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GOUT
“The disease of kings" or “Rich man's disease".
Saurabh M. Limani
Definition
• Disorder of Purine metabolism characterized by recurrent attacks of acute inflammatory arthritis - a red, tender, hot, swollen joint.
• The MTP joint at the base of the big toe is the most commonly affected (~50% of cases). (chronic gout – Helix of the ear)
• it may also present as tophi, kidney stones, or urate nephropathy
• caused by elevated levels of uric acid in the blood which crystallize and are deposited in joints, tendons, and surrounding tissues.
Causes
• Hyperuricemia is the underlying cause of gout
• This can occur for a number of reasons, including diet, genetic predisposition, or under excretion of urate
• Renal under excretion of uric acid is the primary cause of hyperuricemia in about 90% of cases, while overproduction is the cause in less than 10%
• About 10% of people with hyperuricemia develop gout at some point in their lifetimes
• The risk, however, varies depending on the degree of hyperuricemia. (7 and 8.9 mg/dL – 0.5% per year >9 mg/dL - 4.5% per year)
Causes• Lifestyle
Dietary causes account for about 12% of gout. Alcohol, fructose-sweetened drinks, meat, and seafood (+)
Coffee, vitamin C and dairy products as well as physical fitness (-)
• GeneticsFamilial juvenile hyperuricemic nephropathy Medullary cystic kidney disease
Hypoxanthine-guanine phosphoribosyltransferase deficiency
• Medical conditionsMetabolic syndrome
Renal failure BMI >35 in male – risk increase threefold
• MedicationDiuretics, niacin, aspirin and Cyclosporine
Characteristics
• Resembles arthritis
• Sudden pain in big toe, with the pain continuing to the leg
• Usually occurs after the age of 35 and is characterized by specific heritable metabolic defects
• Obesity is usually associated with a gouty condition
Diagnosis
• Hx and PE
• Synovial fluid
• Blood tests
• X-ray
Physical Examination
Management
• Anti inflammatory drugs
• Prophylaxis
• Control of hyperuricemia- xanthin oxidase inhibitor- uricosuric agent
• Adjuvant Rx- Control obesity ,ETOH intake, hyperlipidemia ,HTN - Losartan / fenofibrate – weakly uricosuric- Diet – moderation in purine intake. Makes a difference of up to 1mg %
in s. uric acid
DIETARY MANAGEMENT
Dietary Management• Restriction of Purine rich diet
• Drugs have largely replaced the need for rigid restriction of purine
• All food have some traces of nucleoprotein from which purines are derived
• Purines are synthesized in the body from simple metabolites, which are constantly available from dietary CHO, COOH, Fat and endogenous purine breakdown
• Restriction of food containing nucleoproteins is indicated in patient with high uric acid level
Dietary Management
• Excessive use of fats should be avoided, since fats are believed to prevent the normal excretion of urate
• Protein intake should be adequate but not excessive
• The calories should be maintained with carbohydrates
• Carbohydrates have a tendency to increase uric acid excretion
Acute stage
• Rigid restriction of food containing purine
• Diet high in carbohydrates, moderate in protein and low in fat
• Fluids (up to 3 liters per day) should be forced to assist the excretion of uric acid and to minimize the possibility of calculi formation
• Sodium bicarbonate or trisodium citrate
• Potassium salt of carbonate and citrate
Interval stage
• Dietary management + Uricosuric drugs
• Normal adequate diet adjusted to achieve ideal weight
• Moderate in protein (60 to 70 gms)
• Increase in carbohydrates and relatively low in fat
• Should avoid food high in purine
Severe or Advanced cases
• Limitation of protein to 50 to 70 gms daily(in the form of plant and dairy protein products as much as possible)
• Most of the proteins in the therapeutic diet come from cheese, eggs and milk, which are low in nucleoproteins
• Fluid should be adjusted to produce a normal UO (2000 ml)
Special consideration
• Alcohol
- Mild to moderate- Lactic acid during the metabolism of ethanol
• Obesity - Reduced and maintain a body weight that is 10 to 15 % below the
calculated normal weight- weight reduction should be deferred until the serum uric acid conc. Has
been bought under control
Low purine diet
• Normal diet – 600 to 1000 mg of purine daily
• In cases of severe or advanced gout the purine content of the daily diet is restricted to approximately 100 to 150 mg
• Fat is kept to 40% of the caloric intake
FOOD GROUPING ACC. TO PURINE CONTENT
• GROUP : 1 HIGH PURINE CONTENT
(100 to 1000 mg. of purine nitrogen per 100gms. Of food)
Anchovies MackerelBouillon Meat extractsBrains MincemintBroth MusselsConsomme PartridgeGoose RoeGravy Sardines
Food in this list should be omitted from the diet of patients who have gout ( acute and remission stages)
• GROUP 2 : MODERATE PURINE CONTENT
(9 to 100 mg. of purine nitrogen per 100 gms. Of food)
Meat and Fish Vegetables(except those in Grp.1)
Fish AsparagusPoultry Beans, shellMeat LentilsShellfish Mushrooms
PeasSpinach
One serving (2 to 3 oz.) of meat, fish or fowl or 1 serving (1/2 cup) vegetable From this group is allow each day or five days a week ( depending upon cond.)During remissions.
• GROUP 3 : NEGLIGIBLE PURINE CONTENT
Bread, enriched white Herbs and crackers Ice creamButter or fortified margarine Milk (in moderation) Macaroni productsCake and cookies NoodlesCarbonated beverages NutsCereal beverages OilCereals and cereal products Olives (refined and enriched) Pickles
continue..Cheese PopcornChocolate PuddingsCoffee RelishesCondiments Rennet dessertsCornbread RiceCream (in moderation) SaltCustard Sugar and sweetsEggs TeaFats (in moderation) Vegetables (except those in
Grp. 2)Fruit VinegarGelatin desserts White sauce
Foods included in this group may be used daily
URIC ACID EXCRETION
HYPERTENSION AND GOUT
Low uric acid level
• MS• Parkinson Disease
THANK YOU