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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