necrosis, leucocytosis and ↓ RF
TTT: - Steroids - Renal dialysis
![Page 149: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/149.jpg)
![Page 150: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/150.jpg)
![Page 151: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/151.jpg)
![Page 152: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/152.jpg)
![Page 153: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/153.jpg)
![Page 154: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/154.jpg)
![Page 155: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/155.jpg)
![Page 156: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/156.jpg)
Pegloticase pegilated uricase
• 8 mg in 250 cc N or half normal saline over 2 hours.
• Every 2 weeks.
• Pre ttt by hydrocortisone iv, acetaminophen 500 -1000 mg
iv & antihistaminics.
• Monitor serum uric acid before each dose ( Auto Abs).
• Colchicine for 3 mos at least.
• Flare of acute attack, Nephrolithiasis, Arthralgia, Nausea,
Dyspepsia, Diarrhea, Rash, Back pain.
CI : G6PD
![Page 157: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/157.jpg)
![Page 158: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/158.jpg)
Rasburicase recombinant uricase
• 0.2mg/kg iv over 30 min qd * 5 days
• Every 2 weeks.
• Leukemia , lymphoma , chemotherapy
![Page 159: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/159.jpg)
ACR 2012 Guidelines
![Page 160: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/160.jpg)
![Page 161: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/161.jpg)
(CAN’T LEAP)1-Cyclosporine2. Alcohola. Associated with lactic acid productioni. Reduces renal excretion of urateb. Increases synthesis of urate by accelerating the degradation ofATPc. Beer contains a lot of purine guanosine
3. Nicotinic acid4. Thiazidesa. Interferes with urate excretion at the proximal convoluted tubule5. Lasix6. Ethambutol7. Aspirina. Low dose <2 g/day8. Pyrazinamide
![Page 162: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/162.jpg)
![Page 163: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/163.jpg)
![Page 164: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/164.jpg)
![Page 165: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/165.jpg)
![Page 166: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/166.jpg)
![Page 167: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/167.jpg)
![Page 168: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/168.jpg)
![Page 169: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/169.jpg)
![Page 170: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/170.jpg)
![Page 171: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/171.jpg)
![Page 172: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/172.jpg)
![Page 173: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/173.jpg)
Rees, F. et al. (2014) Optimizing current treatment of goutNat. Rev. Rheumatol. doi:10.1038/nrrheum.2014.32
![Page 174: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/174.jpg)
![Page 175: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/175.jpg)
![Page 176: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/176.jpg)
![Page 177: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/177.jpg)
![Page 178: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/178.jpg)
![Page 179: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/179.jpg)
![Page 180: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/180.jpg)
![Page 181: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/181.jpg)
![Page 182: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/182.jpg)
![Page 183: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/183.jpg)
![Page 184: Gout; state of art](https://reader036.vdocuments.site/reader036/viewer/2022062401/5881a8011a28ab1a398b6caf/html5/thumbnails/184.jpg)
Thank you