Diagnosis and Management of Gout

Posted by e-Medical PPT Sunday, July 15, 2012
Gout is associated with elevated serum uric acid
Uric acid is the end product of purine metabolism
Enzymatic deficiencies and increased nucleic acid turnover account for only 10% of gout patients.
Remaining 90% are “primary gout” due to an unknown defect limiting the ability to excrete uric acid.
Uric acid normally dissolves in plasma
Poorly soluble in synovial fluid and precipitates out as MSU crystals
Acute attack is not related to the presence of crystals in the joint, but rather to a cascade of events that occurs after activation of synovial macrophages.

What is the relationship between hyperuricemia and gout?
What is an abnormal uric acid level?
Gout screening
How low does the uric acid need to be?

There was no specific level at which uric acid was abnormal
Many patients who are hyperuricemic do not have symptoms
Since there was no definitive cut off, uric acid levels >6mg/dl in men and >5.6mg/dl in females were arbitrarily picked as abnormal values

Clinical features
25% had only one attack during the study
The average number of attacks was 5
23% of men and 10% of women had >5 attacks
No difference in the mean uric acid levels in those with >10 attacks versus the gouty population as a whole
84% had at least one episode of podagra
90% had podagra or attack involving the foot
Only 13% ever had an attack involving the upper extremities.

Diagnosis
Crystal identification is the best
If crystals cannot be obtained, use the history
Determination of uric acid excretion is not mandatory unless underlying pathology is suspected (young age, signs of malignancy) or long-term antihyperuricemic agents are needed
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