Clinical Case #6Clinical Case #6

By Chen , chun-Yu (Kim)By Chen , chun-Yu (Kim) Chen , I -chun (Afra)Chen , I -chun (Afra)

When he was 30 years old, a construction worker deWhen he was 30 years old, a construction worker developed redness and swelling of the instep of his right veloped redness and swelling of the instep of his right foot without a recognized antecedent injury. The affefoot without a recognized antecedent injury. The affected area was intensely painful and tender. Hot soaks cted area was intensely painful and tender. Hot soaks were applied, and after 10 years he was able to return were applied, and after 10 years he was able to return to work.to work.

During the following 2 years, he experienced increaDuring the following 2 years, he experienced increa

singly frequent episodes of intense inflammation of josingly frequent episodes of intense inflammation of joints of the feet. The swelling and pain persisted for loints of the feet. The swelling and pain persisted for longer and longer periods of time. In one attack where nger and longer periods of time. In one attack where he developed a swelling on the back of his heel, he wehe developed a swelling on the back of his heel, he went to his physician, who diagnosed gout and prescribent to his physician, who diagnosed gout and prescribed high dose colchine.d high dose colchine.

His serum uric was 12 mg/dl and urate monohydratHis serum uric was 12 mg/dl and urate monohydrat

e crystals were isolated from an ulcerated tophaceous e crystals were isolated from an ulcerated tophaceous mass on his heel. mass on his heel.

Gout Images:Gout Images:

1.what is the primary therapeutic 1.what is the primary therapeutic objective during an acute attack objective during an acute attack

of gouty arthritis?of gouty arthritis?

Answer:Answer: Arthritis is treated first and hyperuriceArthritis is treated first and hyperurice

mia latermia later 。 。

2.Should immediate steps be 2.Should immediate steps be taken to lower serum uric taken to lower serum uric acid ?Why or why not ?acid ?Why or why not ?

Answer:Answer:

no ,because sudden reduction no ,because sudden reduction often precipitates further episodes of often precipitates further episodes of gouty arthritis gouty arthritis

3.What drugs can be used to 3.What drugs can be used to prevent a recurrence of gout prevent a recurrence of gout

until serum uric acid levels are until serum uric acid levels are reduced ?reduced ?

-NSAIDs:-NSAIDs: -Colchicine -Colchicine -corticosteroids-corticosteroids -analgesics-analgesics

4.Describe the actions of the 2 classes of 4.Describe the actions of the 2 classes of drugs available for the control of hypdrugs available for the control of hyp

eruricemia?eruricemia? NSAIDsNSAIDs and and UricosuricUricosuric drugs drugs

– NSAIDsNSAIDs Reduce inflammation caused by leukocytic reactions Reduce inflammation caused by leukocytic reactions

to the deposition of uric acid crystals.to the deposition of uric acid crystals. NSAIDs block prostaglandins, the substance that dilaNSAIDs block prostaglandins, the substance that dila

tes blood vessels and causes inflammation and pain tes blood vessels and causes inflammation and pain of gout.of gout.

– UricosuricUricosuric drugs drugs Inhibit the reabsorption of uric acid by a weak acid caInhibit the reabsorption of uric acid by a weak acid ca

rrier mechanism at the proximal part of nephronrrier mechanism at the proximal part of nephron Work by helping the kidneys get rid of the excess uric Work by helping the kidneys get rid of the excess uric

acid produced in the body.acid produced in the body.

5.What factors determine which of 5.What factors determine which of these drug to use for treatment?these drug to use for treatment?

In In acuteacute gout attacks gout attacks NSAIDsNSAIDs, , colchicinecolchicine, and , and ccorticosteroidsorticosteroids are considered for use. In are considered for use. In chronicchronic g gout attacks the anti-metabolite (allopurinol) and out attacks the anti-metabolite (allopurinol) and uricosuric drugs are considered.uricosuric drugs are considered.– AcuteAcute gout: gout:

NSAIDsNSAIDs are the preferred medication for gout are the preferred medication for gout– Side effectsSide effects

Upset stomachUpset stomach BleedingBleeding Kidney damageKidney damage High potassium levelsHigh potassium levels Retention of sodium and potassiumRetention of sodium and potassium

5.What factors determine which of these dru5.What factors determine which of these drug to use for treatment?(cont.)g to use for treatment?(cont.)

ColchicineColchicine is very effective, but the side effects can be intolerable by is very effective, but the side effects can be intolerable by many patients.many patients.

– These side effects include:These side effects include: DiarrheaDiarrhea VomitingVomiting NauseaNausea Abdominal painAbdominal pain CrampsCramps Suppression of blood cell production in the bone marrow.Suppression of blood cell production in the bone marrow.

CorticosteroidsCorticosteroids aren’t as effective as NSAIDs or colchicine aren’t as effective as NSAIDs or colchicine– Side effects:Side effects:

Retention of sodium with swellingRetention of sodium with swelling High blood pressureHigh blood pressure PainPain DiscomfortDiscomfort Joint damage if over usedJoint damage if over used

5.What factors determine which of these dru5.What factors determine which of these drug to use for treatment?(cont.)g to use for treatment?(cont.)

– ChronicChronic Gout: Gout: AllopurinolAllopurinol

– ActionAction Inhibit Xanthine oxidaseInhibit Xanthine oxidase Prevents the formation of uric acidPrevents the formation of uric acid

– Side effectsSide effects Upset stomachUpset stomach Skin rashSkin rash Decrease in number of white blood cellsDecrease in number of white blood cells Liver or kidney damageLiver or kidney damage Inflammation of blood vessels (vasculitis)Inflammation of blood vessels (vasculitis)

UricosuricUricosuric drugsdrugs– ActionAction

Promote excretion of uric acidPromote excretion of uric acid– Probenicid & Sulfinpyrazone, Side effectsProbenicid & Sulfinpyrazone, Side effects

HeadacheHeadache NauseaNausea VomitingVomiting Kidney stonesKidney stones

6.Should this patient be told to 6.Should this patient be told to avoid alcohol? Why or why avoid alcohol? Why or why

not?not?

Yes, the patient should avoid certain tyYes, the patient should avoid certain types of alcohol such as beer ,because it pes of alcohol such as beer ,because it contains high contents of purine. There contains high contents of purine. There seems to be a link between incidence oseems to be a link between incidence of gout and alcohol intake.f gout and alcohol intake.

7.What analgesic would you tell the 7.What analgesic would you tell the patient to avoid for treatment of a patient to avoid for treatment of a

headache? Whyheadache? Why?? Aspirin should be avoided, because at Aspirin should be avoided, because at

low doses which is what is recommendelow doses which is what is recommended for headaches aspirin causes formatiod for headaches aspirin causes formation of urate. In order for Aspirin to be used n of urate. In order for Aspirin to be used as a uricosuric drug it has to have elevatas a uricosuric drug it has to have elevated doses.ed doses.– Low doseLow dose

1-2 gm/day1-2 gm/day Decrease rate of urate excretion and elevate plaDecrease rate of urate excretion and elevate pla

sma urate concentration.sma urate concentration.

7.What analgesic would you tell the patie7.What analgesic would you tell the patient to avoid for treatment of a headache? nt to avoid for treatment of a headache?

Why?(cont.)Why?(cont.)

– Intermediate dose Intermediate dose 2-3 gm/day2-3 gm/day Does not alter urate excretionDoes not alter urate excretion

– Large doseLarge dose >5 gm/day>5 gm/day

– Uricosuric and lowers plasma urate levelsUricosuric and lowers plasma urate levels