- The document discusses the treatment and management of gout. It provides guidelines on drug dosing for allopurinol and colchicine based on kidney function. - The target for serum uric acid levels with treatment is provided, with lower targets for those with tophaceous gout. - Treat-to-target therapy is recommended to keep serum uric acid levels below the recommended targets in order to prevent gout flares and reduce tophi formation. Regular monitoring of serum uric acid levels is important.

4. BY:
Abdallah Allam MSc
Assistant Lecturer. Department of Physical Medicine,
Rheumatology and Rehabilitation
Faculty of Medicine, Tanta University. Egypt

9. Rees, F. et al. (2014) Optimizing current treatment of gout
Nat. Rev. Rheumatol. doi:10.1038/nrrheum.2014.32

10. Reginato, A. M. et al. (2012) The genetics of hyperuricaemia and gout Nat. Rev. Rheumatol.
doi:10.10.38/nrrheum.2012.144

11. 24 hs urine
uric acid excretion
600-800 mg

24. Cherries as one-half cup, or 10 to 12 cherries.==>
1- DECREASES SERUM URIC ACID
2- Prevents flares
3- Reduces pain and inflammation

27. BMJ VOLUME 332 3 JUNE 2006

29. Over production(5-10%)
Genetic
Acquired

30. Genetic
- HGPRT deficiency X linked,
*partial Kelly Seeg Miller
*complete Lish Nyhan
- G6PD deficiency ( LACTIC )
- Over PR1P synthetase (
sensory neural hearing loss).
Acquired
- Diet
- Obesity
- Tumors
- Chemotherapy
- Alcohol(Lactate, ATP,
Purine guanosine)
- Vigorous exercise.
- Psoriasis.

31. Under excretion(90-95%)
Genetic
Acquired

32. Genetic
- Down.
- PCD.
Acquired
*Decreased exc.
- RF
- KETO ACIDOSIS
- LACTIC ACIDOSIS
- HYPERTRIGLYCERIDEMIA
*increased Abs.
- Dehydration
- Starvation
- Insulin R
- Drugs

33. Associated with:
Obesity,
Hypertension,
Diabetes (Bell shaped curve),
Sleep Apnea Syndrome.
Hyperlipidaemia.

39. · MSU precipitates at the periphery of the body, where
lower body temperatures may reduce the solubility of
MSU.
· Albumin levels decrease, which causes decreased urate
solubility
· Change in ion concentration & decreases of PH
enhance urate deposition
· Trauma promotes urate crystal precipitation

50. Rheumatology 2005;44:1090–1096

57. HPRT

64. CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 75 •
SUPPLEMENT 5 JULY 2008

66. Normal serum uric acid during attack

79. 24 hs urine collection (not done during
attack)
>800mg / d  over producers
< 400 mg / d  under excretors

82. Soft tissue swelling.
Dorsoplantar radiograph
shows mild soft tissue
swelling medial to the first
metarsophalangeal joint.

83. Dorsopalmar radiograph
shows soft tissue masses
around the fourth proximal
interphalangeal joint and
radial to the fifth
metacarpophalangeal joint.
The joint spaces are normal.

103. Dual-energy CT imaging of tophi in patients with gout

105. Arthrocentesis
Gold standard

106. (A) Monosodium urate crystals of gout appear as fine yellow needlelike
crystals that are negatively birefringent under compensated polarized light.
(B) In contrast, crystals of calcium pyrophosphate dihydrate (CPPD) crystal
deposition disease are rhomboid in shape and weakly positively
birefringent under compensated polarized light ABC

126. Probenicid
Sulfinpyrazone
Febuxostate
Losartan
Fenofibrate
Vit C
Leflunomide
Lisinopril
Allopurinol
Febuxostate
Pegloticase
Rasburicase

129. Rees, F. et al. (2014) Optimizing current treatment of gout
Nat. Rev. Rheumatol. doi:10.1038/nrrheum.2014.32

134. Colchicine Creatinine cl
ml/min
Dose
> 50 0.6 mg twice daily
35-49 0.6 mg once daily
10-34 0.6 every 2 or 3
days
<10 stop

138. Avoided in RT TTT by cyclosporine 
neuromyotoxicity myopathy (proximal + increased
creatinine + EMG  STOP FOR 3 WEEKS
CURE

141. Treat to Target
• < 6 mg/dl
• < 5 mg/dl
• < 4 mg/dl ( tophaceous gout)

143. Rees, F. et al. (2014) Optimizing current treatment of gout Nat. Rev. Rheumatol. doi:10.1038/nrrheum.2014.32

147. Allopurinol GFR
ml/min
Dose
N 300 mg/d
60 200mg/d
30 50-100 mg/d

148. ALLOPURINOL HYPERSENSITIVITY SYNDROME
• 5- 10%
• Morbidity and mortality: 20-30%
• MAJOR RISKS:
R I 75%
Diuretic TTT 50%
• ONSET 2-4 WKS
C/P: skin rash , esinophilia, fever, hepatic necrosis,
leucocytosis and ↓ RF
TTT: - Steroids - Renal dialysis

156. Pegloticase pegilated uricase
• 8 mg in 250 cc N or half normal saline over 2 hours.
• Every 2 weeks.
• Pre ttt by hydrocortisone iv, acetaminophen 500 -1000 mg
iv & antihistaminics.
• Monitor serum uric acid before each dose ( Auto Abs).
• Colchicine for 3 mos at least.
• Flare of acute attack, Nephrolithiasis, Arthralgia, Nausea,
Dyspepsia, Diarrhea, Rash, Back pain.
CI : G6PD

158. Rasburicase recombinant uricase
• 0.2mg/kg iv over 30 min qd * 5 days
• Every 2 weeks.
• Leukemia , lymphoma , chemotherapy

161. (CAN’T LEAP)
1-Cyclosporine
2. Alcohol
a. Associated with lactic acid
production
i. Reduces renal excretion of urate
b. Increases synthesis of urate by
accelerating the degradation of
ATP
c. Beer contains a lot of purine
guanosine
3. Nicotinic acid
4. Thiazides
a. Interferes with urate excretion at
the proximal convoluted tubule
5. Lasix
6. Ethambutol
7. Aspirin
a. Low dose <2 g/day
8. Pyrazinamide

173. Rees, F. et al. (2014) Optimizing current treatment of gout
Nat. Rev. Rheumatol. doi:10.1038/nrrheum.2014.32