Se ha denunciado esta presentación.
Utilizamos tu perfil de LinkedIn y tus datos de actividad para personalizar los anuncios y mostrarte publicidad más relevante. Puedes cambiar tus preferencias de publicidad en cualquier momento.

Gout; state of art

386 visualizaciones

Publicado el

Gout from A-Z

Publicado en: Salud y medicina
  • Inicia sesión para ver los comentarios

Gout; state of art

  1. 1. BY: Abdallah Allam MSc Assistant Lecturer. Department of Physical Medicine, Rheumatology and Rehabilitation Faculty of Medicine, Tanta University. Egypt
  2. 2. Rees, F. et al. (2014) Optimizing current treatment of gout Nat. Rev. Rheumatol. doi:10.1038/nrrheum.2014.32
  3. 3. Reginato, A. M. et al. (2012) The genetics of hyperuricaemia and gout Nat. Rev. Rheumatol. doi:10.10.38/nrrheum.2012.144
  4. 4. 24 hs urine uric acid excretion 600-800 mg
  5. 5. Cherries as one-half cup, or 10 to 12 cherries.==> 1- DECREASES SERUM URIC ACID 2- Prevents flares 3- Reduces pain and inflammation
  6. 6. BMJ VOLUME 332 3 JUNE 2006
  7. 7. Over production(5-10%) Genetic Acquired
  8. 8. 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.
  9. 9. Under excretion(90-95%) Genetic Acquired
  10. 10. Genetic - Down. - PCD. Acquired *Decreased exc. - RF - KETO ACIDOSIS - LACTIC ACIDOSIS - HYPERTRIGLYCERIDEMIA *increased Abs. - Dehydration - Starvation - Insulin R - Drugs
  11. 11. Associated with: Obesity, Hypertension, Diabetes (Bell shaped curve), Sleep Apnea Syndrome. Hyperlipidaemia.
  12. 12. · 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
  13. 13. Rheumatology 2005;44:1090–1096
  14. 14. HPRT
  15. 15. CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 75 • SUPPLEMENT 5 JULY 2008
  16. 16. Normal serum uric acid during attack
  17. 17. 24 hs urine collection (not done during attack) >800mg / d  over producers < 400 mg / d  under excretors
  18. 18. Soft tissue swelling. Dorsoplantar radiograph shows mild soft tissue swelling medial to the first metarsophalangeal joint.
  19. 19. Dorsopalmar radiograph shows soft tissue masses around the fourth proximal interphalangeal joint and radial to the fifth metacarpophalangeal joint. The joint spaces are normal.
  20. 20. Dual-energy CT imaging of tophi in patients with gout
  21. 21. Arthrocentesis Gold standard
  22. 22. (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
  23. 23. Probenicid Sulfinpyrazone Febuxostate Losartan Fenofibrate Vit C Leflunomide Lisinopril Allopurinol Febuxostate Pegloticase Rasburicase
  24. 24. Rees, F. et al. (2014) Optimizing current treatment of gout Nat. Rev. Rheumatol. doi:10.1038/nrrheum.2014.32
  25. 25. Colchicine Creatinine cl ml/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
  26. 26. Avoided in RT TTT by cyclosporine  neuromyotoxicity myopathy (proximal + increased creatinine + EMG  STOP FOR 3 WEEKS CURE
  27. 27. Treat to Target • < 6 mg/dl • < 5 mg/dl • < 4 mg/dl ( tophaceous gout)
  28. 28. Rees, F. et al. (2014) Optimizing current treatment of gout Nat. Rev. Rheumatol. doi:10.1038/nrrheum.2014.32
  29. 29. Allopurinol GFR ml/min Dose N 300 mg/d 60 200mg/d 30 50-100 mg/d
  30. 30. 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
  31. 31. 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
  32. 32. Rasburicase recombinant uricase • 0.2mg/kg iv over 30 min qd * 5 days • Every 2 weeks. • Leukemia , lymphoma , chemotherapy
  33. 33. (CAN’T LEAP) 1-Cyclosporine 2. Alcohol a. Associated with lactic acid production i. Reduces renal excretion of urate b. Increases synthesis of urate by accelerating the degradation of ATP c. Beer contains a lot of purine guanosine 3. Nicotinic acid 4. Thiazides a. Interferes with urate excretion at the proximal convoluted tubule 5. Lasix 6. Ethambutol 7. Aspirin a. Low dose <2 g/day 8. Pyrazinamide
  34. 34. Rees, F. et al. (2014) Optimizing current treatment of gout Nat. Rev. Rheumatol. doi:10.1038/nrrheum.2014.32

×