gout (통풍)

소개

Gout의 원인, 증상, 합병증, 진단, 치료, 치료약물 등 gout의 전반적인 내용에 대해
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목차

The Clinical Problem
Clinical Features
The Gout Attack
Clinical phases of gout
Renal manifestations
Biochemical Basis of Gout
Classification of gout
Hyperuricemia : cause and classification
purine nucleotide synthesis
Uric acid crystals
NUTRITIONAL FACTORS
MEDICATIONS
ADDITIONAL RISK FACTORS
Clinical Diagnosis
Diet and Lifestyle
NOTE
MAJOR RECOMMENDATIONS
Pharmacological Intervention
Colchicine
NSAID’S
Corticosteroids
Approaches to Lowering Uric Acid Levels
Pharmacologic Antihyperuricemic Therapy
The Choice?
Uricosuric Therapy:Creatinine Clearence: <80 mL
Allopurinol…..
Areas of uncertainity

본문내용

Gout

<The Clinical Problem>

....


- A definitive diagnosis
the direct identification of urate crystals in the joint
the exclusion of infection

- Serum urate levels are frequently normal during attacks of acute gout

- among postmenopausal women in association with diuretic-treated hypertension and renal insufficiency

- organ-transplant recipients who are treated with cyclosporine have an increased risk of gout



<clinical feature>
* Gout 사진
* 사진 설명
▪ Have hyperuricemia for years before developing symptoms
▪ 75% of initial gout attacks begin in the lower extremities
▪ Podagra most cases begin in big toe (50%)
▪ Sudden, intense pain
▪ Little pain otherwise

* 사진2
▪ Also affected:
▫ Insteps, heels, ankles, knees, fingers, wrists, and elbows
▪ ...



< Clinical phases of gout>

-Asymptomatic hyperuricemia
-Acute gouty arthritis
▪ Gout attack
▪ Most significant presentation
-Intercritical asymptomatic gout
▪ Between attacks
-Chronic tophaceous gout
▪ Long term problem

-12 yrs from onset to chronic
-Impair quality of life, not shorten life
-Most chronic gout patients die of renal failure



<Renal manifestations>
-Nephrolithiasis
▪ Acidic urine saturated with uric acid crystals
▪ As a nidus for calcium oxalate or phosphate stone
-Acute gouty nephropathy
▪ Massive malignant cell turnover
▫ With treatment of myeloproliferative or lyphoproliferative disorders
▪ Blockage of urine flow secondary to the precipitation of uric acid in the
CD and ureter
-Chronic urate nephropathy
▪ ...

.
.
.
…… (중략)


<Clinical Diagnosis>
 그림
▪ H & P for hyperuricemia
▫ Obesity?
▫ Alcoholism?
▫ Drugs like diuretics?
▫ Lead exposure?
▫ Renal disease?
▫ Acute arthritis?
▫ Hypertension or CVD?
▫ Family history?



■ Lab tests
- CBC
- Urinalysis
- Creatinine clearance
- Liver function
- Uric acid levels (serum and urine)

■ Synovial fluid aspiration
- Usually of 1st MTP joint (big toe)
- Increased white cell count (neutrophils)
- ...


Clinical Diagnosis
* 사진 : Monosodium Urate Crystals

■ Radiology
▪ Plain film X-ray
▫ S.T. swelling and edema in joints
▫ Punched out lesions and fractures
▫ Interosseous tophi and joint space narrowing
▪ CT scan
▪ ...
▪ MRI

Clinical Diagnosis
x ray 사진 3장 : Plain film X-rays of foot and hand of gout affected individuals



<Diet and Lifestyle>
▪ weight reduction
▪ decreased alcohol consumption
▪ control of hyperlipidemia
▪ control of hypertension
▪ decrease consumption of foods
with high purine content

NOTE:
Used alone, these measures will not reduce uric acid levels
(Medicine is also needed)

<MAJOR RECOMMENDATIONS>
■ Avoid excessive alcohol
▪ Ethanol increases uric acid production
▪ Beer has a high guanosine content which promotes production
■ ...

■ Avoid high purine foods
▪Red meats
▪Organ meats
▪brain, kidney, liver and heart
▪Shellfish
▪Peas and beans

■ Moderate protein intake
■ Low-fat diet
■ Treat ...
■ Treat ...



<Pharmacological Intervention>
■ Colchicine
■ NSAID’S
■ Corticosteroids
■ ...
■ ...




<Colchicine>
■ Acute Gout
▪ Within the first few hours
▪ hours: 0.6 mg once every hour for up to 3 hr (maximum, 3 pills)
▪ low-dose oral colchicine can
be used as follows for prophylaxis against acute gout
particularly before the initiation of antihyperuricemic therapy
■ Side Effects:
▪Diarrhea
▪Nausea, Vomiting
▪BM suppression for IV.

► 0.6 mg orally twice daily in patients with
creatinine clearance ≥50 ml/min
► 0.6 mg orally per day in patients with
creatinine clearance of 35 - 49 ml/min
► 0.6 mg every 2 - 3 days in patients with
creatinine clearance of 10 - 34 ml/min
► ...
► ...




<NSAID’S>


… (중략)

< The Choice?>

- between a medication that reduces urate production and one that increases urate excretion
- 24-hour urinary urate excretion to identify patients who overproduce urate
- a daily urinary urate excretion in excess of 800 to 1000





<Areas of uncertainity>
Asymptomatic hyperuricemia alone
direct, deleterious effects on arterial smooth-muscle cells, glomeruli,and systemic blood pressure...

참고자료

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