59 yo.

Male
Married
From Batangas
Catholic
CC: bilateral knee pain (1st consult)
15 years PTC
Pain and swelling at 1st toe joint on R foot
Developed over a day
Resolved after several days with intake of Skelan
Recurrent episodes: 3x a year
Patient feels well prior to the onset of the joint
pains and in between attack of pain
2 days PTC
Sudden onset of bilateral knee joint pain and
swelling which hindered ambulation
Minimal pain relief from Skelan
Review of Systems
(+) frequent urination
(+) nocturia
Social History Family History
Non-smoker Eldest sibling has same
Alcoholic beverage drinker joint pains
(Beer, 1-2x a week to
the point of
intoxication)
 Differentials Rule In Rule Out
Differentials Rule In Rule Out
Chronic Gouty arthritis (+) initiallymonoarticular Cannot rule out
Chronic septic arthritis (+) joint pain and swelling (-) fever
(+) chronic
(+) limitation
(+) recurrent of movement
episodes with (-) hx of infections, STDs
(+) knee period
refractory involvement (-) hx of corticosteriods,
(+) recurrent
(+) joint pain andepisodes
swelling with rheumatoid arthritis
(+) st
1 metatarsal involvement
refractory period Cannot rule out
(+) knee involvement
Reactive arthritis (+) exacerbation
(+) asymmetricwith alcohol (-) chronic presentation
Pseudogout (calcium (+)articular
(+) joint pain and swelling (-) fever
Cannot rule out
pyrophosphate dihiydrate) (+)
(+)recurrent episodes with
knee involvement (-) dysuria
refractory period
(+) frequency (-) eye discharge
(+) joint pain and swelling
(+) 1st metatarsal involvement
(-) constitutional symptoms
(+) knee involvement (-) age group<40
(-) skin lesions
Rheumatoid Arthritis (+) articular (+) asymmetry on initial
(keratodermablenorrhagica
(+) chronic presentation
(+) recurrent episodes )(-) involvement of the PIP joints
(+) joint pain and swelling (-)the
of oral ulcers
hand and wrist
(+) knee involvement (-) constitutional symptoms
(-) age of onset> 60
 General
Swollen,Assessment
warm, erythematous and tender
knees
Fairly nourished man, wheel chair borne
Coarse
Afebrile
crepitus of both knees
Not in range
Limited respiratory distressdue to pain of both
of motion
knees
Vital signs
BP 160/90
Other organmmHg
systems were normal
CBC
Hemoglobin 112g/L, normocyticnormochromic
Erythrocyte Sedimentation Rate: 12mm/hr
FBS: 174 mg/dL
Creatinine: 152 umol/L
BUN: 8 mmol/L
Uric acid: 0.81 mmol/L
ECG: lateral wall ischemia
Synovial fluid analysis
Inflammatory fluid with negatively birefringent
needle shaped crystals
Chronic, recurrent Gouty Arthritis
GOUT is a metabolic disorder characterized by
tissue accumulation of excessive amounts of uric
acid

Hyperuricemia can result from increased

production, or impaired excretion of uric acid or
both
 CLASSIFICATION

PRIMARY GOUT SECONDARY GOUT

90% 10%
cause is unknown caused by increased urate
known enzyme defects production
Lesch-Nyhan syndrome rapid cell lysis during
(HGPRT deficiency) chemotherapy for
lymphoma or leukemia
decreased excretion
chronic renal
insufficiency
Tissue injury and inflammation
 STAGES

asymptomatic hyperuricemia

acute gouty arthritis

"intercritical" gout

chronic gouty arthritis

Treatment needed
For Acute Gout Flares
For Chronic Gout
Hypertension
For Diabetes
Should be based on severity of pain and no. of joints involved

For mild/moderate (< or = 6 of 10 on a 0-10 VAS) particularly

those involving 1 or a few small joiints, or 1 or 2 large joints,
monotherapy may be appropriate. Options include oral NSAIDS,
systemic steroids, or oral colchicines (Evidence A).

If polyarticular and severe, combination therapy is

recommended.

No rank as to efficacy of one therapeutic agent over another.

 EFFICACY SAFETY SUITABILITY COST
NSAID ++++ +++ +++
blocks inflammation - poorly tolerated in the - patient has evidence of
(prostaglandin synthesis) by presence of renal renal insufficiency
inhibiting COX1 and COX2 insufficiency
- risk of renal damage
especially in patients with
preexisting renal disease
- risk of GI bleeding
- hematologic reactions
noted with indomethacin
(bone marrow suppression)
Selective COX2 inihibitor ++++ +++ ++
blocks inflammation -less GI toxicity, but same - patient has evidence of
(prostaglandin synthesis) by risks for renal damage renal insufficiency
selectively blocking COX2 - Highly selective COXibs - patient has incurred lateral
pose an increased risk for wall ischemia, which may
arterial thrombosis, increase the risk for
myocardial infarction and thrombotic events
stroke
Colchicine ++++ +++ +++
-prevents microtubule -diarrhea, nausea and patient has evidence of renal
formation, leukocyte vomiting (in high doses) insufficiency Rhea colchicine
migration and phagocytosis; poorly tolerated and P3.30 per 500mcg tablet
also blocks leukotriene B4 dangerous in the presence of
(anti-inflammatory) renal insufficiency
- can potentially severely
damage the liver and kidney
ACTH ++++
-induces adrenals to produce
corticosteroids
Corticosteroids ++++ +++ +++
-Anti-inflammatory and - Glucocorticoids can
immunosuppressive actions: increase blood pressure
Inhibition of gene since it promotes salt
transcription for COX-2, retention
cytokines, cell adhesion - It may also cause
molecules, and inducible hyperglycemia
NO synthase
Blockage of Vit D3-
mediated induction of
osteocalcin gene in
osteoblasts
Modification of
collegenase gene
transcription
Increase synthesis
annexin-1, important in
negative feedback on
hypothalamus and
anterior pituitary gland

good for polyarticular gout

Bring down the serum urate to a target level of
<6 mg/dL (<0.357 mmol/L)

To prevent recurrences and acute flares

To reverse or minimize complications of
urate deposition in joints, kidneys, or other
sites
 EFFICACY SAFETY SUITABILITY COST

Uricosuric agents ++++ +++ ++++ Llanol P9.50 per 100 mg tab
(Probenecid) -inhibit renal tubular AE: Llanol P27.50 per 300 mg tab
reabsorption of uric acid Rash
GI disturbances
Drowsy

Xanthine Oxidase Inhibitors ++++ ++ ++++

(Allopurinol) -prevents formation of uric AE:
acid bu inhibiting xanthine Rash
oxidase Fever
GI problems
Hepatotoxicity

Uric Acid Oxidizers ++++

-facilitate conversion of urate
to allantoin, thus preventing
acute renal failure
Treatment Goal:

Achieve blood sugar level with oral

hypoglycemic agents w/ or w/o insulin
 EFFICACY SAFETY SUITABILITY COST

Biguanide ++++ +++ + ++++

Metformin MOA: AE: Contraindication:
Decrease glucose Lactic Acidosis Cr > 133 umol/L (men)
production in liver, GI upset (diarrhea, Renal insufficiency
increases glucose uptake nausea, abdominal pain) Congestive Heart Failure
Metallic taste Any form of acidosis
Liver disease
Severe hypoxia

Sulfonylureas ++++ ++++ + +++

AE: Contraindication Glimepiride (Solosa)
Hypoglycemia Renal and liver disease ~ P 29.00 per 2 mg tab

Nonsulfonylureas +++ ++++ + ++++

Meglitinides AE: Contraindication Repaglinide
Hypoglycemia, weight Kidney and liver failure ~ P 15.00 per 0.5 mg tab
gain Nateglinide (Starlix)
~ P 26.00 per 120 mg
 EFFICACY SAFETY SUITABILITY COST

Biguanide ++++ +++ + ++++

Metformin MOA: AE: Contraindication:
Decrease glucose Lactic Acidosis Cr > 133 umol/L (men)
production in liver, GI upset (diarrhea, Renal insufficiency
increases glucose uptake nausea, abdominal pain) Congestive Heart Failure
Metallic taste Any form of acidosis
Liver disease
Severe hypoxia

Sulfonylureas ++++ ++++ + +++

AE: Contraindication Glimepiride (Solosa)
Hypoglycemia Renal and liver disease ~ P 29.00 per 2 mg tab

Nonsulfonylureas +++ ++++ + ++++

Meglitinides AE: Contraindication Repaglinide
Hypoglycemia, weight Kidney and liver failure ~ P 15.00 per 0.5 mg tab
gain Nateglinide (Starlix)
~ P 26.00 per 120 mg
Treatment Goal

For hypertensive patients with diabetes or

renal disease, the target BP is < 130/80 mmHg.
 EFFICACY SAFETY SUITABILITY COST
Diuretics ++++ +++ +++ Hydrochlorothiazide
Thiazides AE: Contraindicated in Gout P 4.85 per 12.5 mg tab and P
Loop diuretics Hypokalemia 5.85 per 25 mg tab
K+ Sparing Hyperuricimia Possible Indication:
Hyperglycemia Diabetes
Inc. cholesterol
Inc. triglycerides
Beta Blockers ++++ ++ +++ ++++
AE: Compelling Indicarions: Metoprolol
Bronchospasm Angina ~ P 3.75 per 50 mg tab
Bradycardia After MI
Heart Block Tachyarrythmia
Fatigue
Sexual dysfunction
Inc. triglycerides
Dec. HDl

ACE inhibitors ++++ +++ ++++ +++

AE: Compelling Indications: Enalapril
Cough Heart Failure ~ P 20.00 per 10 mg tab
Hyperkalemia Left ventricular dysfunction
Azotemia After MI
Angioedema Diabetic nephropathy

Possible Indication:
Chronic Renal Parenchymal
Disease
Angiotensin Inhibitor ++++ +++ ++++ +++
Antagonist AE: Compelling Losartan
Hyperkalemia Indications: ~ P 24.00 per 50 mg
Azotemia ACE inhibitor cough tab
Heart failure
Gout/ hyperuricemia
Diabetic nephropathy

Possible Indication:
Chronic Renal
Parenchymal Disease
Calcium Channel ++++ ++ +++ ++++
Antagonist AE: Compelling Amlodipine
Edema Indications: ~ P 6.50 - 15.50 per 5
Constipation Angina mg tab
Bradycardia (Non- Elderly Patients
dihydropyridines) Systolic Hypertension
Heart Block
(Non-dihydropyridines)
1. Patient education

a. Explain to the patient his conditions (Chronic

Gout, Type 2 Diabetes, Diabetic Nephropathy)
in a manner that he fully understands. Explain
what is his condition, how it affects him, and
what can be done
b. Education his family members as well to
facilitate care for the patient
2. Diet
a. Advise the patient to have to have dietary
modifications:

i. Low purine diet food high in purine must be

avoided in order to control the gout. Foods
such as internal organs, shellfish, sardines
mussels, sweetbreads, and other high protein
foods. Foods products that have used yeast are
also high in purine, such as beer.
 ii. Low fructose diet there is a correlation between
fructose intake and gout. High fructose foods include
processed sweetened products like soft drinks, some
ice creams, and high-fructose corn syrup. Fruit intake
should not be excessive

iii. Diabetic diet the patient must control her intake

of carbohydrates. It should be properly planned
depending on his intake of medications to prevent
hyper and hypoglycemia
iv. Low protein diet the patient must have a protein
intake limited to 0.8 to 1 g /
kg body weight day. This is the recommended protein
intake by the ADA for patients with Diabetic
Nephropathy to protect further damage to the
kidneys. In addition, low protein diet are usually also
low in purine which is beneficial for the management
of the gout.

v. Low saturated fatty acid, high unsaturated fatty acid

to help controlling risk factors for DM and HPN
Advise the patient to stop drinking alcohol since
alcohol intake aggravates the gout. In addition, extra
calories coming from the alcohol could lead to obesity
which will further aggravate his other conditions like
DM, hypertension, and
3. Exercise
a. Achieve a healthy weight. Maintain weight at the
desirable body weight range
b. Advise patient to have a 30-minute exercise, light
to moderate intensity, 2 to 3 times per week.
c. Since the patient is wheelchair bound, advice the
patient to undergo resistance training such as weight
lifting.
d. Cardiovascular training such as using stationary
bike can be advised, and be started on an intensity
tolerated by the patient.
e. Also advise the patient to have stretching exercises
1. Patient education, with initiation of diet, lifestyle recommendations
- weight loss for obese patients
- healthy diet
- exercise
- smoking cessation
- stay well hydrated
2. Consider secondary causes of hyperuricemia (co-morbids)
- obesity
- alcoholism
- DM type 2
- hypertension
- hyperlipidemia
- serum-urate-elevating medications
- history of urolithiasis
- chronic kidney disease
3. Consider elimination of non-essential prescription medications that induce
hyperuricemia
4. Clinically evaluate gout disease burden (palpable tophi, frequency and severity of
acute and chronic signs and symptoms)
Long-Term Monitoring
follow-up visits in 1 month - to evaluate if
therapy lowers serum uric acid
follow-up every 1-2 months - if uric acid
therapy has begun; while adjusting dose level
target uric acid level: 5mg/dl (once target uric
level has been achieved, follow up every 6-12
months)
For Acute Gout: Corticosteroid
cataracts and/or elevated intraocular pressure: eye
exam, specifically ocular tonometry and examination
using slit lamp
high blood sugar, may trigger or worsen diabetes:
request for Random Blood Sugar
preventive treatment for osteopenia/osteoporosis:
DEXA scan
elevated blood pressure: regular monitoring of blood
pressure
stomach ulcers: proton-pump inhibitors may be given
For Chronic Gout:
1. Xanthine Oxidase Inhibitor (Allopurinol)
Drug Rash with Eosinophilia with Systemic
Symptoms (DRESS) Syndrome
affects liver, kidney, skin
occurs 6-8 weeks after beginning allopurinol
discontinue allopurinol in patients who develop
rash
For Chronic Gout:
2. Uricosuric Agent (Probenecid)
do not administer for acute gouty attacks
caution if patient has renal impairment (CrCl <50
mL/min
alkalinize urine to avoid renal stones
For Chronic Gout:
3. Uric Acid Oxidizer
Risk for anaphylaxis is higher if serum uric acid level
>6 mg/dL: monitor serum uric acid levels before
infusion and consider discontinuing if levels increase
to >6 mg/dL (particularly if 2 consecutive levels of >6
mg/dL are observed)
G6PD-deficiency (increased risk of hemolysis and
methemoglobinemia)
Gout flare common: initiate acute treatment for gout
For Diabetes: Thiazolinediones
increasing incidence of hepatitis and potential
liver damage
two to three month checks of liver enzymes for
the first year of thiazolidinedione therapy
potential for edema, water retention/weight
gain
For Hypertension:ACE inhibitor
may worsen kidney function of patients with
bilateral renal artery stenosis: check kidney
function before prescribing ACE inhibitor
hyperkalemia (may cause cardiac arrest and
interference in the normal functioning of skeletal
muscles in the patient): monitor serum
potassium levels
efficacy affected by NSAIDS: adjust dose if taken
with NSAID