Gout

Gout

Deposits of sodium urate crystals in articular, periarticular, and subcutaneous tissues

May be primary or secondary Primary – hereditary error of purine metabolism Secondary – drugs that inhibit uric acid excretion or

another acquired disorder

Incidence and Risk Factors

Primary gout accounts for 90% of cases

Affects primarily middle aged men

Risk factors: obesity, HTN, thiazide diuretics, excess alcohol use

Pathophysiology

Uric acid is end product of purine metabolism and is excreted by the kidneys

Hyperuricemia results from Increase in uric acid production Underexcretion of uric acid by kidneys Both

Diet high in purines will not cause gout, but may trigger an attack in a susceptible person

Clinical Manifestations

Gouty arthritis in one or more joints (but less than four

Great toe joint most common first manifestation; other joints may be the foot, ankle, knee, or wrist

Joints are tender & cyanotic May be precipitated by trauma, surgery, alcohol

ingestion, or infection

Clinical Manifestations

Onset usually nocturnal, with sudden swelling and excruciating pain

May have low grade fever Usually subsides within 2-10 days Joints are normal, with no symptoms between

attacks

Complications

Joint deformity Osteoarthritis Tophi may produce draining sinuses that may

become infected Renal stones, pyelonephritis, obstructive renal

disease

Chronic Gout

Diagnosis

History & physical examination

Family history of gout

Diagnostic studies

Diagnostic Studies

Serum uric acid levels > 6 mg/dl May be caused by other factors

24 hour urine uric acid levels Synovial fluid aspiration contains uric acid crystals

Seldom necessary, as diagnosis based on clinical symptoms possible in 80% of cases

X-rays appear normal in early stages; tophi appear as eroded areas of bone

Collaborative Care

Acute attack Colchicine produces dramatic antiiflammatory effects

with relief within 24-48 hours NSAIDs for additional pain relief Corticosteroids (po or intraarticular) Adrenocorticotropic hormone (ACTH) Joint aspiration to decompress

Collaborative Care

Prevention of acute attacks Colchicine combined with:

allopurinol (Zyloprim, Alloprim) – blocks production of uric acid

probenecid (Benemid), sulfinpyrazone (Anturane) – inhibit tubular reabsorption of uric acid

febuxostat (Uloric) – inhibits xanthine oxidase, recently shown to reduce serum uric acid levels

Collaborative Care

Dietary measures Weight reduction Avoidance of alcohol Avoidance of foods high in purines

High: Sardines, anchovies, herring, mussels, liver, kidney, goose, venison, meat soups, sweetbreads, beer & wine

Moderate: Chicken, salmon, crab, veal, mutton, bacon, pork, beef, ham

Collaborative Care

Prevention of renal stones Increase fluid intake to maintain adequate urine output Allopurinol ACE inhibitor losartin (Cozar) – promotes urate diuresis

Nursing Care

Acute gouty arthritis – pain control Gentle, supportive care of affected joints Immobilize and rest affected joints – bed rest or NWB Cradle or footboard to prevent pressure from bedcovers Monitor ROM and degree of pain

Nursing Care

Patient/Family teaching Gout is a chronic disease Drug teaching Need to monitor serum uric acid levels Precipitating factors

Excess calorie intake, alcohol intake, purine rich foods Fasting Niacin, ASA, diuretics Surgery or major medical event such as MI